Diverticular fistulas and their treatment
The treatment of fistulizing complications of diverticulitis is a problem occasionally surgeons face. The most common fistula is placed around bladder 65%. It is more common in men than women and assumes that the uterus in women, to stand with the bladder, offers some protection.
Occasionally, in patients at high risk if they have minimal symptoms do not require surgery, but usually, if there are no such circumstances, we must practice segment colonic resection and resection affection at a time, closing the gap with the bladder and urinary catheter for about eight days, preferably practicing this "cold" when the fistula has become chronic, with no infectious complication, with very low mortality.
In case of colon-vaginal fistula, is associated with a colic resection closure of the vaginal opening and an interposition of omentum although some surgeons favor, as you would in enterocutaneous fistulas low debt, choose a treatment conservative. In the sapling-uterine cramping, or colic, the resection of the fistulous tract only joined the affection of the colon may be sufficient, without need to involve the uterus or tubal resection.
If required by assignment fistulizing ileal resection, the immediate restoration of traffic is the rule.
Diverticulitis associated with obstruction
Disputes arising in this case, the restoration of the continuity or non-traffic, are the same as speaking of the association with the abscess, or even perforation. When a case of colonic obstruction, presumably by a complicated diverticulitis, the patient undergoes surgery to solve urgent, preceded by a short period of resuscitation, including hydration and nasogastric suctioning. If the obstruction is quickly resolved, it is possible to allow a bowel decompression enough to allow time to prepare an appropriate antibiotic and mechanics so that intervention can be performed in a single time.
The most used in cases of intestinal obstruction unresolved for diverticulitis of the colon is the intervention leaving cases to be selected by these same authors, or more open standards others, the practice of primary anastomosis with or without protective colostomy or by intraoperative lavage of the colon or the implantation of a bypass intracolonic type Coloshield. In an unstable patient will be acceptable to perform a transverse colostomy and resection defer to a later date.
Resection after repeated episodes of diverticulitis. The patient who has suffered repeated episodes of diverticulitis should be individualized to minimize morbidity and mortality of the intervention. Factors to be considered when deciding on the resection are the psychological age of the patient, number, severity and interval episodes of diverticulitis, speed and level of response to treatment and persistent symptoms after an acute episode may happen in the last 7-45% of patients. The introduction of a diet rich in fiber may reduce the risk of relapse. As we produce new episodes of diverticulitis, the patient responds to medical treatment worse (70% probability of response in the first episode, against 6% in the third). Therefore, after the second episode of uncomplicated diverticulitis, resection is recommended, as well as in patients with diverticulitis complicated after the first.
Immunocompromised patients
The diverticulitis in immunocompromised patients, including those who continue treatment with steroids, transplants, those with renal failure, the neoplastic, malnourished, elderly, and AIDS may be manifested by a few of the symptoms or signs classics of the disease and thus the diagnosis and treatment should not be unduly delayed, the mortality may reach 40%.
Diverticulitis and hemorrhage
The therapeutic approach must take into account the tendency to spontaneously when the yield is of diverticular bleeding. Treatment should begin in all cases with a resuscitation and blood transfusion in the correction, if necessary, any coagulopathy. The evolution under symptomatic treatment is often favorable. Only very abundant hemorrhage, continuous or recurring are subsidiaries of surgical treatment.
When you have located the origin of diverticular bleeding by a selective arteriography, selective intraarterial infusion through a branch of the inferior mesenteric artery, with a dose of vasopressin 0.2 units / minute or 0.4 U / min if necessary, checked by a control arteriography to 30 minutes if the bleeding has stopped. Treatment can be aggressive to continue to dose for 24 or 48 hours. The impossibility of maintaining the catheter angiography in place a severe ischemic heart disease or cessation of bleeding during the examination are the major contraindications, although it is known that strokes can also cause colic in the wall. This method allows the cessation of bleeding in 90% of cases, although they recur in 40%, but allow preparation of the colon and if necessary regulated resection, avoiding a surgical emergency with an engraved higher morbidity and mortality, and in some elderly patients may be the only recourse available, including the possibility of selective embolization, with the same risk of myocardial wall of the colon. If the bleeding does not respond to this treatment, a right hemicolectomy or left as the most frequent location of bleeding, although 90% of cases a segmental colectomy is sufficient.
When the bleeding has not been located precisely, although other techniques such as making the red blood cell scintigraphy with Tc99-marked with indentations that detects minimum 0.05-0.1 ml/, a colic resection or hemicolectomy or total colectomy, a decision based on the potential location of bleeding, the likelihood of recurrence and the risk surgery. Thus, when any injury has been targeted in the left colon and it is suspected a diverticulum or angiodysplasia in the right, right hemicolectomy is the procedure of choice. And conversely, when it is confined to the sigmoid diverticulosis and no lesion was seen in the right, it is logical to propose a left hemicolectomy, but this gesture implies a recurrence of about 30%, so that some authors advocated in this situation A few years ago, the practice of subtotal colectomy, with a mortality of 15-50%, yet limiting its indication to patients with low-risk surgical colic diffuse diverticulosis, angiodysplasia as a right associated with a sigmoid diverticulosis or as a last resort when there is no identified location of the hemorrhage, although in a recent article is still recommended.
Diverticulitis in young patients
The diverticulitis in young patients is more aggressive and has more complications and recurrences after the initial episode treated medically. So far almost all the authors consulted and are in agreement, though most favor a colonic resection with restoration of continuity, after the episode, whenever possible others as in a study conducted on 63 patients younger than 45 years, is not particularly aggressive disease, even if they see a high rate of emergency, but still think that the indication of intervention routine after the first episode should be reviewed again.
Diverticulitis of the right colon
Surgical treatment of diverticulitis of the right colon is controversial. In itself is difficult clinical diagnosis, especially differential with acute appendicitis and cancer of the cecum. If it is not possible to exclude a laparotomy during the neoplastic process, or if in doubt the viability of the colon, right hemicolectomy should be done, and if the diagnosis of diverticulitis is certainly one can make a segmental colectomy, with a primary anastomosis without preparation of the colon though some like recommended the examination of the intraoperative resection piece-if-part in determining the nature of the injury and act accordingly As for the radical, or if not possible, make right hemicolectomy.
Recurrent diverticulitis after resection
The reappearance of abdominal symptoms after resection for diverticular disease occurs in 1-10% of patients (but not all of them have diverticulitis) and may require re-resection of 0-3.1%. By treating a patient with diverticulitis "appellant," the question is does the fact that the patient was the first time was not one or diverticulitis. The review of the pathology of surgical help us on this, although it is assumed that an inadequate resection is the main cause, but patients with irritable bowel syndrome or inflammatory bowel disease undergo resection of the sigmoid diverticulitis misdiagnosis.
Problems in the time of resection are: 1) to where it should be resected in the proximal edge, and 2) should be practiced where the anastomosis.
It is not necessary to remove the diverticula of the colon. As for the resection of the proximal edge, if you're not inflamed, it looks healthy and the intestine has normal caliber, can be maintained safely even with diverticulosis, but should be incorporated into any diverticulum suture.
Is laparoscopic surgery applicable to complicated colonic diverticular disease?
Transcribe the questions asked someone in his current work on this new path that from a few years ago has revolutionized the surgical techniques. The expansion of laparoscopic surgery has led to colonic surgery is performed with increasing frequency and more sites, highlighting their findings on 148 patients that the postoperative ileus decreases from 20% in open surgery to 7% in laparoscopic, and hospital stay from 8 to 4-5 days in the elective surgery, concluding that the complications of diverticular disease of the colon, including abscesses, perforation, fistula and bleeding, are subsidiary to be treated by this technique. Feel the same way other authors, indicating in stages I and II, and also highlighting the lower cost with the exception of the hospital from greater usage of the operating room. In case of generalized purulent peritonitis, it is also possible that practical approach peritoneal washes, as referred in their short range. Anyway, the comments in the literature, although more studies are required and experience with this technique in this pathology colonic promises a hopeful future.
In the words of Freeman, the diverticulitis is a disease well known to clinicians, who still seek understanding and judicious caution to obtain good results with patients. The disease remains a challenge for both internal and for surgeons
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