Surgical management of complicated colonic diverticulitis

Improvements in surgical techniques, advances in intensive care medicine and progress in the management of peritoneal sepsis have recently favoured colonic resection with primary anastomosis in the treatment of complicated diverticulitis.

Some 224 patients with complicated diverticulitis who had undergone surgery in the preceding 22 years were reviewed. Complications present on admission included acute phlegmon without pus formation (92 patients), paracolic abscess and/or localized peritonitis (99), diffuse purulent peritonitis (33), complete obstruction of the sigmoid colon (eight) and paracolic abscess complicated by fistula (27).

The overall mortality rate was two (1 per cent) of 183 for resection with primary anastomosis, seven of 31 for Hartmann's operation and four of ten for the delayed three-stage procedure. The anastomosis was made by instruments employing the double-stapled technique in 130 patients and hand-sutured in 94. Reversal of Hartmann's operation was undertaken in only 31 per cent compared with 89 per cent for closure of the protective colostomy in patients with primary anastomosis.

The Hartmann operation may be the most popular at present, but resection with primary anastomosis is the safest procedure for all stages of complicated diverticulitis, and reduces costs. There is no longer any clinical indication for the three-stage operation.