Microscopic findings in sigmoid diverticulitis--changes after conservative therapy

Abstract

Introduction: The indications for prophylactic surgery for phlegmonous and covered perforated type of acute sigmoid diverticulitis (SD) are currently matters of debate, and a more conservative approach has been advocated. However, it has not yet been clarified to what extent CT findings indicative of acute SD correlate with histological findings, and it is still uncertain how these findings change in the time interval between initial antibiotic treatment and late elective surgery. The aim of this study was to record time-course changes of inflammation in phlegmonous and abscess-forming diverticulitis after conservative treatment in order to check the indication for surgery.

Material and methods: This study included all patients who underwent surgery for CT morphologically phlegmonous and covered perforated SD from January 2002 to June 2007. Two groups were formed to record time-course changes: early elective surgery (7-10 days after antibiotic treatment) and late elective surgery (4-6 weeks after conservative treatment). Exclusion criteria were emergency interventions, free perforations (Hinchey III and IV), recurrent inflammations, and contrast allergy. The extent of the inflammation recorded preoperatively by CT scan was compared with histological findings.

Results: A total of 257 patients (142 male and 115 female; mean age, 56.6 years) underwent surgery (116 early elective and 141 late elective) for phlegmonous and covered perforated SD. Phlegmonous SD was seen in 127 cases and covered perforated SD in 130 cases. In the phlegmonous type of SD, early surgery led to conformity with the preoperative stage in 56%, to more extensive findings in 11%, and to subsided inflammation in 33%. Late surgery led to conformity in 0% and to signs of subsided inflammation in 100%. In the covered perforated type of SD, early surgery led to conformity in 90%, to subsided inflammation in 10%, and to milder manifestation in 0%. In contrast, late surgery here led to conformity in 26% of the cases and to subsided inflammation in 74%. Considerable histological changes can be detected under conservative therapy. The acute inflammation subsides under antibiotic therapy as awaited. It must be clarified whether the phlegmonous form of SD should, in principal, be regarded as an indication for surgery, since it shows early and nearly complete regression of the inflammation. Otherwise, the covered perforated type of SD still shows marked inflammatory changes after conservative therapy in a high percentage of patients and should thus preferably be treated by surgery. However, the clinical appearance of the patient with sigmoid diverticulitis still remains the most important part of decision making.