What are the surgical considerations for complicated diverticulitis?

Updated: Aug 06, 2019
  • Author: Elie M Ghoulam, MD, MS; Chief Editor: BS Anand, MD  more...
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Consider the following for some forms of complicated diverticulitis:

  • Diffuse peritonitis: An appropriate initial empiric antibiotic regimen must include either single-agent therapy with imipenem/cilastin or piperacillin/tazobactam or multidrug therapy with ampicillin, gentamicin, and metronidazole.

  • Differentiate obstruction from carcinoma. Even if biopsy results are negative, resection may be necessary to exclude carcinoma if there is enough suspicion based upon appearance alone.

  • Abscesses without peritonitis may be amenable to percutaneous drainage with an elective single-stage operation after the episode has resolved. Drainage is usually performed through the anterior abdominal wall, but it may be done transgluteally or through the rectum or the vagina, depending on the location of the abscess. Catheter drainage may be helpful in patients who cannot undergo surgery; the catheter should be left in place until the drainage is less than 10 mL in 24 hours. Obtain periodic catheter sinograms to monitor the resolution of the abscess cavity before the catheter is removed.

  • Fistulas generally do not close spontaneously, but they may be managed with an elective one-stage procedure in most cases. Also, in the absence of urinary tract obstruction, observation appears to be safe in patients with contraindications to surgery.

  • Patients who are immunosuppressed are at an increased risk for perforation. Surgery is necessary in almost all patients who are either already immunosuppressed or are about to start immunosuppressive therapy.

  • Elderly patients: Septic, hemodynamically unstable elderly patients with acute complicated diverticulitis should undergo surgical intervention as soon as possible, regardless of their Hinchey stage. [48] Fit and hemodynamically stable geriatric patients have surgical options similar to those of their younger counterparts; those who are frail but hemodynamically stable should undergo a Hartmann procedure.

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