Operative management of diverticular emergencies - Strategies and outcomes

Hypothesis: A selective surgical approach using either a 1- or a 2-stage re section is relatively safe and effective in the management of acute complic ated colonic diverticulosis. Design: A consecutive cohort study. Setting: A university hospital. Patients: Eighty-nine consecutive patients who underwent emergency operatio ns for diverticular disease between July 1, 1984, and June 30, 1999. There were 53 male and 36 female patients (mean age, 47 years). The ethnic backgr ound was predominantly Mexican American (58 patients ([65.2%]). Interventions: Resections of the affected colon (n = 83) plus construction of a Hartmann pouch or mucous fistula (n = 72) or primary anastomosis (n = 11). Main Outcome Measures: Morbidity, mortality, and length of hospital stay. Results: Sixty-eight operations were performed for perforation at an annual rate that has increased greater than 75% in the past 15 years. Another 14 patients underwent operations for obstruction, and 7 underwent operations t o control unremitting hemorrhage. Surgical therapy included resection of th e affected segment of the bowel in 83 (93%) of the 89 patients, and a Hartm ann pouch Or mucous fistula was added in 72 (81%). A primary anastomosis wa s performed in 4 (80%) of 5 right-sided lesions but in only 7 (8%) of 84 le ft-sided lesions. Morbidity occurred in 38 (43%) of the 89 patients, and th e mortality was 4%, with 4 deaths occurring secondary to sepsis in high-ris k patients with perforations (n = 3) or obstructions (n = 1). The average l ength of hospital stay was 19.7 days (range, 5-80 clays). Conclusions: Emergency operations for diverticular disease are uncommon but ma) be associated with substantial morbidity and occasional mortality. Com plicated diverticulosis may present at a relatively young age, and perforat ed forms appear to be increasing rapidly in prevalence. Most diverticular l esions can be satisfactorily managed using a selective approach based on re section with either a primary anastomosis or a temporary colostomy.