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Clin Colon Rectal Surg 2021; 34(02): 096-103
DOI: 10.1055/s-0040-1716701
Review Article

Complicated Diverticular Disease

Kathleen M. Coakley
1   Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
,
Bradley R. Davis
1   Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
,
Kevin R. Kasten
1   Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
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Abstract

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

Keywords

diverticulitis - complicated - fistula - colovesical fistula - abscess


Publication History

Article published online:
21 October 2020

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  • References

  • 1 Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?. Ann Surg 2006; 243 (06) 876-830 , discussion 880–883
    CrossrefPubMedGoogle Scholar
  • 2 Zaidi E, Daly B. CT and clinical features of acute diverticulitis in an urban U.S. population: rising frequency in young, obese adults. AJR Am J Roentgenol 2006; 187 (03) 689-694
    CrossrefPubMedGoogle Scholar
  • 3 Hall JF, Roberts PL, Ricciardi R. et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence?. Dis Colon Rectum 2011; 54 (03) 283-288
    CrossrefPubMedGoogle Scholar
  • 4 Collins D, Winter DC. Laparoscopy in diverticular disease: controversies. Best Pract Res Clin Gastroenterol 2014; 28 (01) 175-182
    CrossrefPubMedGoogle Scholar
  • 5 Feingold D, Steele SR, Lee S. et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57 (03) 284-294
    CrossrefPubMedGoogle Scholar
  • 6 Bharucha AE, Parthasarathy G, Ditah I. et al. Temporal trends in the incidence and natural history of diverticulitis: a population-based study. Am J Gastroenterol 2015; 110 (11) 1589-1596
    CrossrefPubMedGoogle Scholar
  • 7 Hjern F, Wolk A, Håkansson N. Smoking and the risk of diverticular disease in women. Br J Surg 2011; 98 (07) 997-1002
    CrossrefPubMedGoogle Scholar
  • 8 Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011; 140 (05) 1427-1433
    CrossrefPubMedGoogle Scholar
  • 9 Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR. Do calcium channel blockers and antimuscarinics protect against perforated colonic diverticular disease? A case control study. Gut 2003; 52 (12) 1734-1737
    CrossrefPubMedGoogle Scholar
  • 10 Humes DJ, Fleming KM, Spiller RC, West J. Concurrent drug use and the risk of perforated colonic diverticular disease: a population-based case-control study. Gut 2011; 60 (02) 219-224
    CrossrefPubMedGoogle Scholar
  • 11 Sher ME, Agachan F, Bortul M, Nogueras JJ, Weiss EG, Wexner SD. Laparoscopic surgery for diverticulitis. Surg Endosc 1997; 11 (03) 264-267
    CrossrefPubMedGoogle Scholar
  • 12 Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12: 85-109
    PubMedGoogle Scholar
  • 13 Lué A, Laredo V, Lanas A. Medical treatment of diverticular disease: antibiotics. J Clin Gastroenterol 2016; 50 (Suppl. 01) S57-S59
    CrossrefPubMedGoogle Scholar
  • 14 Rafferty J, Shellito P, Hyman NH, Buie WD. Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49 (07) 939-944
    CrossrefPubMedGoogle Scholar
  • 15 Salem L, Flum DR. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47 (11) 1953-1964
    CrossrefPubMedGoogle Scholar
  • 16 Morris CR, Harvey IM, Stebbings WS, Hart AR. Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008; 95 (07) 876-881
    CrossrefPubMedGoogle Scholar
  • 17 Jarrett TW, Vaughan Jr ED. Accuracy of computerized tomography in the diagnosis of colovesical fistula secondary to diverticular disease. J Urol 1995; 153 (01) 44-46
    CrossrefPubMedGoogle Scholar
  • 18 Kavanagh D, Neary P, Dodd JD, Sheahan KM, O'Donoghue D, Hyland JM. Diagnosis and treatment of enterovesical fistulae. Colorectal Dis 2005; 7 (03) 286-291
    CrossrefPubMedGoogle Scholar
  • 19 Mizuki A, Nagata H, Tatemichi M. et al. The out-patient management of patients with acute mild-to-moderate colonic diverticulitis. Aliment Pharmacol Ther 2005; 21 (07) 889-897
    CrossrefPubMedGoogle Scholar
  • 20 Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005; 48 (04) 787-791
    CrossrefPubMedGoogle Scholar
  • 21 Brook I, Frazier EH. Aerobic and anaerobic microbiology in intra-abdominal infections associated with diverticulitis. J Med Microbiol 2000; 49 (09) 827-830
    CrossrefPubMedGoogle Scholar
  • 22 Spiller RC. Changing views on diverticular disease: impact of aging, obesity, diet, and microbiota. Neurogastroenterol Motil 2015; 27 (03) 305-312
    CrossrefPubMedGoogle Scholar
  • 23 Kaiser AM, Jiang JK, Lake JP. et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005; 100 (04) 910-917
    CrossrefPubMedGoogle Scholar
  • 24 Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 2016; 35: 201-208
    CrossrefPubMedGoogle Scholar
  • 25 Pollard SG. Colovesical fistula. Ann R Coll Surg Engl 1988; 70 (03) 184
    PubMedGoogle Scholar
  • 26 Golabek T, Szymanska A, Szopinski T. et al. Enterovesical fistulae: aetiology, imaging, and management. Gastroenterol Res Pract 2013; 2013: 617967
    CrossrefPubMedGoogle Scholar
  • 27 Miller RE. Role of hysterectomy in predisposing the patient to sigmoidovesical fistula complicating diverticulitis. Am J Surg 1984; 147 (05) 660-661
    CrossrefPubMedGoogle Scholar
  • 28 Lahat A, Yanai H, Menachem Y, Avidan B, Bar-Meir S. The feasibility and risk of early colonoscopy in acute diverticulitis: a prospective controlled study. Endoscopy 2007; 39 (06) 521-524
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Sentovich SM, Fakih M. Colorectal cancer: postoperative adjuvant therapy. In: Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow C. eds. The ASCRS Manual of Colon and Rectal Surgery. 3rd ed.. Vol. 2. New York; London: Springer; 2014: 443-448
    Google Scholar
  • 30 Lavery IC. Colonic fistulas. Surg Clin North Am 1996; 76 (05) 1183-1190
    CrossrefPubMedGoogle Scholar
  • 31 Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM. Medically treated diverticular abscess associated with high risk of recurrence and disease complications. Dis Colon Rectum 2016; 59 (03) 208-215
    CrossrefPubMedGoogle Scholar
  • 32 Angenete E, Thornell A, Burcharth J. et al. Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg 2016; 263 (01) 117-122
    CrossrefPubMedGoogle Scholar
  • 33 Schultz JK, Yaqub S, Wallon C. et al. SCANDIV Study Group. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA 2015; 314 (13) 1364-1375
    CrossrefPubMedGoogle Scholar
  • 34 Ceresoli M, Coccolini F, Montori G, Catena F, Sartelli M, Ansaloni L. Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials. World J Emerg Surg 2016; 11 (01) 42
    CrossrefPubMedGoogle Scholar
  • 35 Franklin Jr. ME, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 2008; 32 (07) 1507-1511
    CrossrefPubMedGoogle Scholar
  • 36 Occhionorelli S, Zese M, Tartarini D. et al. An approach to complicated diverticular disease. a retrospective study in an acute care surgery service recently established. Ann Ital Chir 2016; 87: 553-563
    PubMedGoogle Scholar
  • 37 Parisi A, Gemini A, Desiderio J. et al. Laparoscopic peritoneal lavage: our experience and review of the literature. Wideochir Inne Tech Malo Inwazyjne 2016; 11 (02) 83-87
    PubMedGoogle Scholar
  • 38 Roig JV, Salvador A, Frasson M. et al; en representación del Grupo Cooperativo de la Sociedad Valenciana de Cirugía. [Surgical treatment of acute diverticulitis. A retrospective multicentre study] (in Spanish). Cir Esp 2016; 94 (10) 569-577
    CrossrefPubMedGoogle Scholar
  • 39 Myers E, Hurley M, O'Sullivan GC, Kavanagh D, Wilson I, Winter DC. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95 (01) 97-101
    CrossrefPubMedGoogle Scholar
  • 40 Penna M, Markar SR, Mackenzie H, Hompes R, Cunningham C. Laparoscopic lavage versus primary resection for acute perforated diverticulitis: review and meta-analysis. Ann Surg 2018; 267 (02) 252-258
    CrossrefPubMedGoogle Scholar
  • 41 Oberkofler CE, Rickenbacher A, Raptis DA. et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256 (05) 819-826 , discussion 826–827
    CrossrefPubMedGoogle Scholar
  • 42 Binda GA, Karas JR, Serventi A. et al; Study Group on Diverticulitis. Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis 2012; 14 (11) 1403-1410
    CrossrefPubMedGoogle Scholar
  • 43 Turley RS, Barbas AS, Lidsky ME, Mantyh CR, Migaly J, Scarborough JE. Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis. Dis Colon Rectum 2013; 56 (01) 72-82
    CrossrefPubMedGoogle Scholar
  • 44 Daher R, Barouki E, Chouillard E. Laparoscopic treatment of complicated colonic diverticular disease: a review. World J Gastrointest Surg 2016; 8 (02) 134-142
    CrossrefPubMedGoogle Scholar
  • 45 Toh JW, Wood SJ, Rickard MJ, Keshava A. Treat the patient or radiology? Free intraperitoneal gas in clinically well patients with perforated diverticulitis. ANZ J Surg 2018; 88 (10) E743-E744
    CrossrefPubMedGoogle Scholar
  • 46 Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985; 28 (02) 71-75
    CrossrefPubMedGoogle Scholar
  • 47 Hjern F, Mahmood MW, Abraham-Nordling M, Wolk A, Håkansson N. Cohort study of corticosteroid use and risk of hospital admission for diverticular disease. Br J Surg 2015; 102 (01) 119-124
    CrossrefPubMedGoogle Scholar
  • 48 Klarenbeek BR, Veenhof AA, Bergamaschi R. et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the SIGMA Trial. Ann Surg 2009; 249 (01) 39-44
    CrossrefPubMedGoogle Scholar
  • 49 Klarenbeek BR, Coupé VM, van der Peet DL, Cuesta MA. The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial. Surg Endosc 2011; 25 (03) 776-783
    CrossrefPubMedGoogle Scholar
  • 50 Gervaz P, Inan I, Perneger T, Schiffer E, Morel P. A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010; 252 (01) 3-8
    CrossrefPubMedGoogle Scholar
  • 51 Gervaz P, Mugnier-Konrad B, Morel P, Huber O, Inan I. Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial. Surg Endosc 2011; 25 (10) 3373-3378
    CrossrefPubMedGoogle Scholar
  • 52 Miyagaki H, Rhee R, Shantha Kumara HM. et al. Surgical treatment of diverticulitis: hand-assisted laparoscopic resection is predominantly used for complex cases and is associated with increased postoperative complications and prolonged hospitalization. Surg Innov 2016; 23 (03) 277-283
    CrossrefPubMedGoogle Scholar
  • 53 Halabi WJ, Jafari MD, Nguyen VQ. et al. Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. Dis Colon Rectum 2014; 57 (02) 179-186
    CrossrefPubMedGoogle Scholar
  • 54 Coakley K, Davis B, Prasad T, Lincourt A, Kasten K. Prophylactic Ureteral Stenting for Colectomy: An Analysis of NSQIP and Premier datasets. American Society of Colon and Rectal Surgeons Annual Scientific Meeting; June 10–14, 2017, 2017 Seattle, WA Dis Colon Rectum 2018; 61 (01) 84-88
    PubMedGoogle Scholar
  • 55 Andersen P, Andersen LM, Iversen LH. Iatrogenic ureteral injury in colorectal cancer surgery: a nationwide study comparing laparoscopic and open approaches. Surg Endosc 2015; 29 (06) 1406-1412
    CrossrefPubMedGoogle Scholar
  • 56 Liguori G, Dobrinja C, Pavan N. et al. Iatrogenic ureteral injury during laparoscopic colectomy: incidence and prevention A current literature review. Ann Ital Chir 2016; 87: 446-455
    PubMedGoogle Scholar
  • 57 Boyan Jr. WP, Lavy D, Dinallo A. et al. Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience. Ann Transl Med 2017; 5 (03) 44
    CrossrefPubMedGoogle Scholar
  • 58 Beraldo S, Neubeck K, Von Friderici E, Steinmüller L. The prophylactic use of a ureteral stent in laparoscopic colorectal surgery. Scand J Surg 2013; 102 (02) 87-89
    CrossrefPubMedGoogle Scholar
  • 59 Pathak RA, Taylor AS, Alford S. et al. Urologic-induced complications of prophylactic ureteral localization stent placement for colorectal surgery cases. J Laparoendosc Adv Surg Tech A 2015; 25 (12) 966-970
    CrossrefPubMedGoogle Scholar
  • 60 Kye BH, Kim HJ, Kim HS, Kim JG, Cho HM. How much colonic redundancy could be obtained by splenic flexure mobilization in laparoscopic anterior or low anterior resection?. Int J Med Sci 2014; 11 (09) 857-862
    CrossrefPubMedGoogle Scholar
  • 61 Carlson RM, Roberts PL, Hall JF. et al. What are 30-day postoperative outcomes following splenic flexure mobilization during anterior resection?. Tech Coloproctol 2014; 18 (03) 257-264
    CrossrefPubMedGoogle Scholar
  • 62 Reddy SH, Gupta V, Yadav TD, Singh G, Sahni D. Lengthening of left colon after rectal resection: what all is adequate? A prospective cohort study. Int J Surg 2016; 31: 27-32
    CrossrefPubMedGoogle Scholar
  • 63 Schlussel AT, Wiseman JT, Kelly JF. et al. Location is everything: The role of splenic flexure mobilization during colon resection for diverticulitis. Int J Surg 2017; 40: 124-129
    CrossrefPubMedGoogle Scholar
  • 64 Bonnet S, Berger A, Hentati N. et al. High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses. Dis Colon Rectum 2012; 55 (05) 515-521
    CrossrefPubMedGoogle Scholar
  • 65 Tsujinaka S, Kawamura YJ, Tan KY. et al. Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery. Scand J Surg 2012; 101 (01) 21-25
    CrossrefPubMedGoogle Scholar
  • 66 Sheridan WG, Lowndes RH, Young HL. Tissue oxygen tension as a predictor of colonic anastomotic healing. Dis Colon Rectum 1987; 30 (11) 867-871
    CrossrefPubMedGoogle Scholar
  • 67 Trencheva K, Morrissey KP, Wells M. et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg 2013; 257 (01) 108-113
    CrossrefPubMedGoogle Scholar
  • 68 Borchert DH, Schachtebeck M, Schoepe J. et al. Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease. Int J Surg 2015; 21: 45-50
    CrossrefPubMedGoogle Scholar
  • 69 Cirocchi R, Trastulli S, Farinella E. et al. Is inferior mesenteric artery ligation during sigmoid colectomy for diverticular disease associated with increased anastomotic leakage? A meta-analysis of randomized and non-randomized clinical trials. Colorectal Dis 2012; 14 (09) e521-e529
    CrossrefPubMedGoogle Scholar
  • 70 Wakahara T, Toyokawa A, Ashitani H, Tsuchida S, Hasegawa Y. Comparison of laparoscopic sigmoidectomy with and without preservation of the superior rectal artery: a single-institution retrospective study. Asian J Endosc Surg 2015; 8 (01) 29-33
    CrossrefPubMedGoogle Scholar
  • 71 Masoni L, Mari FS, Nigri G. et al. Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial. Surg Endosc 2013; 27 (01) 199-206
    CrossrefPubMedGoogle Scholar
  • 72 Wise KB, Merchea A, Cima RR, Colibaseanu DT, Thomsen KM, Habermann EB. Proximal intestinal diversion is associated with increased morbidity in patients undergoing elective colectomy for diverticular disease: an ACS-NSQIP study. J Gastrointest Surg 2015; 19 (03) 535-542
    CrossrefPubMedGoogle Scholar
  • 73 Sier MF, van Gelder L, Ubbink DT, Bemelman WA, Oostenbroek RJ. Factors affecting timing of closure and non-reversal of temporary ileostomies. Int J Colorectal Dis 2015; 30 (09) 1185-1192
    CrossrefPubMedGoogle Scholar
  • 74 Urbanavičius L, Pattyn P, de Putte DV, Venskutonis D. How to assess intestinal viability during surgery: a review of techniques. World J Gastrointest Surg 2011; 3 (05) 59-69
    CrossrefPubMedGoogle Scholar
  • 75 Ambrosetti P, Francis K, De Peyer R, Frossard JL. Colorectal anastomotic stenosis after elective laparoscopic sigmoidectomy for diverticular disease: a prospective evaluation of 68 patients. Dis Colon Rectum 2008; 51 (09) 1345-1349
    CrossrefPubMedGoogle Scholar
  • 76 Kream J, Ludwig KA, Ridolfi TJ, Peterson CY. Achieving low anastomotic leak rates utilizing clinical perfusion assessment. Surgery 2016; 160 (04) 960-967
    CrossrefPubMedGoogle Scholar
  • 77 Gröne J, Koch D, Kreis ME. Impact of intraoperative microperfusion assessment with Pinpoint Perfusion Imaging on surgical management of laparoscopic low rectal and anorectal anastomoses. Colorectal Dis 2015; 17 (Suppl. 03) 22-28
    CrossrefPubMedGoogle Scholar
  • 78 Wada T, Kawada K, Takahashi R. et al. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery. Surg Endosc 2017; 31 (10) 4184-4193
    CrossrefPubMedGoogle Scholar
  • 79 Shikata J, Shida T. Effects of tension on local blood flow in experimental intestinal anastomoses. J Surg Res 1986; 40 (02) 105-111
    CrossrefPubMedGoogle Scholar
  • 80 Miesse AM, Stellon MA, Segan R, Miesse E, Bronson DG. Investigating the effects of tension on a stapled anastomosis. Society of American Gastrointestinal and Endoscopic Surgeons 2012 Meeting. Available at: https://www.sages.org/meetings/annual-meeting/abstracts-archive/investigating-the-effects-of-tension-on-a-stapled-anastomosis/. Accessed July 14, 2020
    Google Scholar
  • 81 Hiranyakas A, Da Silva G, Denoya P, Shawki S, Wexner SD. Colorectal anastomotic stricture: is it associated with inadequate colonic mobilization?. Tech Coloproctol 2013; 17 (04) 371-375
    CrossrefPubMedGoogle Scholar
  • 82 Shaw D, Beaty JS, Thorson AG. Reoperative surgery for diverticular disease. Semin Colon Rectal Surg 2015; 26 (04) 224-228
    CrossrefPubMedGoogle Scholar
  • 83 Thaler K, Baig MK, Berho M. et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003; 46 (03) 385-388
    CrossrefPubMedGoogle Scholar