Current indications and role of surgery in the management of sigmoid diverticulitis

Abstract

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

Figure 1

Diverticulitis. A: Uncomplicated sigmoid diverticulitis with colonic thickening and straining at CT (arrow), also referred to as “mild” CT diverticulitis. Two diverticula contain contrast medium without evidence of extravasation outside the sigmoid; B: “Severe” CT diverticulitis with extravasation of contrast and small amount of extraluminal air (arrow). This patient was initially managed non-operatively and eventually required surgery for recurrent disease.

Figure 2

Fistula. A: Colovesical fistula as indicated by the presence of air in the bladder. This patient had symptoms and other CT findings consistent with sigmoid diverticulitis; B: Sigmoid diverticulitis and colovaginal fistula. This patient had undergone previous hysterectomy and complained of feculent discharge from her vagina. CT scan indicated inflamed sigmoid with adherent small bowel loop (arrow). The small bowel loop could be successfully separated from the sigmoid at the time of laparoscopic sigmoidectomy. There was no evidence of coloenteric fistula; Sigmoid diverticulitis with colocutaneous fistula (arrows) (C and D) (courtesy of Dr. Ravi Pokala Kiran, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA).

Figure 3

Sigmoid stricture (arrow) causing large bowel obstruction with proximal colonic dilatation. Clinical and imaging findings at presentation did not allow ruling out sigmoid carcinoma. This patient was treated with initial Hartmann procedure and the pathology report revealed sigmoid diverticulitis. He subsequently underwent Hartmann takedown after 3 mo.

Figure 4

On-table intraoperative colonic lavage (see explanation in text).

Figure 5

Sigmoid diverticulitis complicated by pericolic abscesses (A and C, arrows) requiring treatment by placement of two separate CT-guided percutaneous drains (B and D). This patient underwent laparoscopic sigmoidectomy with primary colorectal anastomosis and removal of both drains 6 wk after percutaneous drain placement.