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  #1  
Old 01-18-2007, 04:13 PM
Earl Snake-Hips Tucker Earl Snake-Hips Tucker is online now
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Diverticulitis surgery: Internal reattachment or colostomy bag?

Background:

Recent reports about Castro’s medical condition seem to indicate that a) he had been suffering from diverticulitis, and b) he opted for an internal reattachment as opposed to a colostomy bag. Since then, the sketchy reports indicate that he has had various complications.

Almost three years ago, my then-82-year-old uncle had the similar situation. Diverticulitis, removal of the colon, and internal reattachment of the small intestine to the rectum. And one after another complication, starting with an abscess at the site of the reattachment. In my uncle’s case, he was laid open for some unknown period because after cleaning up the abscess, he basically had to heal from the inside out.

He also had one complication after another, including various infections, pneumonia, ventilator-assisted breathing (one time for two weeks straight). He was in the hospital for four months, over half that time in the ICU.

The questions: Are there any guidelines for internal reattachment vs. colostomy bags in the cases of colon removal as the result of diverticulitis?

One other thing to add, if it makes any difference: In my uncles case, it was emergency surgery. Because of his age, they thought it would be better to try to control the internal bleeding (the symptom of the diverticulitis) with drugs if possible. In his case, it didn’t work, and his internal bleeding from the diverticulitis went critical—and he had to be rushed into surgery.
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  #2  
Old 01-18-2007, 09:14 PM
Qadgop the Mercotan Qadgop the Mercotan is offline
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Quote:
Originally Posted by Earl Snake-Hips Tucker
The questions: Are there any guidelines for internal reattachment vs. colostomy bags in the cases of colon removal as the result of diverticulitis?
Tons of them. To understand them best, do a general surgery residency. Then you'll be able to make the decision as to which option is best for a particular circumstance as you wade thru the blood and stool and dying bowel tissue of some golden ager with diabetes, vascular disease, and a weak heart at 3 in the morning.

Not to be snarky, but it is a very complex topic. Basically, you need a healthy hunk of distal colon and a healthy segment of proximal colon to attach to it. And you have to be able to stretch the latter far enough to reach the former. And the patient needs to be healthy and stable enough to tolerate the prolonged reattachment procedure and to heal. Surgeons train for years to understand the nuances of making the right decisions.
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Old 01-18-2007, 09:51 PM
Dr_Paprika Dr_Paprika is offline
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Internal reattachment is substantially riskier than a colostomy bag and requires a much healthier patient. Many people who get diverticulitis are more elderly and many have other problems. Diverticulitis can often be controlled with antibiotics, IV fluids, gut rest (NPO) and avoidance of nuts and seeds. It often does not need an operation, and if it does the patient is generally pretty sick. If it goes to the OR, many surgeons would opt for the colostomy bag.

Your post discusses colostomy or reattachment, but many colostomies are "temporary" in the sense they are reversed, with reattachment of the bowel after several months and the patient has been stabilized and allowed to undergo some degree of healing.

Details of Castro's case have been sketchy and I'm sure he had the best possible advice and expertise.

I'd imagine factors would include previous surgery, age, general health, medicines, patient's wish for reattachment, amount of bowel removed, health of bowel AS DIRECTLY VISUALIZED DURING THE OPERATION, equipment and surgical expertise available, urgency of the operation, and probably a dozen other things.
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Old 01-18-2007, 09:59 PM
Earl Snake-Hips Tucker Earl Snake-Hips Tucker is online now
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Thanks for the responses. And although I didn't specifically mention it in the post, given the information my uncle and his family had at hand at the time, I would have agreed with their decision had it been my father (drugs originally vs. surgery), and I don't consider the complications he suffered afterwards the result of bad medicine. Sometimes stuff just happens.
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Old 01-18-2007, 10:10 PM
Qadgop the Mercotan Qadgop the Mercotan is offline
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Quote:
Originally Posted by Dr_Paprika
avoidance of nuts and seeds.
That's one of the things I learned too, but there's really no evidence that nuts and seeds are a problem.

Quote:
There is no convincing evidence to support previously
common advice for patients with diverticulosis to avoid seeds and popcorn
Journal of Clinical Gastroenterology. 40 Supplement 3:S108-S111, August 2006.
Bogardus, Sidney T. Jr MD

Otherwise I agree with the esteemed Dr_Pap who put it much better than I did.
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Old 01-18-2007, 10:25 PM
Rysdad Rysdad is offline
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Both of the docs have already explained the various reasons for/against reattachment. I just wanted to add a smidgen here to give you an idea of what it looks like to me, the X-ray guy who does the barium study.

Here is a radiograph that shows multiple diverticula in the descending colon. There appear to be some in the sigmoid as well, but I can't tell for sure.

Anyway, those little white blobs are the diverticula. They are the 'outpouchings' of the colon filled with barium. ('Inpouchings' are polyps)

If you have diverticula but they're not problematic, then you have the condition called diverticulosis. If they become inflamed, then it's called diverticulitis.

The patient population averages toward the elderly side in the hospital where I work, so I see this condition pretty often. Occasionally we get to do a procedure to see if a patient's colostomy may be "taken down" -or- reattached. That's not too often, though. As the docs said, colostomies aren't often reversed.
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Old 01-18-2007, 11:11 PM
brossa brossa is offline
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Quote:
Originally Posted by Qadgop the Mercotan
Tons of them. To understand them best, do a general surgery residency. Then you'll be able to make the decision as to which option is best for a particular circumstance as you wade thru the blood and stool and dying bowel tissue of some golden ager with diabetes, vascular disease, and a weak heart at 3 in the morning.
Ahh, memories.

The best candidate for removal and immediate reconstruction is a young (<50yo) person who has recovered from their first or second bout of diverticulitis, in whom the bowel can be prepped and the surgery done electively. The elderly or otherwise infirm are generally better treated with a staged procedure, or with a permanent colostomy. The devil is in the details, though - I helped on a case where the patient's belly wall was so thick (fat) that the remaining colon could not be brought through it to form a stoma. So we had to do an immediate reattachment and cross our fingers.

When the patient is fragile, it is normally a good idea to do as little as possible, get out quick, and plan to fight another day. If the patient has had so much diverticuar bleeding as to cause shock, for example, it can be necessary to just remove the bleeding segment of bowel and throw the gut back in with both upstream and downstream ends stapled off. You keep the patient sedated in the ICU for a day to work on reversing their shock, etc, then you take them back to the OR to create a colostomy or what have you.
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  #8  
Old 01-18-2007, 11:36 PM
Dr_Paprika Dr_Paprika is offline
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On one hand, I'm neither as well read nor as experienced as Qadgop. I hadn't heard that nuts and seeds were unproven to exacerbate diverticulitis.

On the other hand, I've diagnosed diverticulitis in young people who had "just eaten" massive quantities of sunflower seeds (two pounds in two days). Maybe it would have happened anyway. A quick google makes it obvious most surgeons think low fibre is the real culprit and that nuts and seeds are not, and indeed may help since they contain ample fibre.

Ignorance fought!
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