Diverticulitis: When is Surgery Necessary?

What is Diverticulitis?

Acute diverticulitis refers to a broad spectrum of pathological conditions characterized by inflammation, each requiring selective treatment. The exact cause of diverticular inflammation remains unclear; traumatic or ischemic factors are suspected.

How Does Diverticulitis Manifest?

Diverticulitis can cause spontaneous and variable pain in the lower left abdomen, which may be palpable. Other common symptoms include abdominal distension, nausea, and bowel disturbances. Signs of inflammation such as fever, increased white blood cell count, and elevated CRP levels may also be observed. Fortunately, with appropriate treatment such as antibiotics, fluid infusions, and rest, combined with fasting, symptoms generally subside within a few days, and the patient recovers their usual health.

When diverticulitis occurs, the diverticulum may perforate into the peritoneum, leading to a serious situation characterized by peritonitis rather than the localized inflammation previously mentioned. It can also manifest as bowel obstruction, a fistula with the bladder, blood loss in the stool, or perforation with an abscess.

In older individuals, in particular, pain may be reduced or absent, and symptoms may be more subtle than in younger people or adults, making diagnosis more challenging.

Diagnosis of Diverticulosis

To diagnose diverticulosis, the doctor will take a thorough medical history through a series of detailed questions, conduct a complete physical examination, and may employ one or more diagnostic tests.

The physical examination usually includes a rectal examination. Your stool will be checked for signs of bleeding, and blood tests will detect signs of infection.

If diverticulitis is suspected, your doctor may order one of the following radiological examinations:

  • Abdominal ultrasound;
  • Computed tomography (CT) scan;

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When is Surgical Treatment of Diverticulitis Necessary?

Peridiverticular Abscess

To treat a peridiverticular abscess, it's crucial to reduce the progression of infection by administering antibiotics and performing surgical interventions, which can vary in invasiveness depending on the size of the infected area. The patient's high fever makes this approach particularly effective.

A small collection can often be easily drained by placing a drainage tube under ultrasound guidance. Under ultrasound vision, a needle guide directs the drainage tube to aspirate the purulent collection. If, however, the collection is larger or located in an anatomically difficult-to-reach area, laparoscopic lavage is the only solution.

This is a surgical intervention, but performed using a minimally invasive laparoscopic technique, which is short in duration. Under video guidance, aspiration and washing of the infected collection with warm saline solution are performed, reducing the microbial load. A drainage tube is left in place to allow further cleaning of the collection.

Hemorrhage and Diverticulitis

In some cases, the acute inflammatory process can cause erosion of blood vessels of varying sizes in the affected colonic segment, resulting in hemorrhage. Diverticular hemorrhages are generally successfully treated with conservative medical management, blood transfusions, and rarely require surgical resolution.

Diverticular Perforation

This is arguably the most feared eventuality in acute diverticulitis. When the diverticular wall ruptures, the colonic contents spill into the abdominal cavity, causing peritonitis.

This constitutes a true surgical emergency, where the patient often presents with severe clinical conditions, suffering from a high fever and generalized abdominal pain with rigidity.

In many instances, the perforation may be minute, and the fat may successfully seal the colon without risky surgery. In such cases, conservative treatment during hospitalization is recommended, administering intravenous antibiotics and fluids while keeping the patient fasting to promote natural healing.

Surgical intervention may be necessary when the perforation is extensive. The main objective of this operation is to control the infection that has spread into the abdominal cavity. To achieve this, frequent and copious washes with warm physiological solution are performed to remove as much infected material as possible.

The postoperative period requires close attention, as it can be affected by problems such as wound infections and, in particular, anastomotic leaks (leakage through the suture line). Fortunately, these complications are often easily managed using antibiotics and effective drainage techniques. Close monitoring of the postoperative course is therefore essential to act quickly if necessary.

Advantages of Minimally Invasive Surgery for Diverticulitis

It is now universally accepted that minimally invasive laparoscopic surgery for the treatment of diverticulitis offers numerous advantages over traditional open surgery. Surgery becomes incisionless, and the operation is performed using only "small holes." But this does not only imply an aesthetic advantage.

Postoperative pain is significantly reduced, leading to less use of painkillers and allowing patients to be fed and out of bed in the days following the operation. Improved postoperative recovery is now possible thanks to new techniques. Using modern anesthesia and analgesia methods, the operation could be performed without general anesthesia or intubation, further accelerating recovery. The benefits of epidural and spinal anesthesia can thus be fully exploited, both for medical procedures and cesarean sections.

In the past, these interventions were certainly devastating for the patient's body and mind. In contrast, the technical and scientific innovations described here result in less stress on the body. The operated patient returns to daily life very quickly.

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