Surgical Management Of Acute Colonic Diverticulitis: Procedure and Complications

Introduction:

Diverticula are small areas with bulging pouches in the digestive system lining. They are often found in the lower part of the large intestine, mainly the colon. Diverticulosis and diverticulitis are two conditions in the colon, a segment of the large intestine.

Diverticula are like inflated areas or bubbles where the raised pressure inside the colon causes pockets or bulges (diverticula) to form in weakened areas of the colon's walls. Diverticula can range from pea-size to much bigger. Diverticulosis is the existence of these small bulges or diverticula in the colon. It is most commonly seen in the lower left side, in the S-shaped segment of the colon called the sigmoid colon. It does not cause any symptoms or require treatment. Regardless, diverticulosis can lead to diverticulitis. Diverticulitis is inflammation and infection in one or more diverticula, which causes abdominal pain, nausea, fever, and more severe and potentially dangerous conditions.

What Is Acute Colonic Diverticulitis?

Acute diverticulitis is an inflammatory reaction of the diverticulum with a sac-like swelling from the colon wall due to micro-perforation. It is seen in about 10 % to 25% of patients with diverticulosis. Diverticulitis can be categorized as a simple or uncomplicated (without any related complications) and complicated stage (associated with complications like the formation of abscess, fistula, bowel obstruction, or perforation).

What Is the Etiology Behind the Acute Colonic Diverticulitis?

Contributory risk factors include:

• Diet is influential, like low-fiber, high-fat, and red-meat diets.

• Obesity and smoking.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like Aspirin and Ibuprofen.

• Steroids and opiates.

• Above 40 years of age.

• Male gender.

• Physical inactivity.

What Are the Symptoms of Acute Colonic Diverticulitis?

• Pain may be constant and last for several days, most commonly involving the lower left side of the abdomen. However, the right side is more painful.

• Nausea and vomiting.

• Fever.

• Abdominal tenderness.

• Constipation.

• Diarrhea (less commonly).

What Are the Investigations for Acute Colonic Diverticulitis?

• Blood Test: Signs of infection, like high white blood cell count, are revealed in the test.

• Stool Sample: It is inspected for abnormal bacteria or parasites as potential causes of infection, abdominal pain, blood in stool, and diarrhea.

• Digital Rectal Exam: The healthcare provider gently inserts a gloved, lubricated finger into the rectum to palpate for any problems in the rectum.

• CT Scan: It displays infected or inflamed diverticula and also reveals the severity of diverticulitis.

• Barium Enema (Lower Gastrointestinal Tract Radiography): Liquid barium is injected into the anus. The barium coats the inside of the colon, providing a better visualization on X-rays and allowing us to rule out any problems in the colon.

• Sigmoidoscopy: A thin, flexible tube with a light on the end is inserted into the rectum and moved into the sigmoid colon.

• Colonoscopy: The entire length of the colon can be inspected. A slim, adaptable, lighted tube with a camera, called a colonoscope, is inserted through the rectum and into the colon.

• Angiography: The arteries that supply the colon are injected with a harmless dye that permits the origin of the bleeding to be noticed.

When Is Surgery for Diverticulitis Indicated?

Surgery for diverticulitis is indicated in the following:

• Abscesses (a collection of pus with bacteria and white blood cells).

• Perforation.

• Peritonitis.

• Fistulas.

• Rectal bleeding (diverticular bleeding).

The surgical intervention is divided into the following parts:

• Bowel Resection With Primary Anastomosis: The surgeon extracts the infected colon (a colectomy) and stitches the cut ends of the two nutritional elements from either side of the earlier infected area. This procedure is called anastomosis.

• Bowel Resection With Colostomy: This procedure involves colectomy and attaches the bowel through an opening in the abdomen called a stoma.

Depending on the recovery over the months, the colostomy may be either temporary or permanent.

• Open: The surgeon creates a six-inch incision in the abdomen to open the intestinal area for inspection.

• Laparoscopic: The surgeon creates tiny cuts for placing small cameras and instruments into the body through small trocars that are usually less than one centimeter.

What Is Hartmann’s Procedure?

It is an emergency surgery where the doctor may conduct a Hartmann's procedure, in which the surgeon removes the damaged or diseased portion of the colon and washes out any infected areas in the abdominal cavity under general anesthesia. It can be accomplished with laparoscopy or an open technique. In case of infection, it may be unsafe for the two ends of the colon to be fixed together immediately after surgery. If so, the surgeon constructs a stoma, an outlet connecting the bowel to the abdominal wall, eliminating the stool.

The surgeon creates an incision in the abdomen and joins part of the intestine to the outlet or opening created in the skin, and the rectum is temporarily closed with sutures. Next, an odor-proof container, named a colostomy bag, is connected to the opening in the skin on the outside of the abdomen to collect the bowel contents. This helps the waste leave the body through the stoma and collect in the bag attached to the stoma enabling the colon to heal.

What Is Elective Sigmoidectomy?

In the laparoscopic procedure, the surgeon creates several tiny incisions in the abdomen through which the instruments are inserted. With the help of a two-dimensional image on a video monitor, the surgery is inspected, and the procedure to remove the diseased part is done.

In robotic-assisted surgery, surgeons utilize an advanced surgical system to conduct the procedure, comprising remote surgical instruments ascended on different robotic arms. An additional arm includes a video camera, which casts a magnified, high-definition, three-dimensional picture on a computer monitor to direct the surgeon.

What Is CT-guided Percutaneous Drainage (PCD)?

Mainly indicated in complicated cases of abscess or acute diverticulosis, including a preoperative catheter drainage treatment followed by single-stage sigmoid colectomy with primary anastomosis without complications. Routine sonography, where the injection of contrast material through the PCD catheter helps to reveal fistulous communications.

What Are the Complications Related to Surgical Interventions?

• Pelvic abscess.

• Intestinal perforation.

• Bowel fistula.

• Bowel obstruction.

• Sepsis.

• Bleeding from rectum.

• Recurrence.

Conclusion:

Acute diverticulitis is an inflammatory complication of the sigmoid colon involving 1 % to 3 % of people who harbor diverticula. The spectrum of the condition is wide, ranging from simple phlegmonous diverticulitis, which almost always responds to conservative management, to bizarre complications, including fistula, obstruction, perforation, and sepsis, which require extensive surgical intervention. The diagnosis of acute diverticulitis is clinically based on the duration of the presentation.