Surgery for Diverticulitis
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In diverticulitis, the colon (or large intestine) develops one or more small diversions or outpouchings that - because of their abnormal shape and position - become irritated and cause painful symptoms or, sometimes, dangerous complications. These bulges, known as diverticula (singular is a diverticulum), cause no symptoms for some patients, while in others they become inflamed or infected. Having diverticula is a condition called diverticulosis. The presence of diverticula or diverticulitis is also referred to as diverticular disease. Today, laparoscopic procedures are rapidly improving surgical treatment for acute and severe diverticulitis.
Most people with diverticulosis will not develop diverticulitis. But about half of all Americans ages 60 to 80, and almost everyone over age 80, have diverticulosis. A significant percentage of them will become symptomatic. The disease is common in developed or industrialized countries - particularly the United States, England, and Australia - where diets tend to be lower in fiber. Diverticular disease is rare in countries such as Asia and Africa, where people eat high-fiber diets that are more heavily based on vegetable food sources.
Diverticula are partly the result of increased pressure in the colon, the main cause of which is constipation that, in turn, causes muscles to have to strain to move stool that is hard and compacted. This can force weak spots in the colon to bulge out. These areas are a kind of herniation of the inner intestinal lining through junctures of the muscular wall, forming a protruding pouch on the colon. Physicians do not know what causes infection in some diverticula, but believe it may begin when stool or bacteria are caught in these areas.
Diverticulosis may not cause any discomfort for some people. For still others, it may cause only mild cramps, bloating, or constipation. When the condition develops into diverticulitis, however, abdominal pain and tenderness around the left side of the lower abdomen are usually present. If diverticular bleeding occurs, blood may be apparent in the stool. When diverticulitis causes infection, the patient may experience fever, nausea, vomiting, chills, and further cramping or constipation. Less commonly, the diverticuli in the colon can rupture, which results in infection in the tissues that surround the colon, a dangerous condition. Thus, serious complications of diverticulitis can include bacterial peritonitis (abdominal cavity infection), bleeding in the colon, or colon obstruction.
Conservative Therapy, Surgery for Complications
When possible, physicians will always attempt to treat diverticulitis noninvasively. A change in diet to include more fiber can be a step that increases stool volume and thus prevents constipation. (However, once diverticula are formed, they are generally permanent unless removed surgically.) Bed rest, liquid diet, and antibiotics can also help for acute bouts. Diverticulitis can require treatment with medications for pain, infection and inflammation, and muscle spasms. Hospitalization or surgery are sometimes needed for acute attacks.
Sometimes, specialists can treat some serious symptoms of diverticulitis, such as bleeding or intestinal blockage, with colonoscopy. But often patients with severe disease, or complications of the disease, will require surgery, using either a laparoscopic approach or open procedure.
Some patients are candidates for surgery because of multiple, severe attacks of diverticulitis in the course of one or more years; a narrowed or partially blocked colon; repeated bleeding in the colon; or an ulcerous opening (fistula) from the colon to nearby tissue or organs. Patients who need surgery because of complications also include those who have a diverticulum that has ruptured; infection that has spread into the abdomen or into the blood; an obstructed bowel; or severe bleeding.
Minimizing the Invasiveness of Surgery
In operations to treat these conditions, the surgeon removes the deformed and inflamed portion of the large intestine (an operation called a partial colectomy, sigmoid resection, or segmental resection) and then reconnects the ends of the intestine to restore continuity of the digestive tract. Increasingly, surgeons can offer these procedures laparoscopically. The team makes small incisions at several locations in the lower abdomen and uses these to access the colon with endoscopic equipment. These tools are slender tubes, including a scope with a self-lit lens at the end, that permit the surgeon see and manipulate the colon during the operation. Using laparoscopy, the colorectal surgeon can perform surgery while watching a video monitor of the endoscopic images and of the instruments used to resect and suture the intestine. The skilled surgeon can take advantage of these techniques to resect and repair the colon safely - providing for an easier procedure for patients to undergo, compared to conventional, open surgery.
The laparoscopic approach means less blood loss, a shorter hospital stay, quicker healing, less pain, faster recovery (including of bowel function), and more prompt return to activities, when compared to open colon resection. Patients with more extensive inflammation, however, may need a traditional, open operation.
The surgeon may perform the partial colectomy as one operation or as a two-step procedure used more commonly for patients with extensive inflammation. In the latter case, the surgeon first removes the diseased section of colon and then attaches the upper end of the intestine to a small opening in the abdominal wall (stoma), permitting temporary collection of fecal matter outside the body (an operation called a colostomy) while the inflammation and infection of the intestine subsides and the colon heals. After a number of weeks or months, when the colon and rectum have recovered enough to make the second phase of the operation safe, the surgeon reconnects the ends of the intestine, to re-establish the digestive tract, and closes the ostomy. (For a few, mostly older or sicker patients, the ostomy may be permanent.) The two-step approach is also used in cases of emergency, life-threatening abdominal infection.
The surgical team places patients under general anesthesia during a partial colectomy. These operations require several days of hospitalization and several weeks of recovery.
Treatment for diverticulitis can also involve abscess drainage. If the medical team identifies the abscess early enough, it may be able to drain it through the skin as an alternative to surgery.