12. Colorectal Anatomy
• Lymphatic Drainage
– Epicolic Nodes
» under the serosa of the wall of the intestine
– Paracolic Nodes
» on the marginal artery
– Intermediate Nodes
» along the SMA & IMA
– Principal Nodes
» at the root of the SMA & IMA
15. HINT OF HISTORY
• Cruveilhier-1849- first described colonic
involvement by diverticular disease.
• Term “ diverticulosis” – first used in 1914.
• Acute diverticulitis recognized at the turn of
the 20th century (due to” excess of
roughage”!).
• Burkitt &Painter-geografic distribution of the
condition (Western vs.Third world)-due to
industrialization of milling of FLOUR.
• Diverticulosis is a DEFICIENCY disease!!
16. • Painter and Burkitt most responsible
for our current understanding of
diverticular disease
• No description before industrial
revolution
• Roller-milling wheat flour (1880)
developed in Europe 25 years before
first cases of diverticulosis
• During the 20th century, progressive
increase in diverticulosis while
decreased consumption of
unprocessed grain and increased
consumption of sugar and meat
17. Epidemiology
• Most studies report women are more
commonly effected
• Incidence increases with age
• Correlation with presence of disease and
incidence and duration of symptoms is less
clear
• Young men are more likely to require surgery
than elderly patients
• Inheritable factors? Resections for identical
twins have been documented
• Several studies have suggested an
association between use of NSAIDS and
development of complications from
diverticular disease
18. Epidemiology
• 5-10 percent of the population over 45 years
old will be affected by diverticular disease
• Almost 80 percent over the age of 85
• Symptomatic diverticulitis will develop in
only 20 percent
• 20 percent of patients with diverticulitis will
be less than 50 years old
19. Pathogenesis
• Increased intraluminal pressure and weakening of
the bowel wall
• Diminished stool bulk leads to alterations in GI
transit time and elevated colonic pressure
• In patients with diverticular disease, motor studies
show exaggerated response of pharmacologic
stimulation, increased intraluminal pressures, and
faster frequency waves and rapid contractions
• Hypersegmentation and increased pressure cause
herniation of colonic mucosa at areas of
weakening adjacent to points of penetration of the
vasa recta through the bowel wall
20. Pathogenesis
• Laplaces law: tension in the wall of bowel is
proportional to the radius multiplied by the
pressure; explains why diverticula develop
more frequently in the sigmoid colon
• Diverticula are arranged in rows between the
mesentery and lateral taeniae coli
• Once present, particles of undigested food
become inspissated within them
• Obstruction of the neck then sets the stage
for distention as a result of mucus secretion
and overgrowth of colonic bacteria
21. Histology
• These diverticula are of the pulsion type,
containing only mucous membrane and
peritoneum
• In the absence of inflammation, the lining is
completely normal except increased number
of lymphoid follicles
• Muscular thickening without cellular
hypertrophy or hyperplasia
28. Diagnosis
• Triad: LLQ pain, fever and leukcytosis
• Changes is bowel habits are frequent:
diarrhea or absence of bowel movements are
possible
• Often complain of urinary problems (dysuria,
urgency, frequency, nocturia) which may be
secondary to impingement of inflammatory
mass on the wall of the bladder
• Colovesical fistula: pneumaturia, fecaluria, or
recurrent UTI’s
29. Diagnosis
• Physical exam: tenderness is localized
to the LLQ
• Generalized peritonitis with rupture of a
peridiverticular abscess or free
perforation
• Colonic obstruction
• Pylephlebitis
• Atypical: elderly and
• immunocompromised
30. Diagnosis
• CT Scan
– safest and most cost effective method
– diagnostic and therapeutic with treatment
of abscesses
– inflammation of the pericolonic fat,
presence of diverticulum, thickening of the
bowel wall, and peridiverticular abscesses
– false negative rates of 2-21 percent
31. Diagnosis
The CT scan shows inflammation of the pericolic fat, manifested as
increased attenuation and stranding occupying the sigmoid mesocolon
between two sigmoid loops (S). Extraluminal gas (arrow) adjacent to a
thick-walled diverticulum is suggestive of the site of perforation.
33. Diagnosis
• Three Distinct Clinical Entities
– Symptomatic, uncomplicated diverticular
disease: symptoms, pain or change in
bowel habits, without evidence of
inflammation
– Uncomplicated diverticulitis: pain, fever
and leukocytosis
– Complicated diverticulitis: stricture,
fistula, abscess, mass or perforation
34. Modified Hinchey Classification
• Stage I: Pericolic abscess confined by the
mesentery of the colon
• Stage IIa: Distant pelvic abscess amenable to
percutaneous drainage
• Stage IIb: Complex abscess associated with
or without fistula
• Stage III: Generalized peritonitis
• Stage IV: Fecal peritonitis
Surg Clin North Am. 2000; 80:1299-1319
35. Treatment: Uncomplicated
Diverticular Disease
• Colonoscopy or flexible sigmoidoscopy to
confirm diagnosis
• Increase dietary fiber intake
• Unlikely to progress to diverticulitis: only
1.4% of patients progressed when followed
prospectively
• Most patients who develop diverticulitis do
so in the absence of a previous history of
diverticular disease
Dis Colon & Rectum. 2007; 50(9):1460-1464
36. Treatment: Uncomplicated Diverticulitis
• Outpatient (Tolerate a diet, No systemic symptoms
or peritoneal signs, Reliable patient)
– Oral antibiotics
– Bland Diet
• Inpatient (Immunocompromised, steroid, Advanced
age)
– IV antibiotics
– NPO +/- NGT
• CT scan if no improvement in 48 hours
• Surgical intervention
– Peritonitis
– Abscess not amenable for percutaneous drainage
– No improvement in 3-4 days and CT shows no
abscess
37. Treatment: Antibiotic Coverage
• Antibiotics should target anaerobes such
as Bacteroides fragilis and
Peptostreptococcus, Peptococcus, and
Clostridium species, as well as aerobes
such as Escherichia coli and Klebsiella,
Proteus, Streptococcus, and
Enterobacter species
• Single agents as effective as
combination
• Cipro/Flagyl, Bactrim/Flagyl, Zosyn,
Ancef/Gent/Flagyl, etc…
38. Treatment: Complicated Diverticulitis
• Abscess
– Most abscesses less than 5 cm will regress
with antibiotic treatment alone
– CT-guided drainage with antibiotics for
abscess greater than 5 cm
– Elective surgical resection with primary
anastomosis
– Low pelvic abscess – Transrectal or
Transvaginal drainage
– Surgical Drainage – laparoscopy vs open
39. Treatment: Complicated Diverticulitis
• Fistula
– Colovesical (70%)
• Pneumaturia, fecaluria, Recurrent UTI, Hematuria, abd
pain.
• CT scan – air in the bladder without recent catheterization
• Foley cath drainage for 7 days; Larger openings repaired
with absorbable sutures
– Colovaginal (25%)
• Vaginal discharge, air or stool per vagina
• Contrast enema or methylene blue enema with a vaginal
tampon
– Colocutaneous, Coloenteric, Colouterine and
Coloureteric
40. Treatment: Complicated Diverticulitis
• Fistula
– Develop in 2% of pts with diverticulitis, but
accounts for 20% of patients undergoing
surgery
– Malignancy must be excluded
– Most patients can be managed electively
with resection of the diseased segment,
primary anastomosis, and repair of the
contiguous organ
41. Treatment: Complicated Diverticulitis
• Stricture
– Repeated mild episodes can cause fibrosis
& stricture
– Gradual onset: constipation & diarrhea
– Tapered appearance on Barium enema
– On scope: narrowed but with normal looking
mucosa
– Can present with acute obstruction
– Rx: operation vs dilation and stenting
42. Treatment: Complicated Diverticulitis
• Perforation
– Requires emergency operation
– Historic 3 stage operation
– Current 2 stage operation (Hartmann’s
procedure 1921)
– 1 stage operation-increasingly advocated
– Reversal of colostomy should be delayed at
least 3 months
– Only 30-75% go on to have colostomy
closure (NEJM 1998; 338(21): 1521-1526)
43. Treatment: Recurrent Diverticulitis
• About 5-25% of patients will develop a second episode.
• Successful response to medical management drops
from 70% after first attack to 6% after third attack
(Parks et al. Br J Surg 1970; 57: 775-8)
• Younger patients are at a higher risk of recurrent
attacks
• Chautems et al. DCR 2002; 45:962-966
– 118 pts with acute diverticulitis followed long term
(median 9.5 yrs).
– Poor outcome associated with young age (< 50 yrs)
and disease severity on CT
– Incidence of complications at 5 years was 54% for
young pts with severe disease compared to 19% for
older pts with mild disease
44. Treatment: Recurrent Diverticulitis
• Retrospective study of 3165 pts with acute
diverticulitis – 12 Kaiser Permanente
hospitals
• Emergency colectomy in 614 pts (19.4%)
• Elective colectomy in 185 pts – young age,
fewer comorbidities, percutaneous abscess
drainage
• 2366 pts were followed –mean f/u 8.9 yrs
• 314 pts developed recurrence (13.3%)
• 222 had a single recurrence and 92 had a
rerecurrence
• Younger age was associated with recurrence
and a first recurrence was the only factor that
predicted rerecurrenceBroderick-Villa et al. Arch Surg 2005; 140: 576-581
45. Current Recommendations
• Elective surgical resection
–After 2 attacks of acute diverticulitis
–After 1 attack in patients younger
than 50 and in immunocompromised
patients
–After percutaneous drainage of
abscess
–Complications – Fistula, Stricture
46. Is it time rethink the rules ?
• Chapman et al
– Majority of patients (53%) with complicated
diverticulitis had no history of diverticulitis
– Perforated diverticulitis, which has the
highest risk of mortality and morbidity,
most commonly was the first manifestation
of complicated diverticular disease.
– Significant association between perforated
diverticulitis and increased mortality and
morbidity in patients who are
immunocompromised
Ann Surg 2005; 242: 576-583
47. Is it time rethink the rules ?
• Janes, et al
– Elective resection after 2 attacks of uncomplicated
diverticulitis has been questioned Janes, et al
– Suggestions based on cost-effective analysis and
morbidity/mortality of elective operation - elective
resection may be delayed until after the 3rd or 4th
episode of uncomplicated diverticulitis
BJS 2005; 92:133-142
48. Is it time rethink the rules ?
• Young patients – 5-10% of pts <50yo develop
diverticulitis; Traditionally thought to be more
virulent disease
• 2 studies suggest that increased risk may be
chronological rather than pathological
phenomenon
– Young patients should be managed according to
the same protocol as those >50yo
Janes et al. BJS 2005; Biondo et al. BJS 2002
49. Immunocompromised patients
AIDS, chemotherapy, postorgan transplantation,
steroid use, renal failure and cirrhosis
– Higher % fail medical management
– Higher rate of free perforation (43% vs 14%)
– Higher rate of need for surgery (58% vs 33%)
– Higher postoperative mortality (39% vs 2%) versus
noncompromised patients
– Most advocate elective resection after 1 attack
50. Surgical Principles
• Remove all indurated & thickened bowel. Not
necessary to remove all proximal diverticula
• Distal resection margin should be across the
proximal third of rectum. Level of distal
transection is the only factor which influences
the rate of recurrent diverticulitis after
surgery*
• Splenic flexure mobilization
• Identify left ureter
• ? Preserving the superior rectal artery
Benn et al. Am J Surg 1986; 151:269-271
*Thaler et al. DCR 2003; 46: 385-388
53. Laparoscopic Surgery for Diverticulitis
• Technically challenging
–Acute inflammatory process
–Thick sigmoid mesentery
–Associated abscess or fistula
–High conversion rate
54. Laparoscopic colectomy vs. open
colectomy for sigmoid diverticular disease
Laparoscopic
(n = 66)
Open
(n = 88)
p
Blood loss (ml) 143 ± 8.7 314 ± 11.2 < 0.05
OR time (min) 212 ± 7.2 143 ± 5.7 < 0.05
Oral intake (days) 2.9 4.9
Hosp. Stay (days) 4.8 8.8
OR charges ($) 9,566 7,306
Hosp. Charges ($) 13,953 14,863
Dwivedi et al. Dis Colon Rectum 2002; 45 (10): 1309
55. Laparoscopic colectomy vs. open
colectomy for sigmoid diverticular disease
Laparoscopic (%) Open (%)
Postoperative
complications
18.1 23.8
Partial SBO 3.0 10.2
Anastomotic leak 1.5 3.4
Atelectasis 3.0 1.1
Wound infection 1.5 2.3
UTI 7.6 4.5
Ureteral injury 1.5 2.2
Dwivedi et al. Dis Colon Rectum 2002; 45 (10): 1309
56. Laparoscopic vs. Open Colectomy for
Diverticulitis
Laparoscopic
(n = 56)
Open
(n = 215)
p
OR time (min) 170 ± 45 140 ± 49 <0.001
ICU transfer 1 39 <0.001
Length of stay (days) 4.12 9.06 <0.001
Complications 9% 27 % <0.01
Mortality 0 3
Hospital charges ($) 17,414 25,700
Lawrence et al. Am Surg 2003; 69(6): 499
57. Laparoscopic vs Open Colectomy
Outcomes comparison based on large nationwide
databases
• Analyzed 18,444 pts. from Nationwide Inpatient
Samples from 1998 to 2000
• Laparoscopic Sigmoidectomy was associated
with
– Shorter hospital stay (p < 0.001)
– Fewer gastrointestinal tract complications (p = 0.03)
– Lower overall complication rate (p = 0.007)
– Higher routine hospital discharge rate (p < 0.001)
Guller et al. Arch Surg 2003; 138(11): 1179
58. BMC Surgery
Study protocol Open Access
The Sigma-trial protocol: a prospective double
blind multi-center comparison of
laparoscopic versus open elective sigmoid
resection in patients with symptomatic
diverticulitis
Bastiaan R Klarenbeek1, Alexander AFA
Veenhof1, Elly SM de Lange2, Willem A
Bemelman3, Roberto Bergamaschi4, Piet
Heres5, Antonio M Lacy6,Wim T van den
Broek1, Donald L van der Peet1 and
Miguel A Cuesta*1
