Diverticulitis: Selective Surgical Management George M. Rugtiv, MD, Mountain View, California

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeon, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of treatment in past decades should be integrated with current surgical technics. This report presents my personal experience with the surgical treatment of diverticulitis from 1954 to 1974 and documents how this experience has altered my approach to the surgical management. Complex problems in management attended by increased risk, multiple complications, prolonged hospitalization, and increased staging are discussed, along with selective surgical management in special circumstances. Clinical Data During the period from 1954 to 1974, one hundred fifteen patients with diverticulitis were treated surgically. (Table I.) The average age was 62.8 years. The youngest patient was a 31 year old woman, and the oldest patient was an 88 year old woman with a large, quite symptomatic colovesical fistula. Single-stage resection with primary anastomosis was performed in sixty-eight, or 59 per cent. Indications for resection were those generally accepted, including repeated symptomatic episodes, suspicion of neoplasm, a pelvic mass that failed to resolve, significant bleeding, walled-off abscess in the mesentery, and colovesical fistula (six patients). Cecostomy was employed in sixteen patients on the premise that it provided some decompression if the anastomosis was slow in opening, permitted early removal of the Levin tube, From the Department of Surgery, Stanford University School of Medicine, Stanford, California. Reprint requests should be addressed to George M. Rugtiv, MD. 2500 Hospital Drive, Mountain View, California 94040. Presented at the Golden Anniversary Meeting of the Pacific Coast Surgical Association, Scottsdale, Arizona, February 16-20. 1975.

Volume 130, August 1975

and allowed oral intake of fluids until bowel function was established. In recent years, cecostomy has not been used. Special attention was given to safe anastomosis, the details of which are discussed later. Cecostomy fails to protect a faulty anastomosis [1,2]. As seen in Table II, complications were minimal and there were no anastomotic leaks. Follow-up studies revealed excellent results. One patient, with x-ray evidence of diverticula above the anastomosis, complained of episodes of abdominal pain years after resection. After a long period of medical treatment, reresection was carried out with no evidence of diverticulitis. The pain was believed to be of musculoskeletal origin. One patient who underwent operation in 1961 had associated carcinoma and underwent reoperation in 1974 for cholecystitis revealed no evidence of recurrent tumor. Two other patients had single-stage management, but without resection or colostomy. Both patients were elderly and critically ill with perforated diverticulitis, and the involved sigmoid was exteriorized and maintained in a subcutaneous position. The perforation was allowed to heal, the skin healed over the colon, and bowel function returned. This method is presented more fully later. The remainder of the patients in the series (forty-five cases) had staged resection because of other complications of the disease, such as free perforation with spreading peritonitis, large pelvic abscess, obstruction, pericolic abscess, or complicated fistula. From 1954 to 1967 the standard three-stage procedure was used for these complications. The initial stage consisted of diverting right colostomy and local drainage to effect resolution of the acute diverticulitis, associated peritonitis, and abscess formation. Sigmoid resection was carried out after three to six months. The third stage was closure of the colostomy after ten to fourteen days when barium enema revealed an open anastomosis

219

Rugtiv

TABLE

I

Type of Operation 1954-1974

for Diverticulitis,

(115 cases)

Operation

Number

Primary resection and anastomosis (one-stage) Primary resection and anastomosis with cecostomy (one-stage) Colostomy, resection, colostomy closure (three-stage) Primary resection without anastomosis (Hartmann procedure) with later anastomosis (two-stage) Other operations Appendectomy, transverse colostomy (not opened), followed by resection and replacement of colostomy (two-stage) Exteriorization of involved segment without resection or colostomy Cecostomy, transverse colostomy, resection, colostomy closure Sigmoid resection followed by closure of colostomy and associated fecal fistula and hernia (colostomy and drainage performed elsewhere) Total

52 68 16 38 3

2

2

15

without extravasation or “leak out.” One patient demonstrated a small extravasation at the site of anastomosis, and closure of the colostomy was delayed for six weeks. In two patients, the colostomy was closed at the time of sigmoid resection to avoid the third stage. In one patient, the site of closure failed to function and required revision without further complications. In the second patient, anastomotic breakdown was suspected on the seventh postoperative day, with the findings of free air on the abdominal x-ray film, fever, shock, ileus, and leakage of contrast medium into the pelvis on Gastrografin@ enema. Colostomy was immediately established with drainage of the upper abdomen. The pelvis and the lower abdomen were drained through an incision in the left lower quadrant. The colostomy was closed eight months later. Acolovesical fistula developed, which closed spontaneously, and the patient later required repair of an incisional hernia. TABLE

II

Complications Anastomosis

of Primary

Complication Wound infection, superficial Urinary retention Pneumonitis Pulmonary insufficiency Thrombophlebitis Pronounced ileus

220

Resection

and

(68 cases) Number

Per Cent

8

11.4 22.8 11.4 5.6 1.4 2.7

16 8 4 1 2

Another patient, a fifty-one year old man presenting with perforated sigmoid diverticulitis and pericolic abscess, demonstrated the high complication rate in the group of patients with three-stage resection. (Table III.) After the first stage, loops of small bowel prolapsed around the site of colostomy after an episode of straining with vomiting, which required reduction and repair using anesthesia. In the third stage, the cecum was found in the right upper quadrant and it was noted that diverting colostomy had been made in the ascending colon. In addition, there was an inflammatory mass secondary to a mucocele of the appendix from an old perforation. Right colectomy was performed as the third stage. Repair of an incisional hernia, both at the site of colostomy and in the left lower quadrant, was required. In summary, the patient had a six-stage procedure, plus other complications including aspiration pneumonia. This patient had been on corticosteroids for many years. Cantor and Shorb [3] have reported a high incidence of acute perforation of colonic diverticula associated with prolonged adrenocorticosteroid therapy, and this was believed to have contributed to the other complications in this patient. Other patients in the group with three-stage resection had major abdominal complications, increased morbidity, and prolonged hospital stay. One case is too complex to present in detail. In summary, this patient required nine operative procedures for multiple complications. He is currently completely well and symptom-free. In retrospect, this complicated course could have been avoided if resection without anastomosis had been employed as the first stage. Other Procedures. A highly instructive case with surprising findings occurred in a sixty-one year old obese woman scheduled to undergo elective one-stage resection because of a history of chronic recurrent episodes of diverticulitis. A barium enema two weeks before operation was interpreted as showing diverticulitis without evidence of spasm. Routine bowel preparation was carried out, and at operation there was extensive subacute and chronic diverticulitis with a brawny firm pelvis grossly indistinguishable from neoplasm. Partial obstruction of the small and large bowel was also present. Mobilization of the colon was accomplished with extreme difficulty. As primary resection with anastomosis was inadvisable, it was decided to close the distal segment with staples, resect the sigmoid, and establish an end sigmoid colostomy, or a Hartmann procedure. Postoperatively, multiple abscesses developed in the abdominal

The American Journal of Surgery

Diverticulitis

wall around the site of colostomy and diabetes mellitus subsequently was found. Because of these complications and the patient’s obesity, the second stage of anastomosis was deferred. After a safe resection in this setting, I fully appreciated for the first time the recommendation by other authors [1,2,4-141 of this safe and effective procedure. Selective Procedures. In this series of cases, selective surgical management was used in special circumstances. First, in a patient who underwent operation for what was diagnosed as appendicitis, an inflamed sigmoidal mass, with exudate but no perforation or abscess, was found. After appendectomy, transverse colostomy was established, and the patient was observed carefully and treated medically to allow the acute process to subside. The colostomy was not opened but maintained in a subcutaneous position and the skin closed over the colostomy in three to five days when the patient was doing well. Sigmoid resection was performed in two to three months, at which time the site of colostomy was replaced into the abdomen and the fascial defect closed. This procedure has limited application and was used in only two patients. It does provide decompression if the subacute process fails to resolve. This error or misdiagnosis of appendicitis often can be avoided. In the charts in each of these patients, low suprapubic pain was noted, which should have been a “tipoff” for the proper diagnosis of diverticulitis. The second method of selective management, which was referred to earlier, consisted of exteriorization of the perforated sigmoid in the acutely ill, elderly patient with multiple system disease. The exteriorized sigmoid was left in a subcutaneous location and the perforation allowed to heal for a period of weeks. The skin later healed over the bowel with resumption of bowel function. Resection or colostomy was not required. Two patients were managed by this method in the early years of this series. Currently, resection without anastomosis is the preferred procedure in this situation. The inconvenience of colostomy care is added, but the possibility of recurrent diverticulitis in the retained subcutaneous sigmoid is avoided. Comments

Management of these cases confirms the complexity of this subtle but potentially fatal disease. The proper procedure for each individual case can be controversial. However, definition of the pathologic factors eliminates this controversy and indicates the operation that subjects the patient to the

Volume 130, August 1975

TABLE

III

Complications Procedures

of Three-Stage

(38 cases)

Complication Wound infection, superficial Urinary retention Pneumonitis Pulmonary insufficiency Congestive heart failure Thrombophlebitis Hernia, incisional Hernia, paracolostomy Intra-abdominal abscess, multiple Aspiration pneumonia Anastomotic leak Delirium tremens lleus Acute gastric dilatation Colovaginal fistula Stoma1 dysfunction, temporary Stoma1 dysfunction, after closure of colostomy, requiring revision Adrenal insufficiency

Number

Per Cent

4 11 6 3 2 1 3 1 1

10.5 29.0 15.7 8.1 5.2 2.9 8.1 2.9 2.9

1 1 1 4 2 1 1

2.9 2.9 2.9 10.5 5.2 2.9 2.9

1

2.9

2 _ -.

5.2

least risk, minimizes the morbidity, and reduces the number of stages required, the length of hospital stay, and hopefully, the mortality. Interval primary resection and anastomosis in one stage for chronic recurrent disease can be performed with minimal morbidity and mortality. Patients with associated colovesical fistula, mesenteric abscess, and subacute disease that subsides on initial medical treatment can also be included. In 1957, Waugh and Walt [15] reported a series of ninety-three primary elective resections, including eighteen patients with fistula, with only one death unrelated to the surgical procedure. Schlicke and Logan [16] reported that primary resection was successful in thirty-five cases when performed during a quiescent phase of the disease, even in the presence of a mass, provided the patient was in good condition and well prepared. They stressed the absence of proximal distention, an empty and well prepared bowel, and avoidance of tension on the anastomosis. Management of perforated diverticulitis by the three-stage procedure was successful but associated with a high complication rate, prolonged and repeated hospitalization, and added procedures. Many authors [2-11,14,17-233 have stressed the danger of continued peritoneal contamination from colonic contents in the defunctionalized loop of colon as one reason for the prolonged disability. Because of this, many authors have urged use of

221

Rugtiv

the two-stage procedure, consisting of sigmoid resection without anastomosis by the Hartmanri procedure or Mikulicz resection. The second stage of anastomosis is carried out in six to eight weeks. Resection of the diseased segment without anastomosis combines the advantage and safety of both the primary and three-stage procedures. Excision of the involved segment does not seem to promote extension of infection to the retroperitoneal tissues. The duration of hospitalization and morbidity are markedly reduced. Rodkey and Welch [14] repoi%ed a significant reduction in hospital stay after the two-stage procedure. Boyden [I] recommended the two-stage procedure for complicated diverticulitis in 1950 and re-emphasized the effectiveness of this procedure in 1960 [Z]. Many of the patients in this series who had three-stage procedures would have been spared the exceedingly high morbidity if the two-stage procedure of resection without anastomosis had been adopted earlier. Many other authors [I 7-221 advocate primary resection and anastomosis for perforated diverticulitis with abscess or spreading peritonitis. This bold approach, if successful, does decrease morbidity. However, as stated by Colcock [12], the decreased morbidity is of little value if the patient dies from a complication of the one-stage resection. Schrock, Deveny, and Dunphy [24], in their review of all colonic anastomoses at the University of California, concluded that emergency resection of lesions of the left colon remains unfavorable for healing of a primary anastomosis, and any colonic anastomosis in the presence of infection is extremely hazardous. Anastomotic complications remain the major cause of mortality and serious morbidity after operations for diverticulitis. This pertains to anastomosis in primary resection as well as to anastomosis in staged resections and includes systemic and local factors. These complications can be prevented only by application of sound surgical principles and judgment based on experimental and clinical experience [24-291. For anastomosis, each end of the bowel must be pliable and free of induration and inflammation, adequate circulation must be identified, and there must be no tension on the anastomosis. In this disease, particularly in a patient requiring low anastomosis with excessive bleeding and anticipated fluid accumulation, suction catheters should be placed to allow surrounding tissue to fall in around the site of anastomosis. Recent experimental studies by Hunt, Hawley, Dunphy, Irvin, and their co-workers [24,26-301 on

222

the healing of colonic anastomosis have shown many of the factors unfavorable to primary anastomosis. These include inflammation, infection, distant trauma, shock, tension, and local hematoma, which appear to operate by enhancing collagenase activity. Any physiologic situation that increases the lysis of collagen or delays the onset of collagen synthesis is likely to lead to a weak suture line and can be expected to produce anastomotic complications. Conditions that increase collagen lysis include starvation, steroids, infection, and inflammation. Collagen synthesis is affected by starvation, specific nutritional deficiencies such as deficiency of ascorbic acid, steroids, infection, inflammation, trauma, hypoxia, hypovolemia, and pharmacologic agents. Summary The surgical treatment of complications of diverticulitis remains most challenging. A review of twenty years’ experience with one hundred fifteen cases is presented with one proved anastomotic leak and no deaths. Interval primary resection with anastomosis for chronic recurrent disease including colovesical fistula and mesocolic abscess was proved safe with low morbidity. The three-stage procedure for perforated diverticulitis with spreading peritonitis or pericolic abscess was associated with a high rate of complications and morbidity. An aggressive approach with resection without anastomosis in two stages is indicated. References AM: The surgicaltreatmentof diverticulitis of the colon.Ann Surg 132: 94, 1950.

1. Boyden

2. Boyden AM, Neilson RO: Reappraisal of the surgical treat-

ment of diverticulitis of the sigmoid colon. Am J Surg 100:

206, 1960.

3. Cantor JW, Shorb PE Jr: Acute perforation of colonic diverticula associated with prolonged adrenocorticosteroid therapy. Am JSurg 121: 46, 1971. 4. Linder JM, Hoffman S: Exteriorization in the surgical management of acute free perforation in diverticulitis of the sigmoid colon. Surg Gynecd Obstet 114: 755, 1962. 5. Smiley DF: Perforated sigmoid diverticulitis with spreading peritonitis. Am J Surg 111: 431, 1966. 6. Watkins GL. Oliver GA: Management of perforated sigmoid diverticulitis with diffusing peritonitis. Arch Surg 92: 926, 1966. 7. Herrington JL Jr, Graves HA Jr: Emergency and non-planned removal of the left colon. Surg Gynecol Obsfet 126: 1045, 1966. 8. Dardik H. Delaney HM, Hurivilt ES: Recurrent diverticulitis in a defunctionalized colonic loop. Am J Surg 108: 914, 1984. 9. Byrne JJ. Garick El: Surgical treatment of diverticulitis. Am J Surg 121: 379, 1971. 10. Localio SA, Stahl WM: Divedicular disease of the alimentary

The American Journal of Surgery

Diverticulitis

11. 12. 13. 14.

15.

16. 17.

16. 19.

20. 21.

22. 23. 24.

25.

26. 27. 26. 29.

30.

tract. 1. The colon. Curr Probl Surg Chicago, Year Book Medical, December 1967, p 29. Miller DW Jr, Wichern WA Jr: Perforated sigmoid diverticulitis. Am JSurg 121: 536, 1971. Colcock BP: Surgical treatment of diverticulitis: 20 years experience. Am J Surg 115: 264, 1968. Colcock BP: Recent experience in the surgical treatment of diverticulitis. Surg Gynecol Obstet 121: 63, 1965. Rodkey GV, Welch CE: Surgical management of colonic diverticulitis with free perforation or abscess formation. Am J Surg 117: 265, 1969. Waugh j, Walt AG: An appraisal of one stage anterior resection in diverticulitis of the sigmoid colon. Surg Gynecol Obstet 104: 690. 1957. Schlicke CP, Logan AH: Surgical treatment of diverticulitis of the colon. JAMA 169: 1019. 1959. Madden JL, Tan PY: Primary resection and anastomosis in the treatment of perforated lesions of the colon with abscess or diffusing peritonitis. Surg Gynecol Obstet 113: 646, 1961. Staunton MD: Treatment of perforated diverticulitis coli. Br MedJ 1: 916, 1962. Belding HH Ill: Acute perforated diverticulitis of the sigmoid colon with generalized peritonitis. Arch Surg 74: 511, 1957. Large JM: Treatment of perforated diverticulitis. Lancet 1: 413, 1964. Madden JL: Primary resection and anastomosis in the treatment of perforated lesions of the colon. Am Surg 31: 781, 1965. Ryan P: Emergency resection and anastomosis for perforated sigmoid diverticulitis. Br J Surg 45: 611, 1958. Smithwick RH: Surgical treatment of diverticulitis of the sigmoid. Am J Surg 99: 192, 1960. Schrock TR, Deveny CW. Dunphy JE: Factors contributing to leakage of colonic anastomosis. Ann Surg 177: 513, 1973. Garnjobst W, Hardwick C: Further criteria for anastomosis in diverticulitis of the sigmoid colon. Am J Surg 120: 264, 1970. Hunt TK, Hawley PR: Surgical judgment and colonic anastomosis. Dis Colon Rectum 12: 167, 1967. Hunt TK, Hawley PR, Dunphy JE: Aetiology of colonic anastomotic leaks. Proc R Sot A&d 63: 28, 1970. Dunphy JE: The cut gut. Am J Surg 119: 1, 1970. Hawlev PR. Hunt TK. Dunohv JE: Infection: the. cause of anastomotic breakdown,’ ai experimental study. Proc R Sot Med63: 752, 1970. Irvin TT, Hunt TK: Reappraisal of the healing process of anastomosis of the colon. Surg Gynecol Obsfet 138: 741. 1974.

Discussion Harry E. Peters, Jr (Oakland, CA): It is generally accepted that the one-stage operation without a concomitant proximal vent is the procedure of choice whenever feasible. Such is possible in a majority of patients undergoing elective operation for diverticulitis, including patients with persistent symptoms from diverticular disease despite medical treatment and patients with failure of medical treatment as assessed by the persistence of a mass and/or significant changes demonstrated by barium enema. One-stage resection is also possible in many patients with localized small pericolic abscess and in a majority of those with vesicocolic fistula. It has been my policy to assume an aggressive approach in patients fifty years of age or youngek, carrying out resection before hazardous complications develop. I agree that one-

Volume 130, August 1975

stage resection with anastomosis in the presence of a large abscess or significant inflammatory reaction exposes the patient to a preventable risk that may result in disaster. Doctor Rugtiv advocates resection and double colostomy, or a Hartmann procedure, in those patients with serious complications of diverticulitis when one-stage resection with anastomosis is undesirable. I heartily endorse this, since it can be performed with acceptable mortality, removes the source of infection, and substitutes a two-stage operation for the previously recommended three-stage procedure. Although there was no mortality in Doctor Rugtiv’s series, his statistics for the three-stage operation support the findings reported in the surgical literature indicating prolonged hospitalization and relatively high morbidity. The three-stage procedure should have very limited use, except perhaps in poor-risk patients with complicated fistula, a large abscess plus obstruction, or extensive peritonitis. Doctor Rugtiv no longer uses concomitant cecostomy because it fails to protect an anastomosis, and this may or may not be true. I do believe when the surgeon is dissatisfied with the anastomosis after a difficult low anterior resection, concomitant transverse colostomy can be life-saving. It has not been my practice to use drains or sump catheters after low anterior resection, but I do not close the peritoneal floor. It is my impression that drainage near an anastomatic site might actually contribute to leakage and fistula formation. I have had little experience with Doctor Rugtiv’s transverse precolostomy or with exteriorization of a perforated segment of sigmoid from diverticulitis; however, under certain restricted circumstances, each might have application. It is well that any discussion of the Reilly myotomy in the treatment of diverticular disease of the colon has been avoided, for I believe this procedure shduld remain within the &fines of the British Empire. I have one question. Does Doctor Rugtiv find colonoscopy a useful adjunct in determining whether elective surgical intervention is indicated? Alex Gerber (Alhambra, CA): I commend Doctor Rugtiv on this almost miraculous series of one hundred fifteen consecutive, surgically treated cases of diverticulitis without a mortality and only one anastomotic leak. I would like to make a plea for an aggressive approach to this disease. Many of these patients are managed medically through episode after episode of diverticulitis, and surgical consultation is sought only after serious complications supervene. I prefer to resect areas of colonic diverticulitis in the subsiding phase of the first episode of the disease. Operation is relatively simple at this stage and prevents fistula formation and the cement-like pelvis that may be encountered after repeated episodes. With this regimen, I have not found it necessary to complement resection with proximal colostomy or cecostomy. In all patients, operation is preceded by sigmoidoscopy and a Hypaque@ enema.

223

Rugtiv

Doctor Rugtiv showed one slide of the situation after resection of the sigmoid colon and anastomosis of the descending colon to the upper rectum. I assume this slide was diagrammatic because the splenic flexure was still under the diaphragm. I do not believe anastomosis can be performed safely after resection of an appreciable portion of the sigmoid or left colon without mobilization of the distal transverse colon and splenic flexure downward so that the ends of the colon can be sutured together without tension. Tension on the suture line is the cause of the great majority of anastomotic leaks, and I do not believe an anastomosis should ever be carried out until the colon has been sufficiently mobilized so that the ends lie in apposition to one another without the aid of clamps or gut sutures. Richard E. Robins (Vancouver, BC): I would like to comment further about patients under the age of fifty years. With Doctor J. Baker, the son of one of the Past Presidents of this Association, I studied diverticulitis in patients younger than fifty during a five year period at the Vancouver General Hospital. Although this group of forty-two patients who were younger than fifty years comprised only 10 per cent of those hospitalized for diverticulitis, 25 per cent of the operations required were carried out in this group. Twenty-two patients had elective resection; all of these had a one-stage procedure with primary anastomosis and we were fortunate in having no anastomotic leak. We found that even these patients can have serious complications of diverticulitis. Two patients, both in their early thirties, had colovesical fistula, and one forty-three year old man whose primary problem was diverticulitis was found at operation to have associated carcinoma of the sigmoid. Most interesting were the twenty patients who required emergency operation. The majority had no previous symptoms prior to catastrophe, and many indeed had catastrophe. Of the twenty, four had free perforation with generalized peritonitis, which is a very high rate of free perforation in diverticulitis. Six had large abscesses, not a mesenteric abscess but perforation with a pelvic or iliac fossa abscess. Ten required operation because of obstruction. Very few of this latter group could undergo a singlestage procedure, and like Doctor Rutgiv, we have preferred the Hartmann procedure for complicated problems, when it is technically possible. Subsequent reconstruction can be difficult; however, end to side anastomosis may be helpful. Leon Morgenstern (Los Angeles, CA): Our experience with complicated diverticulitis has been much less successful than that reported by both the author and some of the discussants-perhaps our patients have more severe disease or are less hardy. Our rate of leakage at the anastomotic line after resection for diverticulitis has been reported previously and is inordinately

224

high, particularly in patients who are obese, diabetic, steroid-dependent, or very aged. We have also noted a very significant increase in collagenase at the resected margins of diverticulitis specimens, and we have attributed the high leakage rate partially to this factor. Even pliable margins, as we have previously reported, show significant inflammatory reaction at the line of resection, particularly distally. Finally, we have encountered a small group of patients with what we have labeled “malignant diverticulitis” (in the sense of malignant hypertension, malignant exophthalmos, malignant hyperpyrexia, and so forth), characterized by extensive intramural inflammation, often below the peritoneal reflection, a high incidence of fistulization, and high morbidity and mortality after resection without preliminary colostomy. I think the simpler treatment outlined by Doctor Rugtiv would be impossible in this group. We certainly have not experienced the dire complication rate of the three-stage procedure, and I believe it is still quite useful in selected cases of diverticular disease. George R. Mason (Baltimore, MD): My primary comments have to do with the Hartmann procedure, which Doctor Rugtiv has described as safe and effective. In our experience, it has not actually been all that safe and effective. We have observed a number of complications, including breakdown of the cuff with ensuing hematoma or pelvic abscess formation and, in some cases, fistula formation from the rectal stump into either the vagina or the bladder. A final difficulty involves colostomy closure. The long rectal stump may be in a mass around the bladder and vaginal cuff or uterus, which may cause difficulty in freeing the stump and constructing the anastomosis. As a matter of fact, on one occasion the interior of the bladder was mistaken for the lumen of the colon. As a result, we currently recommend to our staff and resident group that when the rectal stump is of sufficient length, it be sutured to the peritoneum laterally and somewhat anterior to avoid the vasculature if possible. In other words, the distal stump should be straightened out so that it can be recognized at reoperation. One other postoperative maneuver is manual anal dilatation as sometimes the fecal mass within the rectum does promote disruption of the cuff. A third technical adjunct would be placement of a rectal tube from the anus at the second operation to facilitate recognition of the rectal stump. Allen M. Boyden (Portland, OR): The absence of mortality in this remarkable series of cases attests not only to Doctor Rugtiv’s surgical ability but particularly to his good judgment. The use of the twoistage rather than the three-stage operation in many patients undoubtedly helped avoid many serious complications. In 1960, we presented to this Association our reappraisal of treatment of complicated diverticulitis at the Portland Clinic over the eleven year period since our earlier re-

The American Journal of Surgery

Diverticulitis

port in 1949. We emphasized the advantages of twostage operation, that is, the Hartmann, modified Mikulicz, or Rankin operation, and outlined the indications for such procedures in our cases. Actually, the percentage of two-stage procedures had tripled and that of the three-stage operations had decreased by two-thirds. Three years ago at the New England Surgical Association meeting, a report from the Boston City Hospital showed the mortality after three-stage operation for perforated diverticulitis was over 30 per cent. The authors and the discussants suggested that it might be reasonable to use the two-stage operation in an effort to reduce this figure. I hope this trial has been made. There are very few reasons for colostomy as a first stage. Obstruction of the colon is an obvious one. When large abscesses are present, drainage and diverting colostomy may be wise. Almost all fistulas can be treated definitively without preliminary colostomy. Doctor Rugtiv’s report has shown again the advantages of individualizing operative treatment in these complicated cases. Carleton Mathewson, Jr (San Francisco, CA): A number of years ago Doctor W. W. Greene, a member of this Association, and I reviewed thirty years’ experience with this disease at the San Francisco County Hospital. We found that often the medically treated patients had been hospitalized as long as 200 days before undergoing operation. Since we saw most of these patients late in the course of disease, we used three-stage operations, and our morbidity and mortality, as elsewhere, were very high. I agree that the three-stage operation is rather outmoded currently; however, when preliminary colostomy is required, it should never be constructed in the transverse colon. It should be located as close to the perforation as possible to avoid formation of a large sump between the colostomy and the perforation. I also agree that many of anastomotic leaks occur because anastomosis is attempted without proper mobili-

Volume 130, August 1075

zation of the bowel. The splenic flexure should be mobilized to avoid tension at the site of anastomosis. If the pelvic anastomosis is below the pelvic floor, presacral drainage from below is wise. Drainage should be dependent, not from above. Doctor Arthur Cohen, one of our members, reported to this Association the wisdom of irrigation of the distal bowel in the management of perforations of the rectum. To prevent complications after a Hartmann procedure, the distal stump should be irrigated before it is closed. George M. Rugtiv (closing): I am gratified by the informative and generous comments of all the discussants. Doctor Peters’ kind remarks are appreciated because of his surgical judgment and wealth of clinical experience. Doctor Robins’ observation of the aggressive nature of the disease in young patients is pertinent. These patients present without antecedent symptoms and usually require definitive surgery. I respect the critical and objective review of the morbidity and mortality in Doctor Morgenstern’s series, as discussed today and as published. I agree that some patients have a more severe form of the disease, and this frequently is not appreciated until the abdomen is opened. Doctor Mathewson’s suggestion of perineal drainage in low pelvic anastomoses is surgically sound. In this disease it is seldom necessary to place the anastomosis below the peritoneal reflection, and the method of anterior drainage I have described has proved successful. We are all aware of Doctor Boyden’s contribution to the management of diverticulitis. As he proposed resection without anastomosis in a paper published in 1950, I should have used this procedure earlier in my practice. Addressing Doctor Mason’s question about the difficulty of identifying the distal segment in the second stage of the Hartmann procedure, I would suggest suturing the segment to the peritoneum over the promontory of the sacrum. I have considered wrapping Silastic@ around the sutured end.

225

Diverticulitis: selective surgical management.

The surgical treatment of complications of diverticulitis remains most challenging. A review of twenty years' experience with one hundred fifteen case...
881KB Sizes 0 Downloads 0 Views