Reappraisal of the surgical treatment of diverticulitis of the sigmoid colon: With special reference to the choice of operative procedure

Abstract

The surgical treatment of diverticulitis of the sigmoid colon at The Portland Clinic during the interval from January 1949 through December 1959 has been reviewed. Resection of the sigmoid was performed in forty-four out of a total of forty-six patients. Primary resection was accomplished in thirty-six patients (80 per cent). Ten of these had obstructive resections. Three-stage procedures were elected in only eight patients. This series is compared to a series in the preceding twenty years and previously reported. Morbidity has been greatly reduced not only by the frequent selection of primary resection but also by reduction in the duration of colostomy prior to resection in procedures performed in stages. Critical evaluation of the four deaths in the series reveals that this lowered morbidity has been accomplished without increasing the surgical risk incident to treatment of diverticulitis and its complications. The several indications for election of various methods of treatment have been considered in detail. It is of great importance to consider each situation individually rather than to accept the arbitrary rules of therapy suggested in the past. Many patients with recurring attacks of diverticulitis should undergo definitive operation at an elective interval to avoid the severe complications of peritonitis, abscess, obstruction, and fistula. Study of the present series indicates that resection and anastomosis can be completed safely in many situations heretofore thought to require three-stage procedures. Obstructive resection has proved to be highly effective, particularly for free perforation with peritonitis. In such situations we prefer this method to the alternative of drainage and proximal colostomy since its use prevents continuing contamination and permits immediate elimination of the focus of infection. The dictum that obstructive resection is usually impossible or unwise has been shown to be mistaken. The disfavor into which this method has fallen is undeserved. Thoughtful individualization of each problem resulting from diverticulitis of the sigmoid colon will permit early elimination of the offending segment of bowel with safety in the great majority of patients. Only in this way can morbidity be reduced.