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Sigmoid diverticulosis and its complications account for a major bulk of work in colorectal units in developed countries¹. In India diverticulosis is relatively uncommon, though with increasing life span and change in life style, there seems to be a rising trend indetection of the disease.Between 10 to 25% of patients will develop a complication and around 5% of these will need an intervention². Since the last decade there has been a move towards a more conservative approach in treating diverticulitis especially if uncomplicated. In complicated disease surgery is usually indicated. There is a paucity of publications on surgery for sigmoid diverticulitis in the Indian literature^3-5. In this retrospective study of prospectively collected data we outline our results of surgery for diverticulitis.  This is the largest reported number of cases of sigmoid diverticulitis from India spanning a period of 18 years.

From January 1998 to December 2016, all patients with sigmoid diverticulitis who were operated upon, were prospectively entered into a database. An informed consent of patients was taken regarding data collection. The hospital ethics committee permission was taken accordingly. Patient demographics, radiological and endoscopic investigations, operations performed and complications were recorded in detail. Patients were admitted in an emergency or an elective setting. Emergencies comprised of patients with generalised peritonitis, large bowel obstruction or those with localised disease with abscess formation. The elective admissions were those with fistulae and recurrent bouts of uncomplicated diverticulitis. (Table 1)

Patients in the emergency setting were given intravenous fluids (IV), broad spectrum antibiotics with anaerobic coverage and ionotropic support if required. After a baseline sonography, most patients had a CT scan. A plain CT scan was done for those with peritonitis. In the group with obstruction, IV contrast with rectal contrast was used and those with abscesses a full CT scan with oral, IV and rectal contrast was used. 

Patients with fistulae and recurrent diverticulitis also had a full CT scan. The disease was graded as per the Modified Hinchey classification (Table 1). In the elective setting a complete colonoscopy was attempted to rule out an associated malignancy of the colon.

Patients with generalised peritonitis and intestinal obstruction underwent a Hartmann’s resection or a resection and anastomosis with a diverting stoma.

Those with large, (> 4 centimetres ) or distant abscesses (Hinchey type IIb) had an attempt at CT or laparoscopic guided drainage of the abscess. When this was not possible, a laparotomy with a Hartmann’s or a resection anastomosis and a diverting stoma was done.

Patients with fistulae and recurrent diverticulitis were always operated upon in the elective setting when the disease was quiescent. A one stage resection was attempted in all patients and a diverting ostomy was only added when patients had multiple co-morbidities. Since 2014 we have used a laparoscopic resection whenever possible in the elective setting. 

Post-operative complications were classified as per the Clavien-Dindo (CD) Classification (Table 2).

Reversal of a Hartmann’s procedure and closure of the stoma was done 3 months after the initial operation.All patients were followed up for a minimum of 6 months after their last intervention. This was done by clinical evaluation by the 1st author.

Ninety-six patients were operated upon during this study period. (Figure 1) The age range was from 36 to 97 years (mean 66) and there were 50 female patients.

Thirty-three patients were admitted in an emergency. Fifteen with generalised peritonitis (14 Hinchey type III, one patient Hinchey type IV). Two patients had intestinal obstruction and 16 had large or complicated abscesses.Sixty-three patients were admitted for elective sigmoid resection. 

In the emergency setting, 15 patients with peritonitis had a laparotomy. Thirteen underwent Hartmann’s resection and 2 a resection anastomosis with ileostomy.

Sixteen patients had complicated abscesses (Hinchey type 2B). These were perforations with abscesses which were larger than 4 cms or in the pelvis.Six could be drained by CT guided pigtail catheters and subsequently went on to have elective resections, 3 open and 3 laparoscopic. Two patients had laparoscopic drainage of abscesses, one of whom had to be converted to a Hartmann procedure 20 days later due to continued sepsis. The other patient settled and refused elective surgery. In the remaining 8 patients the abscesses could not be accessed for drainage. All had open surgery, 3 Hartmann’s resections and 5 resection and anastomosis with a diverting stoma.

Two patientswith strictures presented with obstruction and marked dilatation of the proximal colon. Both underwent a Hartmann’s procedure. 

Sixty-three patients were admitted for elective resections. Twenty-five had acute diverticulitis, (Hinchey type I and IIA) and had suffered 1 to 4 attacks requiring prior admission to hospital and treatment with antibiotics.Thirty-six patients presented with fistulae, 32 colo-vesical and 4 colo-vaginal. Two had strictures with recurrent pain, severe enough, to warrant elective surgery.

Colonoscopy was attempted before all elective resections, however only 36 could have complete colonoscopies. Two patients had associated colon cancers, 1 with a stricture and the other with a colo-vesical fistula.

Thirty patients with fistula underwent a one stage resection, 7 laparoscopic and 23 open surgery. Six had resection anastomosis with ileostomy. All patients with uncomplicated diverticulitis had one stage resections (16 open, 9 laparoscopic). Two patients with strictures had elective one stage laparoscopic resections.

Six patients died within 30 days of surgery (Clavien Dindo V) (6). Three had generalised peritonitis and sepsis, 3 with colovesical fistula died of myocardial infarctions.  The hospital stayranged from 4 to 115 days (mean 12.4). Nine patients had complications requiring interventions (Table 2). Fifteen had wound infection and 14 had incisional hernia (10 main wound, 4 from stoma sites).

Twenty-one patients had further surgery to restore continuity of the alimentary tract which comprised of 7 ileostomy closures and 14 Hartmann reversals. The time of closure ranged from 3 to 18 months. 

At 6 months follow up 12 patients complained of an unsatisfactory outcome. Five had recurrent left sided pain but no obvious cause was found. Three patients had increasing constipation and dependency on laxatives. A further 4 patients had developed large incisional hernia which affected their daily routine. 

Sigmoid diverticulosis, a predominantly western disease is showing an increasing trend in India.^7-9 Data from publications from India suggest an increase from 3 to 9% in incidence. Hence surgeons and physicians in India need to be aware of the disease, its complications and manage patients with the best available evidence. Diverticulitis develops in  10 to 25% of patients and of these 5% percent will need anintervention². Being a disease of the elderly, these patients are often frail and have co-morbid conditions which increases the morbidity. Hinchey classified diverticulitis into 4 grades. This has been modified with the advent of CT scan and is the most common grading system used. Uncomplicated diverticulitis is disease restricted to the colon or pericolic region. Complicated disease comprises of distant or complex abscesses, fistulae, stricture and perforations.

Barium enema to evaluate diverticulitis has largely been replaced by a CT scan. A CT scan helps in grading the disease and can alsoassist for catheter drainage of an abscess¹⁰. Abdominal sonography is a good initial study but has several limitations, especially if there is an ileus¹¹. We used a CT scan in 91/96 cases. We believe a colonoscopy is always indicated in the elective setting to rule out an associated malignancy². This can be difficult in a thickened distorted sigmoid colon, even with a paediatric scope. In our series it was possible in 36 of 65 patients.

Over the last decade our treatment plan for diverticulitis has changed from an aggressive surgical approach to a more conservative one. Patients with uncomplicated disease were initially offered surgery after 1 or 2 two attacks. However recent evidence suggests that in these patients surgery need not be offered, irrespective of the number of attacks¹². Exceptions to this are those who are immuno-compromised and should be operated upon after a single episode of diverticulitis^13,14. We now offer patients with uncomplicated disease surgery only after a third attack, or those who have recurrent pain without evidence of an abscess, an entity labelled as smouldering diverticulitis.¹⁵

Patients who have had a complicated attack of diverticulitis have high recurrence rates. Resection of the sigmoid is advised after an initial attack.Those with large or distant abscess, should have an attempt at drainage by a CT guided pig tail catheter ora laparoscopic assisted method. This is an emerging concept and avoids resection with adiverting stoma. A one stage resection can be planned once the disease settles. We had 16 patients with complicated abscesses. In 6 a CT guided drainage was done and in 2 a laparoscopic drainage.  These patients went onto to have elective resections. In the other patients, drainage was not possible and they had surgery.

Fistulae were found in a third of our patients. There were 32 colo-vesicaland 4 colo-vaginal fistulas. Colo-vesical fistulae were more common in males. Recurrent urinary tract infection was the main symptom and pneumaturia was an alarm sign that made patients seek an opinion. All 4 women with colo-vaginal fistulas had hysterectomies done. The uterus acts as aprotective buffer between the sigmoid and vagina. Surgery for these patients in our series was always elective and a one stage resection was possible in 30/36 patients. A stricture is an uncommon reason to operate  and those who need surgery often do so in an emergency situation with a staged procedure¹⁶.  We had 4 patients with strictures, 2 presented with acute obstruction and 2 with chronic recurrent pain and obstructive symptoms. 

Laparoscopy has revolutionised surgery for diverticulitis and there is good evidence to support this^17,18. In our own series of 21 resections results have been extremely gratifying with a mean stay of 5 days.The only complication was one incisional hernia froma specimen extraction wound.

Recently, laparoscopy has been used for lavage and drainage in Hinchey type III disease as an interim procedure, followed by a one stage resection.  After a seminal publication¹⁹ and then some controversial reports, this method has gained acceptance in Scandinavian counties²⁰. We have no experience yet with laparoscopy for Hinchey type III disease.

A Hartmann’s resection was our procedure of choice in the emergency setting and a majority could be reversed^14,18. However, literature suggests that only 40% of patients get a reversal, since this is a major operation and many elderly patients do not become fit to undergo surgery. Because the quality of life is adversely affected for those with a colostomy²¹, there is an increasing trend to perform a resection anastomosis  with a temporary stoma.  Evidence suggests that patients who present with peritonitis and are hemodynamically stable^22,23 can safely undergo a resection anastomosis with a diverting ostomy. Our experience also supports this and we have done 7 primary resections with a stoma in 25 emergency operations.

Complications and mortality after surgery for diverticulitis have been well documented²⁴. We had 9 serious complications (CD grade III), 15 wound infections (CD grade I) and incisional hernia in 14 (CD d) (Table 2). Hernias occur from the main wound and from stomasites are often large and difficult to treat. Most occurred within the first 6 months of surgery. Six months after surgery 84 patients could lead a normal life. Twelve were dissatisfied with recurrent pain, constipation and troublesome hernia. A more prudent case selection in uncomplicated disease could have avoided this. 

In this case series spanning almost 2 decades our treatment for diverticulitis has changed. For uncomplicated disease we use a conservative approach and will offer surgery only after a third attack. For complicated abscesses a CT or laparoscopic guided drainage is attempted followed by elective one stage resection. In the emergency setting a resection anastomosis with a temporary stoma is done if the patient is haemodynamically stable.  Since 2014 we have used laparoscopic resections with good results and this has reduced the morbidity of surgery and has allowed enhanced recovery.