Sabiston Diverticulitis Flashcards
(19 cards)
Diverticula
Diverticula are classically formed on the mesenteric side of the colonic wall in regions where vasa recta traverse through the muscular layer to provide blood to the mucosa
The sigmoid and descending colon are typically affected, whereas the rectum, having an extra layer of muscle, is generally not affected.
This has implications for surgery and is why the distal anastomosis margin in operations for diverticulitis should always be within the rectum.
risk of diverticulitis
Western dietary patterns high in red meat, fat, and refined grains are associated with an increased risk of the disease
whereas increased fiber intake, with abundant fruit, vegetables, and whole grains, reduces the risk of diverticulitis.
Central obesity and smoking increase the risk
whereas physical activity such as running has been correlated with a decreased risk
Modified Hinchey classification system
see
In Abscess
Following recovery, elective surgery is generally recommended; however, some of these patients, especially those with smaller abscesses that were treated without drainage, can probably be managed nonoperatively
Fistula
The most common type, especially in men, is a colovesical fistula to the dome of the bladder.
Patients will present with recurrent urinary tract infections, which are in many cases polymicrobial.
Pneumaturia and fecaluria may also be present.
CT can reveal air or contrast in the bladder in the absence of prior instrumentation.
Cystoscopy will usually disclose inflammation at the site of the fistula
Colovaginal fistulas , Colocutaneous fistulas
Colovaginal fistulas occur almost exclusively in women who have undergone previous hysterectomy and present with vaginal discharge and passing of air per vagina.
Colocutaneous fistulas usually present at a previous drain site in patients who have undergone percutaneous drainage
Tx for Fistula
Initial management includes broad spectrum antibiotics to decrease the inflammation.
Patients are then investigated with colonoscopy and appropriate imaging (i.e., cystoscopy) to exclude malignancy and Crohn disease.
Surgical principles then encompass resection of the involved colon and fistula tract with primary anastomosis.
If possible, the fistula opening into the secondarily involved organ is primarily suture repaired
Fistula to Bladder, Small Bowel Tx
In the case of the bladder, with small fistula openings, drainage of the bladder with a Foley catheter for 7 to 10 days will usually allow for healing. A cystogram can be done to confirm fistula healing prior to Foley removal.
Fistulas to the small bowel will characteristically require resection and primary anastomosis.
Obstruction
Patients with a partial obstruction can usually be initially treated with a nasogastric tube for decompression, antibiotics, fluids, and bowel rest.
If the obstruction resolves, elective resection can be planned.
It is usually important, prior to resection, to perform a colonoscopy to rule out malignancy.
Surgical Emergency
Hinchey grades 3 and 4 are considered a surgical emergency
Perforation Tx
The mainstay of treatment in these cases has traditionally been the Hartmann procedure, which removes the involved colon and exteriorizes an end colostomy.
Reversing the colostomy, however, requires a second major surgical procedure with its own significant morbidity and mortality. Practically, up to 50% of patients will never be reversed
Another Options
laparoscopic lavage
> irrigation of the abdominal cavity to reduce the abdominal contamination and placement of drains without resection (mainly for Hinchey grade 3 diverticulitis).
> results in lower stoma rates
significantly higher rates of ongoing and recurrent sepsis and emergency reoperations.
Another option is performing a resection with a primary anastomosis and diverting ileostomy
> found to be safe and significantly simplifies and shortens the second operation.
Overall morbidity and mortality are similar
much higher proportion of patients will have their stomas reversed (94%–96% for primary anastomosis vs. 65%–72% for Hartmann).
attractive option for patients who are stable enough to withstand the additional time of the initial surgery.
Uncomplicated Diverticulitis Tx
clear liquids
followed by a low-residue diet until the inflammation subsides.
Antibiotics have traditionally been prescribed to cover colonic bacteria.
A systematic review and metaanalysis assessing the effect of antibiotic administration in patients with uncomplicated diverticulitis has not shown the usage of antibiotics to accelerate recovery or prevent complications or subsequent surgery.
After recovery
it is recommended that patients undergo a colonoscopy after 4 to 8 weeks to exclude malignancy.
recurrence
Following the initial episode of acute, uncomplicated diverticulitis, only 10% to 35% of individuals will have another episode.
Now A days they Recommend
recurrences in general tend to follow the severity of the initial episode.
As a result, the number of attacks of uncomplicated diverticulitis has fallen out of favor as an indication for surgery.
Currently, an individual assessment is performed on the frequency of attacks, ongoing symptoms, and their effect on quality of life versus the age and medical condition of the patient and their surgical risk
Margins ?
When removing the sigmoid colon, the proximal margin should be in soft pliable bowel, but it is not necessary to include all proximal diverticula.
The distal anastomosis, however, should be to the upper rectum, since leaving a section of distal sigmoid colon is associated with a higher risk of recurrent diverticulitis.
Immunocompromised Patients
they are more likely to present with free perforation and complicated disease because of their impaired ability to mount an inflammatory response.
Because of this risk, there should be a lower threshold for resection after a single attack of diverticulitis.
Immunocompromised patients who require emergency surgery and resection should probably not undergo primary anastomosis at the initial surgery because of their impaired immune system and healing.
Young Patients
Current guidelines do not support treating young patients differently than others.
