Complicated diverticular disease - our recent experience

Introduction
Diverticular disease and its complications are considered as a "landmark of westernization". In Romania experience with this disease is growing. First described in 1700 by Littré, diverticulosis of the colon was very uncommon until the industrial age. The first case of diverticular disease was described by Cruveilhier in 1849 but the term was first used in 1914. Colonic diverticular disease is a condition characterized structurally by mucosal herniation through the colonic wall, generally accompanied by muscular thickening, elastosis of the taenia coli and mucosal folding (1,2). This condition may be either asymptomatic; and is referred to as "diverticulosis", or either associated with symptoms and termed "diverticular disease" (3). It is present especially on elderly people and can be found all over the world. The incidence of diverticular disease is varying being higher in western world than in developing countries (4). The estimated incidence of diverticulosis is 0.1-1% in U.S.A. and is affecting 5% of the people aged 40. Some estimates the incidence of the disease at 10 patients/100,000 per year (5). More than 60% of the people over 60 years old will develop the disease (1,6). Approximately 25%-30% of these patients will develop a complication. More than 85% of cases of diverticulitis occur on the sigmoid and descending colon. Right colonic diverticulosis is more common in Asia being frequently congenital (7). No sex-related predominance has been demonstrated but a higher incidence in female was demonstrated by some (1,8). In Romania the incidence of diverticulosis is unknown but it is certainly lower than that in Western Europe. Classification of the diverticular disease is presented in Table 1 (1).
The most common complications seen in diverticulosis are inflammation, bleeding and perforation. Inflammation of the diverticuli is known as acute diverticulitis. Only 75-80% patients with diverticulosis will develop symptoms and from these only 20% of the patients will develop diverticulitis, complications of diverticulitis or haemorrhage. Finally, only 1-2% of patients will require hospitalisation and 0.5% will require surgery (9). The most commonly used classification for perforated diverticulitis was proposed by Hinchey (Table 2); although still useful, Hinchey classification is not validated (1).
The diagnostic methods employed in diverticular disease rely especially on CT-scan but also on enemas with water-soluble contrast in complicated disease. Endoscopy is used especially in uncomplicated cases.
In our practice in the Bucharest Emergency Hospital the incidence of complicated diverticular disease is growing. What was before an exotic disease in our practice is today more frequently seen, hence, the objective of this study in trying to address to our new experience with complicated diverticular disease were guidelines are still being developed.

Materials and Methods
A retrospective review of the patients admitted with diverticular disease in the Surgical Clinic of Bucharest Emergency Hospital was performed between January 2004 and December 2007.
All patients were admitted and treated in our surgical unit mainly for complicated diverticular disease. The records of all the patients were analysed for demographic data, comorbidities, clinical presentation, diagnostic procedures, surgical procedures and postoperative results.
Between January 2004 December 2007, 46 patients with confirmed diverticular disease were admitted in the Surgical Clinic of Bucharest Emergency Hospital. All patients were admitted for acute pain and suspicion of a surgical disease. The diagnostic methods were used as judged necessary by the attending surgeon. All patients had a laboratory check-up which included routine blood tests (haemoglobin, hematocrit, urea, glycaemia, ionogram, coagulation profile). Other tests were done in accordance with the history and clinical findings. Plain abdominal X-ray was routinely performed while ultrasound, CT-scan and endoscopy were employed as was deemed necessary by the attending surgeon. Irigography was used in only one patient. In three cases the diagnostic work-up showed colon tumours and diverticular disease and these patients were included in the study because of the association with complication necessitating emergent intervention. In cases with complicated acute diverticulitis modified Hinchey classification was used (Table 2). Statistical analysis was performed.

Results and Discussion
There were 46 patients included with complicated diverticular disease. The mean age of the patients was 62.9 ±15.7 years and a median of 62.5 years. There were no patients under 40 years old. Our group age is fairly similar with those classically reported (5,9,13). Sex-ratio male: female was 1.4 (27 men and 19 women). The men predominance is more evident than was reported by others (5,13). The difference is important but the number of patients included in our study is too small to make firm assumptions. The mean age for women subgroup was higher 67.2±15.2 years than in men's group (59.8±15.7 years) but there was no statistical significance (p=0.401). This result is in accordance with others (11). The majority of our patients were from urban areas (35 patients). We assume that this finding is an indirect demonstration of the alimentary regimen low in fibres more common in urban areas in contrast with more unprocessed diet that can be found in rural parts of our country.
The main symptom was abdominal pain, either diffuse or localised. Only three patients were admitted for recurrent attacks and they were submitted to a laparoscopic procedure. In other three patients the symptoms were mild but the main complain was inferior haemorrhage. Of the three patients reported with haemorrhage in one the haemoglobin value was 5 g/dl and blood substitutes being administered. In the four year study period, the case distribution was fairly similar, as can be seen in Fig. 1.
Leukocytosis was present in 32 cases (69%) as can be seen in Fig. 2 and was present in all the cases with complicated diverticulitis; mean leukocytosis was 15,540 elements/mm3 (range 9,400-25,700 elements/mm3) - Fig. 2. There is no correlation with the severity of the disease.
Diagnostic procedures involved routinely abdominal X-ray for those without anaemia. Plain X-ray is useful but nonspecific. In our study in 4 cases pneumoperitoneum was described. All these 4 patients were over 70 years-old. The characteristics of these patients are depicted in Table 3.
In all 4 cases diffuse peritonitis was clinically evident. In one patient a previous history of perforated ulcer and the presence of penumoperitoneum made the attending surgeon to consider a perforated ulcer. Even so, the decision for urgent intervention was clearly made and perforated diverticulitis was diagnosed intraoperatively. All these patients had important associated co morbidities mainly cardiac diseases. They were all operated in emergency settings and different procedures being employed. One of them developed a MSOF and finally deceased.
In all other patients the plain abdominal radiography was less helpful, generally hydro-gaseous images being seen only in 13 cases (28.4%). The sensitivity of the method is small but it can help discriminate from other conditions and, in cases of a frank diverticular rupture into the peritoneum it is very helpful when the pneumoperitoneum is seen.
Ultrasound examination was used in 37 of our cases (80.4%). It is innocuous but operator-reliable and helps discriminate from other conditions. When it is positive it shows liquid or collections in the peritoneum and bowel changes (wall thickening and distension mainly). It is clearly non-specific but in our study was positive in 27 cases (73% sensitivity).
In 9 patients mild symptoms or the presence of blood in the feces imposed colonoscopy. The method was employed in cases shown in the Table 4.
The most useful diagnostic method was CT-scan. It was performed in 27 cases (58.7%) and in 26 patients CT-scan diagnostic. Sensitivity of the method is high (96.3%) in our study. In our opinion CT-scan is the best method for diagnostic, especially for diverticulitis and perforation.
The diverticuli are most frequent found on the left colon. Their distribution in our study is depicted in Fig. 3. The majority of our cases had diverticuli located on the sigmoid colon (33 patients - 71.7%); in other words more than 90% of our cases had the disease located on the left colon (Fig. 3). This distribution is matching other authors' observation (12).
In 28 cases (61%), abscess or peritonitis was the cause for the surgical intervention in emergency settings. Modified Hinchey classification was used to evaluate these patients. The distribution of cases is presented in Table 5.
In complicated diverticulitis the mean time from admittance to the operating room was 32.4 hours. If we exclude one outlier the mean time was 19.4 hours. Surgical procedures of the 45 cases are presented in Table 6.
We observed that the most frequent procedure, was simple lavage with drainage in 9 cases and another 2 patients had associated suture. In all, there is a total of 11 cases (23.9%) benefited only from the simplest surgery. In 2 patients the colonic haemorrhage was the main complication imposing surgical intervention. In one case total colectomy was done successfully, in the other case simple surgical haemostasis was performed. The lack of blood derivatives and the repeated bleeding of the patients without endoscopic success in haemostasis, forced us to a more aggressive approach. In 3 patients laparoscopic sigmoidectomy was performed because of repeated attacks of diverticulitis. Only one patient was conservatively treated successfully.
The high conversion risk described by others (13) and the small number of patients where laparoscopy can be useful, explains the small number where the method was employed. In our study 3 patients were included because of the concomitant association of colonic neoplasia and diverticulosis. It is believed that patients with advanced colonic neoplasia and diverticular disease could derive from distinct groups. This concomitance was studied by others and we agree that the association between colon cancer and diverticular disease is fortuitous similar factors being involved in pathogenesis of both conditions (3,14).
But from these cases the subgroup with complicated diverticulitis (28 cases) registered the majority of simple lavage and drainage of the peritoneal cavity (9 cases) and all the Hartmann procedures (7 cases) and colostomy. The surgical procedures performed in these 28 patients are depicted in Fig. 4. The laparoscopic approach is gaining ground, being more frequently employed in acute situations. We did not perform it in our cases, though there is a growing support for this approach (15).
Hartmann procedure is still frequently employed (7 cases - 15.2%) but there is a trend in our unit for primary anastomosis when proper conditions are met. Three-stage procedures are practically extinct in our practice but, we prefer a Hartmann procedure when the risk for postoperative fistula is high (fecaloid peritonitis, heavy contamination). This is in accordance with other authors (16).
Postoperative fistula was encountered in 2 cases (4.4%), only one case necessitating reoperation which consisted in lavage and tailoring a colostomy. Both patients recovered well. Other postoperative local complications are depicted in Table 7.
There were 4 deaths (8.1% or 8.8% if we exclude the patient that was not operated) all in the subgroup with complicated acute diverticulitis. This is consistent with results reported by others (mortality of 7.7%) (17). There were no differences among surgical procedures in term of results.
Statistical analysis (chi square test) revealed that a significant prognostic factor is Hinchey stage (p=0.002) although other factors are probable also significant (e.g. comorbidities and the severity of sepsis).

Conclusions
Complicated diverticular disease is more frequently encountered in our practice, especially the septic complication of diverticulitis (28 of our cases). We did not encounter young patients with complicated diverticular disease. Correct diagnostic is necessary especially when a surgical procedure is deemed necessary. In this respect CT-scan is the most useful tool with a sensitivity of 96.3%. Hinchey classification is, within its limits, valuable and clearly correlates with the prognosis. Perforated diverticulitis is still a highly lethal complication with a global mortality of 8.8%. Urgent surgical intervention is necessary and it should employ resection, if it is possible with primary anastomosis or, if the risk of dehiscence is high. Hartmann procedure is still our choice.

References
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