I have had a couple of cases of acute diverticulitis over the past several weeks and am interested in how everyone approaches this subject:
First, a reasonably healthy 65 year old presents with LLQ pain, fever and mass exam. Abdominal CT show an abscess next to the sigmoid colon, presumable diverticular in origin. This is percutaneously drained by the radiologist and then surgeons are consulted. After drainage, the patient feels well and his white count normalizes. When should sigmoid resection be performed?
- 1) prep bowel and operate during index admission,
- 2) wait about 6 weeks,
- 3) not operate.
Second, when operating for acute, complicated diverticulitis, who does what operation? To keep things standard, I understand the Hinchey classification as follows:
- Stage I = pericolic phlegmon or abscess;
- Stage II = contained pelvic, abdominal, retroperitoneal abscess;
- Stage III = purulent peritonitis;
- Stage IV = fecal peritonitis.
Surgical options include resection with anastomosis, resection with anastomosis and protecting/diverting ostomy, resection with colostomy (Hartmann), drainage with delayed resection and anastomosis. Of course, the laparoscopic approach could be used for any of these. Who would do on-table colonic lavage?
Another case. 86 year old lady who is confined to a nursing home. She has Alzheimer’s dementia, though she recognizes family and can feed herself. Remote history of coronary disease, but no other medical co-morbidities. Well nourished. Presents with abdominal pain, distension, vomiting that the nursing home staff thought was small bowel obstruction. Seen by the internists in the ER who agree and place her in the hospital with NG suction and antibiotics. The following morning, the radiologist calls to report free air on the abdominal X-rays from the prior night (had been missed by the ER staff and the internist, despite being easily seen by a third year medical student to whom I showed the films). Surgical consult is then obtained. At this point the patient is hemodynamically normal, febrile (38.5), WBC elevated to 13.5 with left shift, and abdomen is obviously surgical. The family desires that surgery be performed but refuse to give permission for a colostomy. At surgery, perforated sigmoid diverticulitis is present with diffuse purulent peritonitis, but no fecal soilage. Stool in the proximal bowel is soft. Where should we go from here?