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Surgical Approach to Cecal Diverticulitis

John S Lane, MD, Rajabrata Sarkar, MD, PhD, Paul J Schmit, MD, FACS, Charles F Chandler, MD, FACS,
Jesse E Thompson Jr, MD, FACS

Background: Cecal diverticulitis is a rare condition in in the unprepared colon with few complications. Exci-
the Western world, with a higher incidence in people of sional treatment for cecal diverticulitis prevents the re-
Asian descent. The treatment for cecal diverticulitis has currence of symptoms, which may be more common in
ranged from expectant medical management, which is the Western population. (J Am Coll Surg 1999;188:
similar to uncomplicated left-sided diverticulitis, to 629–634. © 1999 by the American College of Surgeons)
right hemicolectomy.
Cecal diverticulitis is a rare condition that presents
Study Design: A retrospective chart review was con-
the surgeon with a diagnostic dilemma. Its presenta-
ducted of the 49 patients treated for cecal diverticulitis
at Olive View-UCLA Medical Center from 1976 to tion can mimic acute appendicitis with fever, leuko-
1998. This was the largest-ever single-institution review cytosis, and right lower quadrant abdominal pain.1
of cecal diverticulitis reported in the mainland US. For this reason, the correct preoperative diagnosis of
cecal diverticulitis is rarely made, and the surgeon is
Results: The clinical presentation was similar to that of often confronted with this condition at the time of
acute appendicitis, with abdominal pain, low-grade fe- laparotomy. But with the increased use of radiologic
ver, nausea/vomiting, abdominal tenderness, and leuko- studies in the evaluation of right lower quadrant ab-
cytosis. Operations performed included right hemico-
dominal pain,2 a correct preoperative diagnosis can
lectomy in 39 patients (80%), diverticulectomy in 7
patients (14%), and appendectomy with drainage of in- be made. The surgeon must be prepared to treat this
traabdominal abscess in 3 patients (6%). Of the 7 pa- rare condition both before and during the operative
tients who had diverticulectomy, 1 required right hemi- procedure.
colectomy at 6 months followup for continued The incidence of cecal diverticulitis is low in
symptoms. Of the three patients who underwent appen- the Western population, with a higher occurrence
dectomy with drainage, all required subsequent hemico- among people of Asian descent. This difference in
lectomy for continued inflammation. Of the 39 patients incidence may be explained by distinct pathophysio-
who received immediate hemicolectomies, there were logic mechanisms that are responsible for the disease.
complications in 7 (18%), with no mortality. In the Western population, most cecal diverticuli are
Conclusions: We endorse an aggressive operative ap- solitary; 81% of the cases in a study by Graham and
proach to the management of cecal diverticulitis, with Ballantyne1 were solitary. Solitary diverticuli are be-
the resection of all clinically apparent disease at the time lieved to be congenital, arising as an outpouching of
of the initial operation. In cases of a solitary diverticu- the cecum at 6 weeks’ gestation.3 These are consid-
lum, we recommend the use of diverticulectomy when it ered true diverticuli and are comprised of all layers of
is technically feasible. When confronted with multiple the colon wall, including the muscular layer. Patho-
diverticuli and cecal phlegmon, or when neoplastic dis- logic studies are often unable to identify the muscular
ease cannot be excluded, we advocate immediate right layer in specimens of solitary diverticuli because of
hemicolectomy. This procedure can be safely performed concomitant inflammatory changes. Multiple diver-
ticuli are seen more commonly in the Asian popula-
No competing interests declared. tion and are thought to be pathophysiologically re-
Presented at the American College of Surgeons 84th Annual Clinical
Congress, Orlando, FL, October 1998. lated to the false diverticuli of the left colon.4 In the
largest-ever review of an Asian population for cecal
Received October 26, 1998; Revised February 23, 1999; Accepted February 26, diverticulitis, Sugihara and associates4 found that, of
1999.
From the Department of Surgery, UCLA School of Medicine, Olive View- 614 patients with diverticulosis, 80% had right-sided
UCLA Medical Center, Sylmar, CA 91342. disease. They also found higher intraluminal pres-
Correspondence address: Jesse E Thompson Jr, MD, Department of Surgery,
Olive View-UCLA Medical Center, 14445 Olive View, Sylmar, CA 91342. sures in the right colon in those patients with diver-

© 1999 by the American College of Surgeons ISSN 1072-7515/99/$19.00


Published by Elsevier Science Inc. 629 PII S1072-7575(99)00043-5
630 Lane et al Cecal Diverticulitis J Am Coll Surg

Table 1. Clinical Characteristics of Patients with Cecal cations for operative intervention, operation(s) per-
Diverticulitis formed, and morbidity and mortality.
Characteristic No recognized cases were managed nonopera-
Median age (y) 32 (range 12 to 72) tively. All patients received broad-spectrum antibiot-
Sex distribution (M:F) 30:19 ics before operation and continued on them for 3 to
Asian: non-Asian distribution 11:38 7 days postoperatively. Surgical exploration was car-
Abdominal pain duration* (days) 3.660.4 days
Nausea/vomiting duration* (days) 2.160.3 days
ried out through either a right lower quadrant appen-
Temperature* 37.660.1°C dectomy incision or a midline approach; this was left
Hematocrit* (%) 41.760.5 to the discretion of the operating surgeon. The extent
WBC* 13,400 6500 of surgical resection was determined at the time of
RLQ tenderness (%) 92
RLQ mass (%) 8 operation and included right hemicolectomy, divert-
*Measurements expressed as mean 6 SE.
iculectomy, or appendectomy with drainage alone.
RLQ, right lower quadrant. Intestinal anastomoses were performed using a stan-
dard, hand-sewn, double-layer technique in most
ticulosis than in control subjects. These findings in- cases (93%), or by the use of surgical stapling devices.
dicate that the disease may have two etiologies with Nasogastric and urinary catheters were used when it
distinct natural histories in different groups of was deemed clinically necessary. Patients were dis-
patients. charged when they were afebrile, tolerated oral feed-
The treatment for cecal diverticulitis has ranged ing, and when all complications had been addressed.
from expectant management to aggressive surgical They were seen in a followup clinic 2 weeks after
resection. Most surgeons agree that if the diagnosis is discharge, with additional visits when appropriate.
made preoperatively, a trial of conservative manage- Data were compiled on an IBM personal computer,
ment with intravenous antibiotics is warranted.4-8 using a standard Excel 5.0 spreadsheet. Statistical
But there is considerable controversy surrounding analyses were performed using IBM software (Mi-
the surgical treatment of cecal diverticulitis found at crosoft, Seattle, WA).
the time of laparotomy. Reports from Hawaii9 and
Singapore,10 where the majority of patients are of
Asian descent have favored a conservative surgical RESULTS
approach. This involves a prophylactic appendec-
Demographics
tomy and leaving nonperforated diverticular disease
in situ. Those studies found a low complication and Forty-nine patients were identified as having cecal
recurrence rate with subsequent medical therapy. diverticulitis between 1976 and 1998. During this
Other reports11-14 from the mainland US have same period, approximately 7,300 patients were
recommended resection of all gross disease and had treated for acute appendicitis; the ratio of appendici-
favorable results. The purpose of this study is to tis to cecal diverticulitis was 150:1. There were 30
review our experience with surgical management of males (61%) and 19 females (39%) with a median
cecal diverticulitis in a predominately non-Asian age of 32 (range 12 to 72 years). Eleven patients were
population. of Asian decent (22%) and 38 were non-Asian
(78%).
METHODS The clinical presentation of cecal diverticulitis
From 1976 to 1998, 49 patients were treated for was similar to that of acute appendicitis (Table 1).
cecal diverticulitis at Olive View-UCLA Medical Acute abdominal pain was present in all patients,
Center, a university affiliated county hospital that with an average duration of 3.6 days (range 1 to 21
serves the greater Los Angeles area. This was the days). Nausea or vomiting occurred in only 5 (11%)
largest-ever single-institution review of cecal diver- patients for an average of 2.1 days (range 1 to 5 days).
ticulitis reported in the mainland US. All charts with Right lower quadrant tenderness was the most com-
a pathologic diagnosis of cecal or right colonic diver- mon physical sign, found in 45 (92%) patients,
ticulitis were reviewed. Specific data extracted in- and this was accompanied by a palpable mass in
cluded presenting complaints and physical signs, only 4 (8%) patients. A low-grade fever (mean 6
preoperative diagnosis, laboratory and radiographic SE) of 37.8 6 0.1°C was often present, along with
findings, length of symptoms before treatment, indi- mild leukocytosis (13,400 6 500 WBC).
Vol. 188, No. 6, June 1999 Lane et al Cecal Diverticulitis 631

Preoperative studies cases of anastomotic leaks, 1 of which required emer-


Radiologic studies were performed in 59% of pa- gent ileal diversion for peritonitis; intestinal continu-
tients: abdominal plain x-rays in 18 (36%), contrast ity was re-established in this patient in 3 months. The
enema in 6 (12%), CT scan in 7 (14%), and abdom- second leak presented as a fistula 21 months postop-
inal ultrasound in 10 (20%). A correct radiologic eratively and resolved without surgical intervention.
diagnosis was possible in only three patients; one was Of the 7 patients who underwent diverticulectomy,
made using barium enema and two confirmed on there was only 1 complication (14%). This was the
CT scan. Despite these correct radiologic diagnoses, result of an inadequate surgical resection of a pre-
no patients were managed nonoperatively. The most sumed solitary diverticulum that required interval
common preoperative diagnosis was acute appendi- hemicolectomy. All three patients who underwent
citis in 82% of patients. In all patients, the indication appendectomy with drainage required reoperation
for surgery was intraabdominal sepsis from a correct- and hemicolectomy for continued inflammation.
able surgical etiology. Pathologic examination revealed 37 patients
with solitary diverticuli (76%) and 12 with multiple
Operations performed diverticuli (24%). Because of the severity of the in-
At the time of laparotomy, a correct intraoperative flammatory response, the delineation between true
diagnosis of cecal diverticulitis was possible in 41 and false diverticuli was not possible in a significant
patients (84%). In the other eight patients, an in- number of patients (Fig. 1).
flammatory mass was found in the right colon and a The length of stay in patients who underwent
perforated carcinoma could not be excluded. Initial emergent right hemicolectomy was 10.561.3 days.
operations performed included right hemicolectomy In those who underwent diverticulectomy alone,
in 39 patients (80%), diverticulectomy in 7 (14%), hospital stay was 4.960.5 days. For the three pa-
and appendectomy with drainage of intraabdominal tients who had appendectomy with drainage, hospi-
abscess in 3 (6%). This was performed with a right tal stay was prolonged because they required reopera-
lower quadrant incision in 34 patients (69%), while a tion; the average stay in this group was 25.3613.5
midline laparotomy was used in 15 (31%). Subse- days, with individual stays of 52, 15, and 9 days.
quent operations included four additional right
hemicolectomies, which were performed as reopera- DISCUSSION
tive procedures in patients with continued inflam- The diagnosis and treatment of patients with right
matory symptoms. In 1 patient who underwent ini- lower quadrant pain and cecal diverticulitis has been
tial diverticulectomy, residual diverticular disease the subject of considerable controversy. Because this
was left in place, necessitating elective right hemico- entity mimics acute appendicitis, a correct preopera-
lectomy at 6 months. The three patients who under- tive diagnosis is often not possible. The surgeon may
went appendectomy and drainage procedure re- first be confronted with the disease at the time of
quired reoperation and right hemicolectomy despite operation, and the disease may exist in two distinct
postoperative antibiotic treatment. One patient re- pathophysiologic entities. Solitary diverticuli are
quired emergent reexploration for intraabdominal more commonly found in the US and are thought to
sepsis at 4 days postoperatively, and the remaining be congenital in origin.1 Multiple diverticuli are
two underwent elective hemicolectomy after 3 to 6 more frequently seen in the Asian population, and
weeks for continued inflammation. Overall, 43 pa- may be more closely related to the false diverticuli
tients received right hemicolectomy as the definitive found in the left colon.4
treatment for cecal diverticulitis. Previously, it has been thought that routine ra-
diologic examination of patients with right lower
Outcomes quadrant pain was neither feasible nor cost-
No deaths occurred in any patients treated for cecal effective.11 With the publication of the landmark ar-
diverticulitis in this period. Seven of 39 patients ticle by Rao and coworkers,2 the use of appendiceal
(18%) who underwent immediate right hemicolec- CT in the evaluation of right lower quadrant pain has
tomy experienced complications. These included 2 become more commonplace. These authors found
superficial wound infections, 1 intraabdominal ab- appendiceal CT scans to be 98% sensitive and 98%
scess that required percutaneous drainage, 1 flank specific in the diagnosis of acute appendicitis. This
abscess, and 1 wound dehiscence that required oper- would make routine CT scanning a cost-effective
ative closure on postoperative day 10. There were 2 tool in the diagnosis of acute appendicitis by reduc-
632 Lane et al Cecal Diverticulitis J Am Coll Surg

Figure 1. Low-power photomicrograph of a solitary cecal diverticulum. Note the surrounding inflammatory response
with nonvisualization of the muscular layer.

ing unnecessary hospitalization and negative explo- right-sided diverticulitis may range from 15%9 to
rations for appendicitis. Interestingly, in the course of 71%.15 Third, patients with residual diverticular dis-
their study, the authors were able to correctly diag- ease after the initial operation require prolonged hos-
nose two patients with right lower quadrant pain pital stays for antibiotic treatment; this yields a min-
with cecal diverticulitis; no followup data were pro- imal reduction in the length of stay.9 Finally,
vided. In another study,8 six of seven patients diag- retrospective reviews have shown that emergent right
nosed radiologically with cecal diverticulitis on heli- hemicolectomies can be performed safely for cecal
cal CT scan were successfully treated without surgical diverticulitis with a low mortality rate (1.4%).1
intervention. In a study from the Netherlands,15 37 The operative treatment of cecal diverticulitis has
of 44 cases of cecal diverticulitis diagnosed by CT or varied in Asia and in the West. Most studies for the
ultrasound were successfully treated nonoperatively. mainland US advocate the use of surgical resection
Despite differences in philosophy regarding routine when addressing cecal diverticulitis.11-14 Some re-
CT scanning, the surgeon may now be faced with an ports from centers that treat predominately Asian
increasing number of patients with a preoperative populations have shown the benefit of taking a con-
diagnosis of cecal diverticulitis (Fig. 2). servative surgical approach.9,10 Ngoi and co-
When confronted with the diagnosis of cecal di- authors,10 in a study from Singapore, treated 68 pa-
verticulitis in the operating room, the surgeon tients with appendectomy and drainage alone for
should elect to perform a complete resection of all cecal diverticulitis, and with diverticulectomy in the
visible disease. This policy is supported by a number case of a perforated diverticulum. Hemicolectomy
of observations. First, a review of the American liter- was reserved for cases in which carcinoma could not
ature found that a correct intraoperative diagnosis be excluded. The only significant complications in
was possible in only 65% of patients who underwent this study occurred in patients treated with appen-
emergent right hemicolectomy,1 similar to the 84% dectomy only (cecal fistula and liver abscess) and
in our review. In this situation, a diagnosis of carci- followup showed one patient with recurrent symp-
noma cannot be excluded and an appropriate cancer toms that required hemicolectomy. Harada and asso-
operation should be performed. Second, if divertic- ciates,9 in a study from Hawaii, reviewed 90 cases of
ular disease is left in place, the recurrence risk of cecal diverticulitis, 78% of which were Asian descen-
Vol. 188, No. 6, June 1999 Lane et al Cecal Diverticulitis 633

Figure 2. Contrast CT scans obtained in a patient with cecal diverticulitis. (A) The cecal wall is thickened with
visualization of multiple diverticuli (large arrow), pericecal inflammation, and fat stranding (small arrows). (B) A normal
appendix (large arrow).

dants. They found only 1 patient of 29 treated with with appendectomy alone. In a 10-year followup,
appendectomy alone developed a complication. The Harada and associates found that only 4 of 27 pa-
complication, however, was progressive peritonitis tients (15%) who had appendectomy developed re-
with azotemia and septicemia, and the complication current symptoms.
rate in that study does not agree with our experience While these studies have been used to support a
634 Lane et al Cecal Diverticulitis J Am Coll Surg

conservative surgical approach to cecal diverticulitis 14. Schmit PJ, Bennion RS, Thompson JE Jr. Cecal diverticulitis: a
continuing diagnostic dilemma [see comments]. World J Surg
in a predominately Asian population, we believe that 1991;15:367–371.
they underscore the need for a complete surgical re- 15. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diver-
section to reduce the risk posed by leaving disease in ticulitis: US and CT findings—new insights about frequency and
natural history. Radiology 1998;208:611–618.
situ. Because the pathophysiology of cecal diverticuli
may be different in a predominately Asian popula-
tion, these studies may not be applicable to the main-
land US.
As a result of our experience, we advocate an Invited Commentary
aggressive operative approach to the management of
cecal diverticulitis. In our initial experience, three Jack Pickleman, MD, FACS
cases of perforated cecal diverticulitis were treated
Maywood, IL
with appendectomy alone; all required subsequent
right hemicolectomy. More recently, when con- This is one of the largest institutional experiences
fronted with this diagnosis at the time of operation, with cecal diverticulitis, and so the authors’ conclu-
we resected all clinically apparent disease with better sions should be carefully weighed. Much has been
outcomes. We advocate diverticulectomy in cases of a made in the past of the differences between “true”
solitary diverticulum, and immediate right hemico- right-sided and solitary diverticula versus “false” di-
lectomy in the case of cecal phlegmon or multiple verticula that occur as part of a more diffuse colonic
diverticuli. This procedure can be safely performed process. In reality, these two entities may be impos-
in the unprepared colon, with few complications. sible to differentiate once inflammation occurs, and
Excisional treatment for cecal diverticulitis prevents so much rumination is not fruitful.
the recurrence of symptoms, which may be more In no published series has the preoperative diag-
common in the Western population. Future studies nosis of cecal diverticulitis been made with any fre-
will be necessary to verify the use of nonoperative
quency, so virtually all decisions will be made in the
treatment when a preoperative radiologic diagnosis
operating room, usually during a laparotomy per-
of cecal diverticulitis is made.
formed for suspected appendicitis through a small
right lower quadrant incision. The authors’ ratio of
appendicitis to cecal diverticulitis of 150:1 bears this
References out. Occasionally, however, there will be a suspicion
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tomography of the appendix on treatment of patients and use
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1998;338:141–146. more likely to harbor cecal diverticulitis or, of course,
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