Digestive and Liver Disease 36 (2004) 435–445

Clinical Review

Diverticulitis: when and how to operate? H.N. Aydin, F.H. Remzi∗ Department of Colorectal Surgery, Cleveland Clinic Foundation, A30 9500 Euclid Avenue, Cleveland, OH 44195, USA

Abstract Diverticular disease, and particularly diverticulitis, has increasing incidence in industrialised countries. Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease. Conservative or medical management is usually indicated for acute uncomplicated diverticulitis. Indications for surgery include recurrent attacks and complications of the disease. Surgical treatment options have changed considerably over the years along with the inventions of new diagnostic tools and new surgical therapeutic approaches. Indications and timing for surgery of diverticular disease are determined mainly by the stage of the disease. In addition to this major factor, the individual risk factors of the patient along with the course of the disease after conservative or operative therapy do play a big role in decision-making and treatment of this disease. In this context, the purpose of this article is to review the surgical treatment of diverticulitis with regard to indications, timeliness of operative intervention, operative options and techniques, and special circumstances. © 2004 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Diverticulitis; Operative treatment; Staging

1. Introduction Colonic diverticulosis is among the most common diseases of developed western countries. Its true prevalence is difficult to measure since most individuals are asymptomatic. However, an increase in its prevalence has been detected and demonstrated over the course of time by various clinical, radiological and epidemiological studies as well as in various autopsy series. Its pathogenesis is attributed to genetic and environmental factors among which the most striking pathogenic factor was found to be a low fibre diet [1,2] along with some other contributing predisposing factors such as obesity, decreased physical activity, corticosteroids, NSAIDs, alcohol and caffeine intake, cigarette smoking, and polycystic kidney disease [3–6] as well as some other important epidemiologic factors such as age, geography, lifestyle, and ethnicity [7] that could possibly increase the incidence of diverticular disease and related attacks and subsequent complications. The changing pattern of distribution of colonic diverticula provides important insights into the genetic and environmental factors that ∗ Corresponding author. Tel.: +1-216-445-5021; fax: +1-216-445-8627. E-mail address: [email protected] (F.H. Remzi).

explain the difference in predominant site of diverticulosis among different races and geographic locations. The diverticula tend to occur almost always in the left side of the colon (50–90%), particularly the sigmoid colon [8], in Western societies, whereas right-sided predominance is mostly encountered in Asia with an incidence rate of 76% [9]. Studies so far have confirmed its predominant prevalence in industrialised nations in about 5–10% of the population by age 50, 30% of those aged over 50, in 50% of those over 70 and in 66% of people over 85 years of age [10]. While most people with diverticular disease remain asymptomatic, between 10 and 25% of patients with diverticulosis will ultimately progress to diverticulitis, and of these 15% will develop significant complications [10–12]. Diverticulitis results from inflammation and subsequent perforation of a colonic diverticulum. The actual incidence of symptomatic inflammation leading to hospitalisation is unknown, but it is estimated at 1–2% [13]. However, diverticular disease and its complications are responsible for 41% of all emergency admissions to hospitals with large bowel pathology in the USA. Ten to 20% of those who are hospitalised will eventually require an operation [14]. Those who survive an attack without surgical intervention do still have a yearly-calculated risk of 2% for subsequent attacks [10,15,16]. In general, 1% of all people with colonic

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diverticula will be operated on at some point in their lives because of a diverticulitis related complication [17]. Patients with acute diverticulitis may present with symptoms ranging from minor complaints to life-threatening clinical pictures in association with its complications. Approximately 75% of patients hospitalised for acute colonic diverticulitis respond to non-operative management that includes appropriate antibiotic therapy, bowel rest and low residue diet, and yet they have a mortality rate of approximately 1–2% [10,18]. Operative intervention is warranted in the remaining 25% of patients because of signs and symptoms of generalised peritonitis due to diverticular disease complications such as abscess, free perforation, fistulisation or obstruction. Most large case series report an overall mortality for patients requiring operative intervention between 12 and 36% [19,20]. Surgical treatment of acute diverticulitis has evolved over the course of approximately 100 years since drainage and proximal colostomy was described by Mayo in 1907. After introduction of the three-stage resection, it was realised that morbidity and mortality could be reduced by removing the infected segment of colon first by exteriorisation and later by resection and end colostomy, the Hartmann procedure. Up until 1980 it was generally accepted that resection and stoma were the correct surgical treatments [21]. Soon after, resection and primary anastomosis started to take its place in the treatment, however, many surgeons were still reluctant to accept and perform this concept except in mild cases either with pre-operative bowel cleansing or with intra-operative on-table lavage. However, the controversy of single-stage operation, i.e. resection and anastomosis, is still a hot topic with its current challenging position with regard to its superiority, advantages and disadvantages over other operative options in advanced peritonitis. In order to be able to provide a more realistic approach to solve diverticulitis and its associated complications surgically and to understand and analyse the outcomes of the treatment modalities, one must consider peri-operative variables, the stage of peritonitis, operative alternatives, and outcome with each of the procedures.

2. Indications for operative treatment Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease [22]. This classification scheme reflects the spontaneous course of the disease and helps us understand the clinical progression from one stage to the next so that it enables us to analyse each and every stage and ultimately to determine the exact timing and indication for surgical treatment of the disease. The indications for surgical treatment of diverticulitis include recurrent attacks and complications of the diverticular disease such as abscess, free perforation, fistulisation and obstruction [23]. An early determination of the stage

of the disease, i.e. differentiating complicated disease from uncomplicated as well as the determination of the degree of intra-peritoneal contamination, is a crucial step in establishing the indications as well as in choosing the right treatment modality in treatment of diverticulitis. Depending on the type of complication and the clinical presentation, the timing of surgery after initial conservative and/or interventional therapy is on an emergency or elective basis. Recurrent attacks are less likely to respond to medical therapy and have a higher mortality rate [10,24] and unfortunately, there is no data available yet on symptoms and signs that might predict the occurrence or severity of an attack. Therefore, most authorities agree that the indications for elective or semi-elective surgery include: (1) patients with two or more previous acute attacks who were treated conservatively; (2) patients with one attack that is to be associated either with a contained perforation, or colonic obstruction, or with a fistula; (3) patients with suspicious colonic carcinoma that cannot be excluded, and finally, although still a controversial topic in the treatment of younger patient population with diverticular disease, (4) patients with less than 50 years of age with a single attack requiring hospitalisation, may be treated surgically because this young patient group has longer life expectancy which does increase the possibility and the risk of subsequent episodes and related complications [23,25,26]. Indications for emergent surgery include patients with advanced stage of peritoneal contamination (Hinchey III and IV disease), patients with evidence of significant bowel obstruction, and immunocompromised or severely debilitated patients. In general, patients on steroid or immunosuppressant therapy should not be treated on an outpatient basis [23]. The patient is preferred to be operated on semi-electively during the same hospitalisation. The risk/benefit analysis is individualised for a specific patient, and consideration is given to the severity and responsiveness of the attack, general health of the patient and the risk to the patient of a subsequent attack compared to that of surgery itself.

3. Initial evaluation and ancillary diagnostic modalities Initial assessment of the patient with suspected diverticulitis is similar to that of any patient presenting with abdominal pain and comprises a through history and physical examination including abdominal, rectal, and pelvic examinations. The majority of patients present with left lower quadrant pain (93–100%), fever (57–100%), and leukocytosis (69–83%) [23]. Other associated manifestations may include

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nausea, vomiting, constipation, diarrhoea, dysuria, and urinary frequency. One should also consider the differential diagnosis of acute diverticulitis, including colon cancer, inflammatory bowel disease, irritable bowel syndrome, ischemic colitis, bowel obstruction, and gynaecologic and urologic diseases [23,27]. Especially, differential diagnosis of colorectal cancer as well as the detection of their possible co-existence is very important. Considering the age factor of this patient population, it is not unusual to encounter colonic as well as other GI tract cancers as either separate or co-existent entities [28]. Useful initial evaluation may include complete blood count, urinalysis, and flat and upright abdominal X-rays. If the clinical picture is clear enough to diagnose diverticulitis, no other tests are indicated [24]. There are many other reasons to order additional tests for diagnosis as well as for treatment of diverticulitis. In cases where diagnosis is in question, tests such as computed tomography scan (CT scan), water-soluble contrast enema, and ultrasound may be performed. Ordering these additional tests not only clarifies the intra-abdominal pathology but also provides great amount of information regarding anatomy, the relationship of the diseased segment of the colon to neighbouring organs, and other co-existing pathologies, thus helps us stage the diverticulitis. The widespread availability and use of CT scan has significantly changed the diagnosis and management of diverticular disease, especially diverticulitis related abscesses. Apart from distinguishing diverticulitis from other intra-abdominal inflammatory conditions, it also provides the opportunity for percutaneous drainage of localised abscesses, potentially converting multi-staged surgical approaches to an elective, single-stage procedure. CT scan evaluation of the abdomen with triple contrast, i.e. oral, rectal and intra-venous contrast administration, has a sensitivity of 69–95% and a specificity of 75–100% [29–32]. It has become increasingly used as the initial imaging study, especially in the acute setting, particularly whenever moderately severe disease or abscess is anticipated. In case of diverticulitis, it demonstrates typical findings for diagnosis of diverticulitis such as colonic wall thickening, peri-colic fat infiltration, peri-colic or distant abscesses, and extra-luminal air [29–31]. It is the most commonly used diagnostic tool to determine the stage of the disease pre-operatively. In addition to its diagnostic feature, it also provides a useful therapeutic aid for percutaneous drainage of intra-abdominal abscesses (Hinchey Stage I–II), thus providing us the opportunity to downstage the intra-abdominal pathology so that it can be treated with single-stage surgical procedure. The only downside of CT scan is that it is not reliable and useful in differentiation of cancer from diverticulitis. This again must be supplemented by contrast studies or endoscopy. Water-soluble contrast enema with a sensitivity of 94% and accuracy of 77% can be used safely in acute diverticulitis, especially in emergency setting [33]. The findings

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for a positive contrast study reading include the presence of diverticula, mass effect, intra-mural mass, sinus tract, and extravasation of contrast. Even though the contrast enema reveals the presence of an abscess in 88% of the cases, it still has got 2–15% of false negative results, most probably related to diverticulitis’ extra-mural nature that again may underestimate the severity of the disease [33]. Abdominal ultrasound has sensitivity and a specificity of 84–98% and 80–97%, respectively [34,35]. Criteria for diagnosis of diverticulitis using ultrasound include wall thickening, abscess, and rigid hyperechogenicity of the colon because of inflammation. However, it is a non-invasive screening tool with a potential drawback that it is very examiner dependent. It is helpful, especially in female patients, for excluding pelvic and gynaecologic pathology. Endoscopy is usually avoided in the acute setting of diverticulitis because of the risk of perforation of the inflamed colon, either by air insufflation or with instrumentation. However, flexible endoscopy is a reasonable and useful diagnostic test 4–6 weeks after resolution of an episode of acute diverticulitis. In cases with diagnostic uncertainty, limited flexible sigmoidoscopy with minimum air insufflation may be performed to exclude other diagnoses.

4. Operative goals and staging systems Whether elective, semi-elective or emergent, regardless of intervention timing, the goals of the surgical procedure are to control or prevent sepsis, eliminate further complications such as fistula or obstruction, remove the causative diseased colonic segment, and restore intestinal continuity. One should also consider minimisation of morbidity, length of hospitalisation, cost, and maximisation of survival and quality of life. The operative treatment of acute left-sided diverticulitis must be individualised depending on the number of episodes, the severity of inflammation, the age of the patient, the patient’s overall condition, immunosuppression, and intra-operative staging and peritonitis scoring systems. These systems provide a more realistic approach to solve diverticulitis-associated complications surgically and help understand and analyse the outcomes of the treatment modalities. These can be divided into peritonitis-based systems and pre-operative factors based systems [36]. Several authors have attempted to classify patients with inflammatory complications of diverticular disease based upon intra-operative findings. The major aim in classifying patients according to these findings was to provide a measure to compare different outcomes from different types of operations as well as to reduce the variability introduced by diverse patient populations. The staging system introduced by Hughes and his colleagues [37] in 1963 evaluates the intra-abdominal degree of inflammation and related complications in four categories.

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These are local peritonitis, local paracolic or pelvic abscess, general peritonitis after rupture of a paracolic or pelvic abscess and general peritonitis secondary to free perforation of the colon. As it can be noticed, this clinical classification based on operative findings, groups patients according to the severity of peritoneal contamination along with the consideration of the degree of localisation and the nature of peritoneal sepsis. A similar system for the degree of perforation recommended by Hinchey et al. [38]. in 1978 suggests four stages. Hinchey classification defines Stage I as diverticulitis with confined paracolic abscess, Stage II as diverticulitis with distant (pelvic, retroperitoneal) abscess, Stage III as diverticulitis with purulent peritonitis, and finally Stage IV as diverticulitis with faecal peritonitis. The important point here to emphasise is the difference between Stage III and IV peritonitis. Stage III disease is considered “non-communicating” with the bowel lumen. It is mainly due to obliteration of the diverticular neck by inflammation, whereas Stage IV disease is reasoned to be “communicating” with a freely perforated diverticulum. A more complex categorisation advocated by Killingback (1983) [39] sub classifies stages of peritonitis as abscess, perforation, gangrenous sigmoiditis and peritonitis. A modification of Hinchey’s was done by Siewert et al. (1995) [40]. They classified the intra-operative findings into three stages. Stage I describes an extra-peritoneal diverticular perforation or a perforation limited to mesocolon. Stage II is defined as localised abscess beyond limits of mesocolon and finally Stage III is defined as generalised purulent or faecal peritonitis. Another modification of Hinchey’s classification offered by Sher and his colleagues (1997) [41] stratifies Stage II disease. In Stage IIa, intra-abdominal abscess is amenable to percutaneous drainage, whereas in Stage IIb intra-abdominal abscess is more complex with a fistula. The main disadvantage of these staging systems is that we are only able to determine the stage of the disease by means of intra-operative findings intra-operatively or by means of histopathologic findings post-operatively. There is another staging system devised by Hansen (1999) [42] that is to be used pre-operatively. This staging system uses clinical examination along with the findings of contrast studies, colonoscopy and computed tomography. It encompasses whole spectrum of diverticular disease from clinically asymptomatic to free perforation along with the findings of confirmatory studies. It also helps stage the patient earlier and pre-operatively, eliminating the delay and the necessity of intra- and post-operative pathologic findings. In addition to the peritonitis based staging systems that usually aim to define or predict intra-abdominal degree of peritonitis, there have also been attempts to develop a scoring method that predicts operative mortality associated with left colonic peritonitis based upon determination of “prognostic

factors” by using uni- and multi-variate logistic regression analysis to determine the influence and role of peri-operative variables on the outcome. In a model developed by Biondo et al. (2000) [43], six factors of peritonitis severity score that significantly impacted the risk of mortality were evaluated. These factors are age (70 years), American Society of Anesthesiologists (ASA) Score (I and II versus III versus IV and V), underlying disease (e.g. ischemic colitis), Hinchey peritonitis score (I–II versus III–IV), pre-operative organ failure and immunocompromised status. Of these six factors, only ASA score and pre-operative organ failure independently influenced post-operative mortality. It has been reported that ASA score of 3 or more is associated with high mortality rate [19]. In another retrospective study in patients with perforated diverticular disease looking for predictors of peri-operative mortality, Setti Carraro et al. (1999) [44] found that APACHE II score independently predicted mortality. There are quite a number of defined peritonitis scoring systems available in the literature. These are often used to predict the outcome in acute peritonitis. Mannheim Peritonitis Index (MPI) [45,46] is one of the most commonly used scoring index that is intended to be simple without need for extensive laboratory data. The parameters it includes are age, gender, organ failure(s), presence of malignancy, pre-operative peritonitis more than 24 h, presence of diffuse generalised peritonitis, site of primary focus, and the nature of peritoneal exudative fluid. Each parameter represented by certain points and the sum of all points provides us the ultimate score. MPI score less than 21 indicates better prognosis compared to a score of 21 or higher (poor prognosis) [47]. The optimal management of patients with diverticulitis entails determining the severity of disease and then correctly classifying the patients with these criteria. Surgical options are based both on pre-operative prognostic indicators of mortality such as age, associated medical disease, duration of symptoms, shock, and immunosuppression as well as the above-mentioned scoring systems such as APACHE II and MPI [48]. As already mentioned, operative findings allow different classifications of acute diverticulitis where Hinchey classification is still most widely used [23,38]. One may weigh the importance of these pre-operative physiologic and health assessments together with an intra-operative classification to identify groups of increased morbidity and mortality. Once this is done correctly, it will allow for accurate comparison of surgical techniques with respect to the disease.

5. Treatment options and recommendations based on staging systems For the various clinical stages of perforated diverticulitis in the complicated disease group, despite of the many classification methods available and offered in the literature, today most commonly preferred and used classification

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system is the original or modified Hinchey classification [38,41]. Surgical treatment options with the contribution of the auxiliary methods like CT guided drainage and on-table lavage to downstage the type and complexity of the surgical operations, may be based on Hinchey classification. Therefore, this paper will also utilise the Hinchey system for all ensuing discussion. The most commonly performed procedures are either single-stage or two-stage procedures that can be performed either laparoscopically in experienced hands that are familiar with this type of procedure or via conventional open method, depending on the severity and the stage of the disease, patient’s overall condition and co-morbidities. Primary resection and anastomosis without a protective stoma is the so-called single-stage procedure that is commonly preferred electively as the treatment of choice for patients without immunosuppression or immunocompromised status presenting either with uncomplicated diverticulitis or with Hinchey I or II that could be downstaged by means of CT guided drainage. Percutaneous drainage of intra-abdominal abscesses is found to decrease morbidity and mortality rates when compared with open drainage and should be attempted when possible. It is found to be successful in 70–90% of patients and Stage I abscesses have a better prognosis than abscesses located in the pelvis or elsewhere in the abdominal cavity [49]. A single-stage procedure is usually associated with decreased hospital stay and has lower mortality and morbidity compared with two-stage and three-stage procedure. Apart from the concept of single-stage procedure, same hospitalisation resection that has also been discussed in the literature is another approach especially for patients with localised disease and who failed the medical therapy or who have resolution of symptoms and would be considered a candidate for future elective surgery [50]. A two-stage procedure is commonly indicated for patients with substantial faecal contamination, inflammation and immunocompromised or suppressed status [51]. The two-stage procedure can comprise Hartmann’s procedure as well as resection and primary anastomosis with a proximal loop ileostomy that again is to be closed on a later appropriate time. This has the advantage of obviating the difficulty with identifying the Hartmann’s pouch at subsequent colostomy closure. The most commonly performed two-stage operation is Hartmann’s procedure with great variability of morbidity and mortality related to the selection and application criteria to different patient population. All these two-stage operations can be successfully accomplished by laparoscopic and laparoscopic-assisted means in experienced hands. Operative options for complicated diverticular disease are: (1) proximal diversion with suture, omental patch of the perforation site and drainage; (2) resection with colostomy and distal mucous fistula or closure of the distal bowel; (3) resection and coloproctostomy; (4) resection with coloproctostomy and proximal diversion. The summary of the sur-

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gical treatment options and their stage related applications is given below. Stage I disease, described as diverticulitis with confined paracolic abscess, is to be initially treated conservatively utilising intra-venous antibiotics. Antibiotic therapy can be instituted and continued for 48 h. A study evaluating the outcome of isolated abscesses complicating diverticular disease without clinical peritonitis, reports that confined abscesses less than 5 cm in maximal dimension usually resolve with antibiotic therapy alone [49,52]. If the clinical condition of the patient fails to improve within this period, a repeat CT scan is usually indicated. An increase in abscess size on CT scan renders CT guided drainage the next available treatment option in the treatment algorithm. Percutaneous drainage in conjunction with adequate antibiotic cover is being advocated as the initial therapeutic manoeuvre in patients with peri-diverticular abscesses >5 cm in diameter [23,49,52]. They usually resolve within 72 h with diminution of pain and resolution of leukocytosis. The advantage implied by these studies is rapid control of sepsis, stabilisation of the patient without the need for general anaesthesia, and the elimination of multi-staged surgical procedures. Percutaneous drainage is successful in 70–90% of patients, and Stage I abscesses have better prognosis than abscesses located elsewhere within the abdominal cavity [49]. Patients with abscesses that are not amenable to CT guided drainage or in whom signs and symptoms of peritonitis persist despite appropriate antibiotic therapy and percutaneous drainage are candidates for surgical intervention. But again, the need of surgical therapy or percutaneous drainage should be assessed on clinical grounds rather than on imaging studies alone. If an urgent surgery is indicated, the most appropriate type of surgery would be primary resection with on-table lavage and anastomosis [53]. After conservative therapy of the first uncomplicated attack, most of the patients become symptom-free. Apart from some of the exceptions, i.e. immunosuppressed or compromised patient, or a patient with less than 50 years of age with a single attack [26], there is no clear-cut indication for elective surgery for this group of patients. An assumption made about a prophylactic resection after first attack to prevent further attacks and complications would be inappropriate since complications like perforation constitute first manifestation of the disease in about 70% of the affected. Treatment of Stage II disease, associated with distant abscess (retroperitoneal or pelvic), depends on magnitude and location of the abscess, the patient’s clinical condition and co-morbidities, and as well as on the possibility of a percutaneous drainage procedure. These are the determinant factors for timing of surgery and the treatment modality as well. Again, small peri-colic abscesses may resolve with antibiotic therapy and bowel rest. Patients with large diverticular abscesses can be drained either percutaneously or surgically. Percutaneous drainage may not only allow stabilisation of the patient but also provides postponement of definitive surgery until the colon can adequately be prepared and

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fully evaluated so that single-stage definitive surgery with avoidance of a temporary stoma and a second operation can be achieved [52]. Abscesses that are not amenable to CT guided percutaneous drainage, and patients who are resistant to conservative therapy, require surgical treatment. In extraordinary conditions like in immunocompromised or toxic patients or in patients with marked pelvic inflammatory residue after resection of diseased colonic segment, a proximal loop ileostomy might be an indication. The occasional patient can undergo primary resection and anastomosis. The outcomes of treatment of Stage I and II disease requiring operative management were retrospectively reviewed by Belmonte and associates [54]. In stage I disease, 53 (87%) patients were treated with resection and non-diverted coloproctostomy, in whom only two (3.8%) anastomotic leaks occurred, and the observed group’s overall morbidity rate was 22%. In Stage II peritonitis, 27 (69%) underwent resection with coloproctostomy, 11 with and 16 without proximal diversion. The overall leak rate was identical at 3.8%, but the group’s morbidity rate of 30% was slightly increased. Laparoscopic resection of diverticulitis can be performed without additional morbidity and with a reduced length of hospitalisation in patients with Stage I or II disease. In a comparative study between complication rates for laparatomy or laparoscopy for Hinchey IIa or IIb patients, no statistical differences were observed [41]. Stage III disease symbolises purulent peritonitis that as a surgical emergency requires preliminary optimisation and immediate resuscitation with IV fluids, broad-spectrum antibiotics, and cardiovascular support when indicated, and prompt operative therapy. Depending on the degree of peritoneal contamination, magnitude of sepsis, timeliness of operative intervention, and associated co-morbidity, the expected mortality is 6% for purulent peritonitis versus 35% for faecal peritonitis [21,55–57]. A prospective randomised study has confirmed that primary resection is superior to secondary resection in the treatment of purulent peritonitis complicating sigmoid diverticulitis [58]. The operative option in Stage III is between Hartmann’s resection and resection with immediate anastomosis ± ileostomy. Controversy remains about the timing of restoration of intestinal continuity after sigmoid colon resection. However, the operative option in Stage III is between Hartmann’s resection and resection with immediate anastomosis ± ileostomy. A one-stage operation with primary resection and anastomosis is appealing in terms of operative technique, reduction of hospital stay and cost, but still the downsides that one-stage operation brings along the way, such as the risk of anastomotic leak due to the bowel inflammation, oedema, unprepared bowel and peritoneal contamination, have favoured a two-stage procedure, i.e. Hartmann’s procedure followed by secondary anastomosis. The safety of primary anastomosis has been reported with low mortality rates (1–6%) and an acceptable anastamotic leak rate

(1–7%) [59,60]. One-stage sigmoid colon resection without intra-operative colonic lavage is also reported to have similar morbidity and mortality rate compared to a two-stage procedure (7.7% versus 7.2, respectively) [61]. However, protective measures for the safety of one-stage procedure such as bowel cleansing by on-table lavage and protective diverting stoma are usually considered if a primary anastomosis is to be performed [62]. On the other hand, some reports failed to demonstrate a significant reduction in mortality after Hartmann’s procedure. One must also consider 30% of reported possibility of irreversibility of Hartmann’s procedure [54,63–65]. In addition, colostomy takedown after Hartmann’s procedure tends to be technically demanding with substantial reported morbidity and mortality of 23–69% and 1–28%, respectively [66–68]. An anastomotic leak rate of 4–16% and an associated mortality rate of 0–4.3% have been reported [54]. However, Hartmann’s procedure is still favoured by its proponents over primary resection and anastomosis, especially in the surgical treatment of perforated diverticulitis (Hinchey’s stages III and IV) [23,51,69]. It is difficult to assess the relative safety of primary anastomosis versus a Hartmann procedure, solely based on the available data in the literature. It is advisable to consider and choose the appropriate operative option based on pre-operative prognostic factors such as age, co-morbidities, duration of symptoms, presentation of the patient, and intra-operative findings. Ultimately, it is up to the surgeon to choose the type of operation to perform because the level of experience of the surgeon is also a major determinant factor amongst others. However, more prospective randomised trials are needed in order to set more objective standardised criteria to determine the best suitable operative option. Patients with an ASA score IV/V and pre-operative organ failure is better to be managed without an anastomosis. Again patients with immunocompromised status, over the age 70 years, and with signs and symptoms of systemic toxicity, may benefit from a diversion. Stage IV disease representing faecal peritonitis, requires operative intervention after preliminary optimisation and resuscitation. Expected mortality rate has been shown to be six times higher than purulent peritonitis. In the literature, there is limited number of studies without enough evidence at this time to suggest primary anastomosis in faecal peritonitis. In addition, the small number of patients, absence of objective criteria and the enthusiasm of the authors rather than solid evidence are the disadvantages of these studies. Currently, surgical treatment recommended for faecal peritonitis is Hartmann’s procedure and drainage. In rare prohibitive cases with adhesions and conditions that hinder effective segmental resection, peritoneal lavage, proximal faecal diversion, omentoplasty and possible drainage should be considered. The outcomes of applications of different surgical treatment options for Stage III and IV disease such as diversion and suture closure, resection and colostomy, resection and

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anastomosis and finally resection and diverted anastomosis were reviewed and reported by Krukowski and Matheson [21], and the mortality rates of these procedures were 26, 12, 9 and 6%, respectively. The outcomes as given favour resection with coloproctostomy over the Hartmann’s procedure. However, they considered using this method only in the most favourable of circumstances. Since this report, only few small series of patients were treated by resection and coloproctostomy with or without proximal diversion, and the overall mortality rate report of these series was found to be around 4%. Based on this fact, some advocated this approach over Hartmann’s procedure mainly because of Hartmann’s takedown-associated morbidity rate ranging from 24 to 65% in addition to its irreversibility rate of 30%. However, the leakage-rate associated mortality rate of an unprotected coloproctostomy was found to be high enough to consider and recommend only the individualised use of this approach. Laparoscopic surgery for acute complicated disease in association with Hinchey III and IV has not been generally accepted as the treatment of choice. However, evidence shows that laparoscopy has been used as a diagnostic tool along with the laparoscopy-assisted lavage procedure in Hinchey III patients [70]. Laparoscopic one-stage surgery for fistulas that complicate diverticular disease has been found to be technically feasible and safe in experienced hands, with low morbidity [71]. However, its effectiveness and safety versus open surgery needs to be tested by means of prospective randomised trials.

6. Principles of operation and operative techniques There are principles and operative techniques to follow in terms of application of pre-planned, less invasive surgery that decreases the chances of staged operations and thus providing the possibility of achieving good operative outcome that improves quality of life along with a decrease in the rate of complications as well as in morbidity and mortality of the patient. General principles that are recommended in association with the timing of the operation are given below. In elective cases, resection of the diseased colon must be the desired goal along with the removal of entire thickened colonic segment(s) but not necessarily all of the proximal diverticula-bearing colon [23]. It may be acceptable to retain proximal diverticular colon as long as the remaining bowel is not hypertrophied. Sigmoid colon should be removed entirely, and when anastomosis is elected, distal margin of the anastomosis should be normal rectum. Bowel ends not only must be well vascularised but they must also be free of tension and oedema. In a study, colorectal rather than colosigmoid anastomosis has been shown to be the single predictor of lower recurrence rates after elective sigmoid resection for uncomplicated diverticulitis [72,73]. Proximal bowel should be free

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of obvious faecal, purulent, or long-standing contamination. There are auxiliary manoeuvres in addition to the strict principles of the operation to fulfil the requirements of a good outcome without any additional morbidity. These include mobilisation of splenic flexure, prevention of any type of injury related to obliterated surgical planes due to the local desmoplastic reaction in pelvis especially in cases of diverticulitis related obstruction or fistula. Splenic mobilisation reduces recurrence rates from 12.5 to approximately 6% [73,74]. By taking preventive measures such as cystoscopy with placement of ureteral stents in complicated cases with large phlegmoneous abscesses, morbidity rates associated with intra-operative injury can be lowered. Even though pre-operative placement of ureteral stents does not eliminate the possibility of ureteral injury all the time, however, it allows for early diagnosis and treatment of ureteral injury during the same laparotomy. Another method of preventing these organs from injury is to identify these structures proximal to the inflammatory reaction by mobilising colonic mesentery and following this plane down into the pelvis. In suspicious obstructive cases whereby the mass cannot be excluded from cancer, we believe a more radical approach with high ligation of inferior mesenteric artery and vein is indicated. In emergent cases, differences of opinion still exist about the best surgical approach to the surgical treatment of acute complicated diverticular disease. Perforation is the most common cause for emergency surgery [14]. For the treatment of perforated diverticulitis, different surgical approaches have been advocated. Some of these approaches are less invasive such as suggested by one single centre trial that the combination of suture closure of a perforation and transverse colostomy produced a lower post-operative mortality than resection [20]. Another non-randomised study suggests that laparoscopic exploration and selective peritoneal lavage is generally sufficient [75]. However, primary resection of the diseased segment of the colon was found to be superior to secondary resection in the treatment of generalised peritonitis complicating sigmoid diverticulitis because of significantly less post-operative peritonitis, fewer re-operations and shorter hospital stay [58]. As a minimum, resection and diversion are generally required. One-stage versus two-stage procedure has already been discussed. A two-stage approach, most commonly Hartmann’s procedure, resection and diversion and followed by restoration of the intestinal continuity in 3–6 months, has generally been the preferred procedure so far. Although still controversial, in selected cases, where sepsis can be removed, a definitive resection with anastomosis with or without proximal stoma may be appropriate. In a study, this has been suggested in patients with purulent peritonitis with a low surgical risk defined as MPI score of less than 21 [58]. But again, further prospective studies are needed to determine the proper role of primary anastomosis. Techniques useful to accomplish one-stage primary resection and anastomosis include the ones already mentioned in the text and on-table lavage.

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Intra-operative irrigation of the colon diminishes faecal loading of the proximal colon and permits anastomosis under conditions in which the faecal load would otherwise make anastomosis risky [76,77]. On-table lavage was recommended in some studies, as a technique that enables one-stage resection and anastomosis for selected patients, i.e. patients without gross faecal contamination of the peritoneal cavity, diffuse peritonitis or a large continuous abscess, it has been shown to be a useful adjunct to resection and anastomosis with or without primary proximal diversion rather than the Hartmann procedure [62,76]. Immunocompromised patients and patients demonstrating hemodynamic consequences of systemic sepsis were recommended to be excluded since a prolonged operation or subsequent anastomotic dehiscence might have dire consequences. As far as the technique of on-table lavage is concerned, these are the steps for an unproblematic lavage [78]. The diseased segment of colon is mobilised and resected in standard fashion and a tape is placed around the colon proximal to the pathologic process to occlude the lumen. The splenic flexure is routinely mobilised, and mobilisation of the hepatic flexure is usually necessary in half of the cases to make milking of intestinal contents and cleansing of the colon easier. The anaesthesia tubing that is inserted through the cut end of the colon proximal to the diseased colonic segment is used to enable the outflow of stool from the colon. This tube is secured with a tape to prevent the spillage of colonic contents. To cannulate the colon for irrigation, a 32F Foley catheter is either passed through the base of the appendix or through a suitable enterotomy site in the terminal ileum that can also be safely used as the site for a pre-planned proximal diversion, in case there is one needed. After the catheter’s balloon is inflated, lavage is accomplished by infusion of 3–6 l of warm saline solution. A 10% solution of povidone iodine is added to last litre of irrigation. When lavage is completed, the Foley catheter is removed, and the stump of appendix is ligated, or the enterotomy is closed unless a proximal diversion is indicated. On-table lavage can be recommended as a very safe measure not to avoid anastamotic leakage but to decrease its severity. On the contrary, there are studies that recommend primary resection with intra-operative colonic lavage in patients with purulent peritonitis, failed percutaneous drainage or even with Hinchey stage IV peritonitis. This is contrary to the majority of authors that recommended Hartmann’s procedure in Hinchey’s stage IV peritonitis. There is a need for prospective trials to eliminate this dilemma. In our practice, we believe Hartmann’s procedure and the takedown of Hartmann’s can be simplified by creating a distal mucous fistula at the subfascial level of the midline incision. This will not only prevent detrimental septic sequelae related to rectal stump blow-out resulting in pelvic sepsis, but it also will ease the technical aspect of Hartmann’s takedown procedure.

7. Special circumstances There are special circumstances where the general recommendations in the diagnostic workup and treatment of diverticulitis may not apply. This is closely associated with the presence of the factors such as presentation of the disease, the patient’s response to the disease and to the therapy for the disease. 7.1. Diverticulitis in the young patients Diverticular disease is relatively uncommon before the age of 40 years and constitutes only 2–5% of the total number of patients in multiple large studies [10,17]. Diverticular disease in the younger age group occurs more commonly in males with obesity (84–96%) being a major risk factor [79,80]. There is ongoing controversy not only about the nature and the course of the disease in this young patient population, but also about the timing of the operation [81–85]. The disease trend in this patient group is towards more recurrence and an increased incidence of poor outcomes ultimately requiring surgery [17]. This might be related to the fact that younger patients have longer life expectancy, which does increase the possibility and the risk of subsequent episodes and related complications. Therefore, surgery is often regarded as the treatment of choice for young symptomatic patients. 7.2. Diverticulitis in immunocompromised patients Conditions that represent an immunocompromised state include severe infection, steroids, diabetes mellitus, renal failure, malignancy, cirrhosis, chemotherapy/immunosuppressive therapy. Although the incidence of diverticulitis does not appear to be increased in this population, the complications and sequelae of the diverticulitis are more severe. This group of patients may lack a normal inflammatory response and present with minimal or subtle signs and symptoms, which may delay the diagnosis and treatment. These patients are associated with an increased rate of free perforation (43% versus 14% in immunocompotent patients), an increased need for surgery (58% versus 33%), and increased post-operative mortality (39% versus 2%) [86,87]. To be more specific, transplant patients, immunocompromised patients and patients under immunosuppression are preferred to be operated on semi-electively during the first episode of initial hospitalisation. Primary resection with proximal diversion is the desired operation, and should be attempted, whenever possible. 7.3. Recurrent diverticulitis after resection Recurrent diverticulitis after surgical treatment is rare, ranging from 1 to 10%. In general, the progression of diverticular disease in the remaining colon is approximately 15% [88]. In such circumstance, the previous diagnosis and

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treatment can be questioned and investigated. Important factors in terms of surgery to be considered are the adequacy of resection meaning the degree of proximal resection and level of distal anastomosis [72,73]. The use of the rectum as the distal margin decreases the rate of recurrence. Care also must be taken to exclude other components of differential diagnosis, especially irritable bowel syndrome, inflammatory bowel disease and ischemic colitis. 7.4. Right-sided diverticulitis As stated earlier, diverticulosis in Asia is predominantly a right-sided phenomenon. Diverticula of the right colon may be singular or multiple. The diagnosis of right-sided diverticulitis is difficult to differentiate from appendicitis due to similar clinical picture and presentation. An abdominal mass is usually found in 26–88% of the cases [89,90]. The surgical treatment is reserved for recurrent and complicated episodes if one is confident with the diagnosis of right-sided diverticulitis. If extensive inflammation is present or multiple diverticula are found, a right hemicolectomy with primary anastomosis is indicated. In selective cases, simple diverticulectomy may be done [91– 93].

8. Conclusion Although colonic diverticulitis is a benign condition, it can sometimes be very challenging to diagnose and treat. It is a common disease and needs to be taken into consideration in the differential diagnosis of patients with abdominal complaints. The increase in morbidity and mortality is associated with the stage of peritonitis and patient related co-morbidities. Therefore, it is worthwhile to emphasise that staging is not only the crucial key for accurate diagnosis and treatment but it also has a pivotal role in decreasing disease associated morbidity and mortality. Multi-disciplinary approach is important for the staging, diagnosis and treatment of this disease. Conflict of interest statement None declared.

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