75 year old obese man presented with difficulty in Bowel movements, No bleeding or mucous discharge. His General condition is otherwise well apart from he is a diabetic and Hypertensive. Along with other investigations, colonoscopy was done which showed multiple diverticulae of sigmoid and descending colon and a stricture not allowing the scope to go pass through the stricture. Stricture is just distal to the splenic flexure.cect is not showing any mass lesion. HP from the stricture is inflammatory. Can we get away with segmental resection or a full Left hemicolectomy is required?
I would rather go for segmental resection than full left hemicolectomy.
If the conservative treatment was fully done without effect, then the segmental resection is recommended. I think.
If the transverse and right colon is dilated due to the stricture i would perform an extended left hemicolectomy. It is a diabetic obese patient with probably not the best vessels an I would prefer it to be a one time surgery.
I think that the diverticular stricture of that colic segment could be occur again in the future also for the sigmoid colon; moreover the anastomosis on a diverticular tract is always quite dangerous for leake's risk in correspondence of diverticula!
So I'd prefer to porpose to the patient a left hemicolectomy enlarged to distal transverse colon with L-t colo-rectal anastomosis, I think safer.
In patients with diverticular stricture I think the best solution is hemicolectomy with anastomosys T-L or if it's possible L-L. First we perform operation it's very important radiologic study by clisma enema and colonscopy, well these examen give the complete picture of the pathology
The location of the structure isnt very tyipical for diverticulitis. Since the patient is old and diabetic, i think, this structure may be related to ischemia. Because of that, i would choose larger resections rather than segmental resection.
After many episodes of diverticolitis the lines interesting is many closed; it's very attractive by Rx-enema the presence of intestine stricture without peristalsis
In view of the multiple co-existing diverticulae and the possibility of an ischemic stricture at this site a full left hemicolectomy may be safer option
Right-sided, diverticulous stricture is exceedingly rare. So, if cancer is absolutely ruled-out, dilation by a covered stent would be safe and easy and if the general state is correct, or concer non absolutely ruled out, I would suggest a right hemicolectomy, which is quick and simple
Strictures of the colon result from chronic inflammation and fixed scarring resulting in luminal compromise. Acute, complete obstruction is uncommon and patients typically present with chronic partial obstructive symptoms. Symptomatic patients should undergo radiographic and endoscopic evaluation to exclude a malignant process and then be offered elective resection.
The use of endoscopic colonic stenting as a treatment of acute obstruction of the large bowel secondary to colonic cancer has been well documented in the literature either as a definitive procedure or as a bridge to surgery and can effectively decompresses the obstructed colon in 90% of cases51. However the use of stents in benign disease is less well documented , with it used mainly as a bridge to surgery52 and because is associated with a higher incidence of complications in acute diverticular disease53 it cannot as yet be recommended.
A colorectal anastomosis is a predictor of lower recurrence rates after elective sigmoid resection for uncomplicated diverticulitis46. Therefore it is recommended that the distal resection margin is taken onto the rectum as opposed to the distal sigmoid and the splenic flexure is fully mobilised to facilitate this4, however in the case of a long redundant left colon this may not be necessary12. The proximal resection margin is less clear but should be made onto soft compliant bowel4 34. Often it is possible to identify the ureters intra-operatively however, there may be cases of complicated diverticulitis in which the extent and degree of inflammatory changes warrant the use of pre-operatively placed ureteric stents to help aid their identification and avoid injury12.
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in view of above evidence I feel Good Proximal & distal resection is better keeping close to bowel as Radical Dissection is not required.
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