We would go for a CT-scan in the first 24h if diverticulitis (clinically diagnosed!) is not settling well (i.e I do not mean the patient is getting septic or instable etc) under antibiotic treatment. This will guide through further decision making and need for intervention. If there is localized abscess, CT-guided percutaneous drainage is usually adequate and settles with further AB-treatment. If you have a very experienced technician you could of course also go for the same procedure under ultrasound guidance. Before elective surgery after an interval of weeks we would request colonoscopy. For early-elective surgery (after 7-10 days treatment for complicated disease) we perform a water-soluble (Gastrografin) contrast enema to show extent of diverticulae, if unsure about rest of colon: intraoperative colonoscopy. Barium enema has no place in our diagnostic decision making, and would certainly not be recommended early during an episode of inflammation for obvious reasons if you might have to operate.
1. Frank perforation, generalized peritonitis etc etc, I think nobody would treat conservatively, all agree? We would always try to go for resection and anastomosis, intraoperative colonic lavage if necessary . If the surgeon is "unhappy" with the anastomosis and/or cannot perform re-anastomosis during the same procedure: covering double-loop ileostomy as adjunct is performed (closure after anastomosis is checked by water-soluble contrast enema or rectoscopy after 6-8 weeks) This is our policy, after our current chief of department was elected. We have compared our prospective results (with a "historic" earlier group): Anastomotic insufficiency rate 2.5% (vs. 7.1%), mortality 2.7% (vs. 9.5%), general complications 25% (vs. 35%), Hartmann's resection 3% (vs. 16%), ileostomies ~6% (vs. 24%). Published locally in German and updated as poster at our annual meeting of the Swiss Surgical Society.
2. If the patient is 45-50y or younger we would suggest elective therapy after the first major episode of inflammation in a quiescent phase (see literature below) or early, after 7-10 days AB treatment, if diverticulitis was complicated (i.e.drained abscess) and has subsided.
3. If the patient is older and has had several bouts or was admitted for complicated diverticulitis we would suggest resection if general condition permits.
Hartmann's procedure (resection, end colostomy, closed rectum stump) in our hands is reserved for the totally unstable patient (septic, old, bleeding) where you want to get in and out quickly. As stated above this was only necessary in 3% of cases.
Is there anybody still doing routine Hartmann's procedures for perforated diverticulitis/peritonitis? (or even three-staged procedures?)
If and when you do a Hartmann operation, what reasons do you have?