La malattia diverticolare del colon: quando e come trattarla


COD: 01_2009_003-8 Categorie: ,

Francesco Tonelli, Valerio Di Carlo, Gabriel Liscia, Alberto Serventi

Ann. Ital. Chir., 2009; 80: 3-8

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Diverticular disease (DD) is one of the most common disorders of the colon with an increased prevalence in Western
populations. There are still many unsolved issues about indications, timing of surgery and modality of surgical treatment.
These topics were discussed during the Consensus Conference (CC).
There is still common agreement indicating surgery after the second acute episode of diverticular disease; however, patients
younger than 50 years should undergo surgery after the first acute episode, because of a higher risk of recurrence compared
to older patients. It is not clear though how to uniformly classify an acute episode (severe, moderate or mild): an
accurate clinical and instrumental valuation (based on CT scan) is recommended to establish the real severity of the
acute episode before recommending a surgical procedure.
In presence of septic complications (abscess or peritonitis) of DD, colonic resection is indicated, but a primary anastomosis
could be at risk of failure due to sepsis. Therefore a Hartmann’s procedure or protective stoma could be preferable.
However, instead of a staged procedure, an appropriate strategy should be to resolve sepsis and perform resection and
anastomosis in election. Abscesses smaller than 5 cm intramesocolic or paracolic can be successfully treated medically; vice
versa larger or pelvic abscesses should undergo percutaneous or laparoscopic drainage, postponing colonic resection in elective
conditions. Limited purulent peritonitis can be favourably treated by means of laparoscopic approach and simple
lavage and drainage of peritoneal cavity.
Diffuse purulent or faecal peritonitis is the most dramatic complication which still has a high risk of mortality and
morbidity. Surgical risk is related to clinical conditions, duration of peritonitis, age of patient and comorbidities. Thus
it is not possible to state a univocal approach, although Hartmann’s procedure keeps being the first choice. On this matter
ftirther randomized studies are required to compare Hartmann’s procedure with other techniques (such as primary
anastomosis with or without diverting colostomy).
A wide left colonic resection (with splenic flexure mobilization) extended beneath sigmoid-rectal junction is recommended
to avoid immediate or late complications. Laparoscopic approach is feasible, even for management of complicated
diverticular disease, if strict patient selection criteria are followed, duration of the procedure is comparable to open surgery
and conversion rate is under 10%.