|
Prince Charles Hospital, Merthyr Tydfil*, Royal Glamorgan Hospital, Llantrisant+ and School of Care Sciences, University of Glammorgan, Pontypridd, Wales
J.R.Coll.Surg.Edinb., 47, April 2002, 481-484
Background: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. Aim: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. Materials and Methods: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. Results: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann’s operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital postoperatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. Conclusions: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.
Key words: diverticulitis, elective colectomy
Colonic diverticular disease is a common problem in the Western world. The incidence of the disease increases with age but only a minority of these patients are symptomatic. Complications of diverticular disease, however, can cause significant morbidity and mortality. Studies about the natural history of diverticular disease and the incidence of complications after an initial attack have reported varying outcomes. There also appears to be a difference in the clinical presentation of the disease between North American and European patient groups.1 In contrast to European patients, North American patients appear to present with recurrent episodes of diverticulitis before developing further complications. This has led to a debate on the value of elective colectomy in preventing complications of diverticular disease.
The aim of this study was to assess whether the complications of diverticular disease requiring emergency or urgent surgical intervention are related to previous episodes of diverticulitis and if elective colectomy might prevent such complications.
All patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995-2000, with a combined catchment population of 350,000, were included. The details of these patients were obtained from the pathology database and from medical records with the help of clinical coding. A retrospective review was performed and the diagnosis was confirmed from histopathology reports. We recorded information on demographics, mode of referral, details of the complications and the treatment given, as well as the final outcome. We also reviewed the past history of these patients with regard to previous investigations or treatment for diverticular disease.
A total number of 108 patients (42 males and 66 females) were admitted with complicated diverticular disease. Ninety eight (91%) patients were emergency admissions and 10 (9%) patients were urgent admissions. Of the 98 emergency admissions, there were 3 patients with rectal bleeding. Ninety five patients were admitted with infective complications, of which three patients were Hinchey’s stage I (pericolic or mesenteric abscess), 6 patients were stage II (walled off pelvic abscess), 59 patients were stage III (generalised purulent peritonitis) and 27 patients were stage IV (generalised faecal peritonitis).2 Seven of the 10 urgent admissions were for fistulae, and three patients were admitted with pelvic masses to gynaecologists, and were subsequently found to have diverticular phlegmons with pericolic abscess formation. Of the 108 patients, 104 underwent emergency or urgent surgery. Four patients were not operated on, due to their poor general condition. In total, 34 (31.4%) patients died in hospital post-operatively. Out of the 108 patients, only 28 (26%) patients were previously diagnosed to have diverticular disease, either by barium enema or endoscopy. The mean duration of diverticular disease in these patients before they presented with complications was 5.7 years (range 1 month-20 years). Eight of the twenty eight patients had required previous admissions for acute exacerbation of their symptoms, three having been admitted twice. Only three patients had treatment for acute diverticulitis with intravenous fluids and antibiotics.
Colonic diverticular disease is being diagnosed with increasing frequency due to the large number of barium enemas and endoscopies being performed. High pressure muscular contractions of the colonic wall linked to a low fibre diet has been suggested as the chief aetiological factor.3
Uncomplicated diverticular disease diagnosed by barium enema or endoscopy is very common and is often considered to be the cause of symptoms such as lower abdominal pain, flatulence and altered bowel habit. Little correlation has been found between the radiological extent of the disease and the clinical symptoms.4 Complications of diverticular disease occur in a minority of patients and include acute diverticulitis, abscess formation, free perforation, fistulae, bleeding and stricture formation.5
Acute diverticulitis responds to medical treatment in the majority of patients.6 A small proportion, of patients, however, may develop further complications leading to urgent or emergency surgical intervention.
Localised or free perforation or bleeding from a diverticulum can be life threatening. Diverticular perforation leading to septic complications carries a high mortality (15-50%), due often to the age and coexisting medical disease of the patient.7 Surgery is often carried out and, more recently, laparoscopic procedures have been suggested. 8 The mortality rate in our series is high (31.4%) and may be due to the high proportion of perforated diverticular disease. All the deaths in our series occurred in this group.
Bleeding in diverticular disease varies in incidence and is often massive. 9 In most cases, it subsides spontaneously, but emergency angiography and surgical intervention may be needed in some patients.
Elective surgery to provide symptomatic relief in uncomplicated diverticular disease has been the focus of many studies. Most of them have concluded that it is a procedure associated with significant risks, which cannot be justified in the absence of life threatening complications. 10 It has also been suggested that surgery is no better than medical management in controlling symptoms. 11 Also, symptoms can recur in a significant proportion of operated patients.10
The role of elective colectomy in preventing future complications of diverticular disease remains unclear. Many studies have concluded that complicated diverticular disease is more common in patients with previous episodes of diverticulitis.1
It has been suggested that early elective resection provides definitive cure analogous to cholecystectomy or appendicectomy. 12 A national audit was carried out in the United Kingdom on a group of patients admitted with complicated diverticular disease between 1985-88. These patients were followed up over the next 5 years. It was observed that recurrent complicated diverticular disease and the resultant mortality were significantly greater in those patients who were treated conservatively during their index admission. As a result, the authors recommended interval sigmoid colectomy in such patients after the initial episode. 13 Others studies, however, point out the low rate of readmission with recurrent disease after an initial attack and argue against elective colectomy. 6,14
Figures from our study show that only 26% of the patients with complications needing emergency or urgent surgery had a previous history of diverticular disease. This is in contrast to other studies in which 50-70 % of patients had had a previous history. 15 The reason for this difference may be due to the possible variation in referral patterns and a difference in the willingness to seek medical advice as the majority of symptoms are non-specific and commonly seen in the community. 16
The authors acknowledge that some degree of inaccuracy of information about the past history of diverticulitis, as recorded in the patients’ case notes, is intrinsic to a retrospective study of this nature.
The natural history of diverticular disease in patients from certain North American institutions appears to vary significantly, when compared with their European counterparts. This may be because, in North America, more patients appear to present with acute exacerbation of the disease before they develop complications. 1 In our study, only 8 (7.4 %) patients had required previous admission for acute exacerbation of their symptoms. This is comparable to a study by Parks (1969) in which 7 % of patients had been treated previously as inpatients.17 Lorimer (1997) carried out a retrospective study on 182 patients hospitalised for treatment of diverticular disease. Ten per cent of his patients admitted with complications had been treated for acute diverticulitis in the past.18
In our study, only three of the 108 patients (2.7%) were similarly diagnosed and treated. However, it is possible that some of the other patients who needed hospitalisation for acute exacerbation of their symptoms could have had acute diverticulitis, despite normal leucocyte counts and absence of pyrexia. Hence, had we followed a policy of elective colectomy after an attack of acute diverticulitis, a maximum number of 8 (7.4%) patients would have benefited out of the 108 patients. Complications would still have occurred in 92.6% of the patients. Elective colectomy for diverticular disease carries a mortality of 1- 4% and the morbidity due to local and general complications varies between 20- 30%.12,19 Considering these factors, it is a clinical dilemma, whether it is appropriate to follow a policy of elective colectomy with the aim to prevent future complications. Elective surgery, however, may be justified in individual patients with longstanding recurrent attacks of diverticulitis, who do not respond to conservative management, where the sole purpose of surgery is to prevent these recurrent attacks and, thereby, provide relief from symptoms. 11
Our study has shown that elective colectomy after an attack of diverticulitis would not have a significant impact on the incidence of life threatening complications, as most of them occur de novo in patients with no previous history of the disease. Further prospective studies are needed in those with known diverticular disease to identify any further risk factors for development of future complications. This would help to identify a group of patients who may benefit from elective colectomy.
1. Veidenheimer MC Clinical presentation and Surgical
treatment of complicated diverticular disease In Allan
RN, Keighley MRB, Alexander-Williams J, Hawkins
CF (eds) Inflammatory Bowel Diseases 1983 pp
519-528 Edinburgh: Churchill Livingstone
2. Hinchey EJ, Schaal PG, Richards GK Treatment of
perforated diverticular disease of the colon. Adv Surg
1978; 12:85-109
3. Halphen M, Blain A: Natural history of colonic diverticulosis Rev Prat 1995 45(8) 952-8
4. Wolff BG, Ready RL, MaCarthy RL, Dozois RR, Beart RW Jr. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis
Colon Rectum 1984 27 : 645-7
5. Keighley MRB Left sided colonic diverticular dis
ease. In Keighley MRB, Williams NS (eds) Surgery
of the Anus Rectum and Colon 1993 pp 1150-51
W.B.Saunders company Ltd
6. Sarin S, Boulos PB Long-term outcome of patients
presenting with acute complications of diverticular
disease Ann R Coll Surg Engl 1994 76(2):117-20
7. Elliott TB, Yego S, Irvin TT. Five-year audit of the
acute complications of diverticular disease Br J
Surg 1997 84(4): 535-9
8. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A Laparoscopic management of generalized peritonitis due to
perforated colonic diverticula Am J Surg 1996 171(4): 432-4
9. Gabrielli F, Chiarelli M, Guttadauro A, Poggi L, Pauna L, Lovaria A Bleeding in diverticular dis
ease of the colon Ann Ital Chir 1998 69(4): 451-7
10. Charnock FML, Rennie JR, Wellwood JM, Todd IP Results of colectomy for diverticular disease of the
colon Br J Surg 1977 64: 417-419
11. Keighley MRB Left sided colonic diverticular dis-ease In Keighley MRB,Williams NS (eds) Surgery
of the Anus Rectum and Colon 1993 pp 1175
W.B.Saunders Company Ltd
12. Hansen O, Zarras K, Graupe F, Dellana M, Stock W Surgical treatment of diverticulitis of the large
intestine- a plea for early elective resection Zentralbl
Chir 1996 121(3): 190-200
13. Farmakis N, Tudor RG, Keighley MR The 5 year
natural history of complicated diverticular disease
Br J Surg 1994 81(5): 733-5
14. Larson DM, Masters SS, Spiro HM Medical and
surgical therapy in diverticular disease: a comparative study Gastroenterology 1976 71: 734-737
15. Hackford AW, Veidenheimer MC Diverticular dis-ease of the colon. Current concepts and management
Surg Clin North Am 1985 65(2): 347-63
16. Janssen HA, Borghouts JA, Muris JW, Metsemakers JF, Koes BW, Knottnerus JA Health status and
management of chronic non-specific abdominal
complaints in general practice Br J Gen Pract 2000
50 (454): 375-9
17. Parks TG Natural history of diverticular disease
of the colon. A review of 521 cases Br Med J
19694:639-42
18. Lorimer JW Is prophylactic resection valid as an
indication for elective surgery in diverticular dis-ease? Can J Surg 1997 40(6): 445-48
19. Letoquart JP, Bansard JY, Kunin N, La Gamma A, Podeur L, Aussel D, Lavenac G, Mambrini A
Surgical treatment of colonic diverticulosis: results
of a series of 70 cases J Chir Paris 1992 129(8-9):
345-51
Copyright: 7 February 2002
Correspondence Professor P.N.Haray, Consultant Surgeon, Prince Charles Hospital, Merthyr Tydfil, CF47 9DT, Mid Glamorgan. Email: mr.haray@nglam-tr.nhs.wales.uk