Highlights of the ASCRS Annual Meeting
Diverticular disease is common in the Western world, but few patients with uncomplicated disease require surgery. When surgery is indicated, the choice of procedure is determined by the degree of contamination and the expertise of the operating surgeon. The management of acute diverticulitis in young patients remains somewhat controversial. Traditionally, acute diverticulitis in patients under 50 years of age has been considered a more virulent entity. Surgery has been recommended for these patients after their initial episode of diverticulitis instead of after the second episode of simple acute diverticulitis, as is done in patients over age 50.
The approach to management of younger patients with acute diverticulitis was examined by N. Hyman, MD, and J. Guzzo, MD, of Burlington, Vermont. They reviewed the treatment and follow-up of 762 patients treated for acute diverticulitis treated over a 10-year period. Of these patients, 259 were < 50 years of age and they comprised the young patient group. The older group included 503 patients > 50 years of age. Surgery was required during the initial hospitalization in 63 (24%) patients in the under-50 group and in 110 (22%) patients in the over-50 group. Of the 196 patients managed medically, 41 went on to elective resection. Only 1 of these patients later presented with a free perforation. The majority of patients (155 [79%]) in the under-50 group who were managed medically required no operation during the study period. Drs. Hyman and Gruzzo concluded that recommending surgical resection after an initial attack of diverticulitis based solely on age might not be the best approach. They recommended that the same approach be used for all patients with acute diverticulitis. As for surgery, Dr. Hyman noted that "a more selective approach based on individual patient characteristics and issues such as recurrence may be preferable."
Single-stage resection and anastomosis without diversion for acute complicated diverticulitis remains a controversial subject. Historically, the recommendations for surgical management of complicated diverticulitis have been to perform a 2-stage procedure: resection and diversion with colostomy followed by colostomy closure at a later date. This approach is based on the concern that a primary anastomosis performed in the setting of complicated diverticulitis would impair healing and increase the leakage rate. Recently, that concept has been challenged in several small series with proponents of a single-stage procedure, who claim that it is as safe as the 2-stage procedure in most patients. S. Shah, MD, and R. Schmitz, MD, of Bergisch Gladbach, Germany, examined the course of 393 patients with acute complicated diverticulitis (excluding patients with Hinchley class IV diverticulitis) who underwent surgery after medical management failed. At operation, all patients underwent resection and primary anastomosis. The splenic flexure was mobilized and the anastomosis was performed below the peritoneal reflection in all patients. There were 11 deaths for a perioperative mortality of 2.8% in the study group. One patient developed an anastomotic leak that was treated with drainage only and resolved without further sequelae. Dr. Shah concluded that "resection of the sigmoid with primary anastomosis without colostomy using a circular stapling device is a safe procedure in patients suffering from acute complicated diverticulitis, excluding those with a Hinchley IV."
Diverticular disease is common in the Western world, but few patients with uncomplicated disease require surgery. When surgery is indicated, the choice of procedure is determined by the degree of contamination and the expertise of the operating surgeon. The management of acute diverticulitis in young patients remains somewhat controversial. Traditionally, acute diverticulitis in patients under 50 years of age has been considered a more virulent entity. Surgery has been recommended for these patients after their initial episode of diverticulitis instead of after the second episode of simple acute diverticulitis, as is done in patients over age 50.
The approach to management of younger patients with acute diverticulitis was examined by N. Hyman, MD, and J. Guzzo, MD, of Burlington, Vermont. They reviewed the treatment and follow-up of 762 patients treated for acute diverticulitis treated over a 10-year period. Of these patients, 259 were < 50 years of age and they comprised the young patient group. The older group included 503 patients > 50 years of age. Surgery was required during the initial hospitalization in 63 (24%) patients in the under-50 group and in 110 (22%) patients in the over-50 group. Of the 196 patients managed medically, 41 went on to elective resection. Only 1 of these patients later presented with a free perforation. The majority of patients (155 [79%]) in the under-50 group who were managed medically required no operation during the study period. Drs. Hyman and Gruzzo concluded that recommending surgical resection after an initial attack of diverticulitis based solely on age might not be the best approach. They recommended that the same approach be used for all patients with acute diverticulitis. As for surgery, Dr. Hyman noted that "a more selective approach based on individual patient characteristics and issues such as recurrence may be preferable."
Single-stage resection and anastomosis without diversion for acute complicated diverticulitis remains a controversial subject. Historically, the recommendations for surgical management of complicated diverticulitis have been to perform a 2-stage procedure: resection and diversion with colostomy followed by colostomy closure at a later date. This approach is based on the concern that a primary anastomosis performed in the setting of complicated diverticulitis would impair healing and increase the leakage rate. Recently, that concept has been challenged in several small series with proponents of a single-stage procedure, who claim that it is as safe as the 2-stage procedure in most patients. S. Shah, MD, and R. Schmitz, MD, of Bergisch Gladbach, Germany, examined the course of 393 patients with acute complicated diverticulitis (excluding patients with Hinchley class IV diverticulitis) who underwent surgery after medical management failed. At operation, all patients underwent resection and primary anastomosis. The splenic flexure was mobilized and the anastomosis was performed below the peritoneal reflection in all patients. There were 11 deaths for a perioperative mortality of 2.8% in the study group. One patient developed an anastomotic leak that was treated with drainage only and resolved without further sequelae. Dr. Shah concluded that "resection of the sigmoid with primary anastomosis without colostomy using a circular stapling device is a safe procedure in patients suffering from acute complicated diverticulitis, excluding those with a Hinchley IV."
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