Surgical Treatment of Perforated, Obstruction and Fistula Acute Diverticulitis

Surgical Treatment for Diverticulitis

The inflammation of the diverticulum is usually localized to the area adjacent to the perforation, thus forming a peri-colic abscess.
This abscess in turn may burrow into one of the viscera which contributed to the process and thus an internal fistula develops.
Only occasionally the peri-colic abscess may burst into the free peritoneal cavity producing purulent peritonitis.
Also rare is that the initial perforation has not been walled-off, so that free perforation occurs with a chance of generalized fecal peritonitis.

With localized peritonitis medical treatment is justified with careful watch.

When acute inflammation has completely subsided, elective operation should be called for.
In case of acute generalized peritonitis emergency operation becomes mandatory.
In case of perforation and peritonitis proximal infective colostomy, closure of perforation and drainage should be performed.
In more infective cases, the diseased bowel is resected; end-to-end anastomosis is performed with proximal decompressing colostomy.
Another procedure may be adopted in which the diseased bowel is mobilized and resected.

Sometimes a patient will present when natural defenses have localized the infection in the pelvis and the patient is not seen by the surgeon till symptoms of intestinal obstruction have occurred.
Partial obstruction may be due to inflammation, spasm and edema with element of paralytic ileum.
Complete obstruction may be due to repeated episodes of diverticulitis with fibrosis and stenosis.
Straight X-ray of the abdomen is valuable to differentiate between small and large bowel obstruction.

After exploration one should first attempt to find out whether or not a carcinoma is present and to do this it may be necessary to mobilize the mass. The main treatment of obstruction with diverticulitis is diverting transverse colostomy and primary resection of the bowel with anastomosis.
If carcinoma is suspected, primary resection is more justified.

Internal fistulas may be seen in 5% of cases between the involved segment of colon and adjacent organs e.g. urinary bladder, ileum, vagina, uterus and ureter.
External fistula (colo-cutaneous) rarely occur spontaneously, but are common post-operative complications through the incision or drainage site.
Pneumaturia (air in the urine) and fecaluria (feces in the urine) are diagnostic of colo-vesical (bladder) and colo-ureteric fistulas.
Fever is also common.
Cystoscopy and cystography are helpful in investigation of the condition.

Fistula in the bladder is dissected out and the bladder wall is closed.
The diseased colon is resected with primary anastomosis.
Supra-pubic drainage is given.
When inflammatory process is extensive, operation is performed in two stages. The diseased bowel is resected and the proximal colon is brought out as end colostomy. The distal portion is closed.
When the inflammation has sub-sided adequate resection is done and end-to-end anastomosis is performed.

Related Topics