Let's Talk Diverticulitis

All right, y'all. Welcome back to Behind The Knife. We got a special episode today because we're joined with some of our directors of Behind the Knife. We have the Dr. Scott Steele, Jason Bingham, Kevin Kniery, myself, Patrick Georgoff. Unfortunately, John McClellan is away defending our country, so he can't be with us at this very moment. But we're excited to be together and we've got a lot to talk about. We are dive in. To a common but complicated and sometimes frustrating topic in diverticulitis. This touches so many different specialties, surgical, medical, everything, em across the board. And we're also blessed to have one of the world experts. Scott, you happen to know a few things about diverticulitis. You've written a few things. You've talked about it a few times, and, you know, so we're excited to, to jump in but before we do, so, I think we wanna share a few things about what we've been up to at Behind the Knife. We recently released something called Dominate Surgery. I. We're really proud of this

material. It's a course that's made specifically for medical students and a separate course made specifically for advanced practice providers, which is pretty great because there's not a lot out there specifically for apps, and the content is pretty fantastic, you must say so ourselves. It's a true multimedia experience, and so. There's high yield text. It's short text. There's original illustrations, there's tables, there's audio that's particularly useful in terms of preparing for clinical scenarios, and the video's pretty sharp as well. And the whole idea is to teach the art and the science of surgery so that when you get on rotation, you can dominate that rotation. We've just onboarded 18 specialty teams. They're gonna start in July. That's really exciting. And we couldn't be more happy with the quality of the educators that applied and the people that are putting the time and energy I. Into what we're doing, and this is something we envisioned a long time ago, is that we could have a platform and master educators would come forward and commit some time and their

energy and enthusiasm for education and that's played out. So we are just tickled by that. We've also got a five really, really top-notch pediatric surgery teams that are putting together a 30 part series that's gonna dive really deep into pediatric surgery. Topics, really high level stuff. And so we're getting ready to release that in, in the near future. And we're getting ready to interview our next round of surgical education Fellows. This has been an awesome program and they've been so amazingly productive as well. And last but not least, we're diving into a general surgery curriculum. This is something that's a very modern format. We think it's gonna outperform other things out there, and it's gonna be something that general surgeons across the country are gonna want to use during. During training. So as always, we'd love to hear from you. If you have any questions, comments, et cetera, ideas, please email us at hello@behindtheknife.org or reach out to us on Twitter or Instagram. Alright, with that, Scott, you ready to talk

about the colon? Bella, it's good to have the game all back together. Nice to see everybody. Good to see you buddy. Okay, so we're gonna talk a little bit today about diverticulitis and specifically kind of some of the finer points. And what I've got in store for us today is we're gonna walk through a scenario first, and then we'll kind of double back a little bit and hit on a little bit of the finer points. Now for each of you, you know, it's lots of nuances here. I completely understand that. But let's delve right in and kind of hit it. Kevin, let's start with you four. You pick on the vascular surgery first. Absolutely. That's the way that I do. It's just like when Kevin was an intern. I had to go back a little bit to him, see if he's sharper than attack. So Kevin, you're asked to see an emergency department consult. Now this is a 48-year-old female. Who's otherwise healthy? She originally presented with a little bit of generalized belly pain, especially kind of in the super pubic region. She hasn't taken much in. She's had some intermittent low grade

fevers over the past week. When you go down to see her, they've given a little IV fluid and her heart rate's kind of nineties, hundreds, or blood pressure's one. 13 over 52. Temperature is a hundred 0.7. When you walk in the door, you're looking at her and you're like, she doesn't look great. She's not septic, you know, or anything like that, but she doesn't look super good. Now, the ED, as we all know, has already got a CAT scan and it showed for all practical purposes, a little bit of a redundant sigmoid colon. A little bit of mesenteric, fat stranding, little bit of some small bits of mesenteric air next to the colon. And it's got a small pocket of pus on there, about three centimeter abscess that's associated with thickening of the do of the bladder there. Labs are pending. So how do you wish to proceed? Having some flashbacks here to Madigan morning report. But in this situation I would you know, I would want to know if she's had anything like this before. Does she have any history of pee air or fate material? And then I do a focus physical exam

really kind of focusing on her abdomen and then follow up her labs and make sure that she got some antibiotics along with that IV fluid. Okay. We'll kind of dig in there in a little bit. So I. Jason to you. So she does not have any prior taxes. This is the first time, and we'll get into a little bit why Kevin asked about she doesn't say, I pee, don't pee any air. There's no fent material. And then when you do a physical examination she's got a little bit of, again, some little bit of guarding, a little bit of tenderness, kind of the super pre region and on the left hand side and in the lab, they're cooking. We'll go from there. Why, why did Kevin, you know, she saw some thickening there. What do you think of Jay? When when he asks about the peeing of the air or the fent material? Yeah, what I think he was, I mean, what I think he was getting at is especially asking what her history was, if she's had prior bouts before you know, he'd be concerned that she has like a a colovesical fistula that could. From

recurrent bout to diverticulitis. You know, when I approach a patient like this, my, and I think you're telling me you're giving me a stable patient. But my first question is always, is this patient stable? Are they unstable? And they, you told me they appear unwell, but I'm assuming their hemodynamics are normal. They're not grossly peritoneal. And you know, that's the first thing really is resuscitate IV fluid, stable, unstable. And then I kind of dive into technically, you know, what's this patient's deal? In other words, what's her past medical history, surgical history, colonoscopy history, all those things. Fantastic. What, what antibiotics would you start her on? For her, I would start her on Zosyn. Fantastic. And like we said before, just to be clear amongst the group, there are no sign of any peritonitis at all. So Patrick, the lab's gonna come back in. They come back hemoglobins 13.5. The white blood cell count is 17,000. A little bit of a left shift. She's got a baseline creatinine of one, and her creatinine is 1.4. Everything else looks kind of normal. What's going through your mind in terms of next steps with her? Yeah, so she gets to hang out with us for a little

bit, so we'll get admitted to the service. Keep her MPO for now. Start some on fluid resuscitate. We just talked about getting on Zosyn, and we can do again keep a close eye in her. Make sure those exams don't worsen. Over time. Okay. So what are your options available? So, you're right. So perfect. We're gonna give her antibiotics, ZOS Sounds fine. I think you said we're gonna just hold tight on letting her eat a steak dinner or anything like that. So throw me kind of just, maybe not necessarily focus on this patient, but what are the, all the different types of options that might be out there? Yeah, so it all depends on how severe their flare is. And so if it's a mild thing, you may be able to send the patient home from Ed if it's. Moderate type issues like this, you wanna get it admitted, get some on some antibiotics. You mentioned an abscess, I think you said it's three centimeters. That's kind of right at the margin of what you may or may not be able to drain. So we wanna think about perk drains when appropriate and surgical approaches for so much sicker patients. And as we're moving to the other end of the spectrum, there's a lot of different ways to do surgery, and we're gonna talk about those

today. Lap lavage, hartman's procedures, resection, anastomosis, et cetera, that all come into play depending on how that patient looks. Fantastic. And Jason, I'm gonna just, let's just knock lap lavage kind of right away 'cause I got a little bit of a bone to pick with it. But tell me a little bit about lap lavage and then we'll kind of go from there. I mean, actually I'd be really curious to hear your thoughts. 'cause I'll tell you, I don't do lap lavage. I don't I've never, I never did a lap lavage for diverticulitis during training. I've never done one as an attending. But there are those patients, right? Like sometimes there's those easy ones. Like they have a big abscess that's easily drainable chip shot for ir, you know, we'll, we're gonna drain this percutaneously, we're gonna give 'em antibiotics and we're gonna kick this can down the road. Then you have, you know, the ones that are just you uncomplicated or a small perol peric colon abscess response to antibiotics. But what about those ones where it's kind of intermediate or somebody where you see a fair, fair bit of free fluid is what always concerns me is if I see like. Free fluid that's

not contained. They're otherwise clinically stable. Yeah. They may respond to antibiotics, but I'm gonna kick it right back to you, Scott, as the expert. What do you do with those patients and what do you think the role of LAP lavage is? Yeah, I'm gonna get to that in a second, but first I should have level set for the audience that may never have heard this Petri. What, how do you do lap lavage? What is it? Yeah. Pretty much what it's described as it laparoscopic instruments go into the belly and you wash 'em out multiple liters. Of, of saline, rinse and repeat and leave some drains. And that's about it. You're not doing any resections. If you can get to a collection, you know, and unroof things drain it, you may wanna do that. But there, there's no colonic resection happening. I. Yeah. Fantastic. And, and I know Connor during the hot wash after this, we will go through and show a little bit of the data, but I would just say in general, Jay, you bring up a great point. The problem with lab lavage is who is it ideal for? You have your patients who do very well without. Surgery you

have, you do have your patients that have percutaneous drainage available, and then you have your patients, you need to go to the operating room. So what is the ideal indication and patient for that particular patient? I tell you know, for a lap lavage, I tell people all the time, so you get in there, you have a abscess that's kinda walled off and stuck up against the abdominal wall. Your b your bowel has kind of said, Hey, listen, I don't want to have free, suck us all over the place. And so do you take that down and now you're staring at a hole. Mm-hmm. The hole was up against there. So, you know, a lot of this is not discussed. And then you have a situation where you've identify the hole and you know, do you, what do you do with a hole? Do you just leave a drain by it? Like it was the original description? Or I've seen videos out there that they almost do a gram patch on it and right. I try to remind myself out there that, you know, the, probably the first person who saw a grand patch ever happen on a hole in a duodenum. That person thought they were crazy, and here it's something that we do right there. So maybe there's something that we don't know, but certainly the

data that surrounds lap lavage, it was all the hot. Things several years ago, and I'm gonna show you a little bit of data later that would suggest that the recurrence rate associated with it and the subsequent need for an operation, 'cause you can't get through is certainly higher than in just if you would resect a loan. And so we'll dig into that a little bit better. So you, do you ever do it in your practice now? Yeah. Any indications? Never, I never do it in my in my pa practice, in my patients. And I gotta say for most people, I would just say that if you're able to take 'em to the operating room, you really think you need to go to the operating room. I feel fairly comfortable that I can do a pretty defined resection on those patients and not necessarily have to run the risk that we're gonna be just right back in for an either an urgent operation or just kind of getting into that. Smoldering diverticulitis, which we'll touch on just a little bit later have, have you ever had to bail and do a diverting proximal diverting loop like ileostomy and maybe do a little washout, but then you do your diverting loop? 'cause things are such a disaster in the pelvis that it's simply not safe.

Yeah. The one thing I like about you, Patrick, is you are absolutely a fan of history in surgery. And so what you're talking about right now is the old three stage procedure for diverticulitis, where back in the day, this was the standard of care. Patients would come in, they would get a diverting ostomy. That would be the first one. In that case, it used to be open, right? Where things were kind of just so stuck down. And then you would go back and you would resect and then put back together. And then the third would be you would take down the ostomy. So, have I ever felt the need to have to do that? I, I would say that that's few and far between, but certainly we all know that in many cases, the inflammatory conditions, especially with bad diverticulitis, can oftentimes be worse than just a cancer resection alone. Okay, so back to our patient Kevin. You end up admitting the patient and initially they're stable. Now you go to round and four days later they start to spike fevers again. And you know, her white count, which initially had dropped down a little bit, is

now up to 23,000. She's got some increasing tenderness in the lower abdomen. What's going through your mind now and how are you gonna proceed? So, you know, things have clinically changed and I, you know, first of course make sure the patient's clinically stable, but I'd probably we're, we're a few days into it. I think I'd want some repeat imaging at this point. Fantastic. And what's that gonna be? So a CT scan. Fantastic. And again, I know that you talked about before and Jason brought it up, but our first thing is always to make sure that you know the patient's clinically stable and in indeed she is. She doesn't have any peritonitis and you get a repeat ct and their abscess, Patrick shows that it, the abscess is now used to be three centimeters, but now it's six centimeters. Pretty large abscess. What's your plan? Yeah, drain that puppy. So you, you know, you talked about drainage and you mentioned it before, but give us a little bit of some background. We'll give a few scenarios, but first, what is the concept of why you drain a particular patient versus just taking 'em right to the operating room?

Yeah, so you're hoping, you, you want to do a surgery that allows the patient to be connected without, you know, for instance, a heart mins. You wanna do, you wanna do a one stage procedure, and if you can get this patient through this course. With antibiotics, with the drain, that's a good thing. 'cause then you see 'em back in clinic, they chill out, they get their colonoscopy, and they come in and get an elective surgery in which they have been prepared for surgery appropriately. And you can hopefully avoid an ostomy in that circumstance. And so that's the primary reason. And sometimes, you know, these patients can have, can have some rocky stays and people say, well, why don't you just do the operation? And if you can avoid again, an ostomy and a multi-step. Or multi-phase, you know, surgical approach, then that's a, that's preferred. Yeah. Fantastic. And so again, what we're hoping for in this particular case is you take a very hot, if you will, inflammatory condition, be able to drain away the pus, give the antibiotics, cool their belly down, and then fight the

fight another day to be able to go in there. So now I'm gonna dig in a little bit more, Patrick. So let's just say that I is successfully able to drain the patient and I'll, and I'll ask both you and Jason this particular question. How do you follow or if you will manage your drains? Jay, you go first. Sure. So well, you wanna follow the patient clinically, make sure that their white count resolves, you know, all that stuff that they're showing, some clinical improvement and some inter and continuing antibiotics. You know, about a two week course. At some point, I'll want to get some repeat imaging, whether that's a repeat CT scan or a drain study to, to to end. You know, some of that's gonna be based on what's coming out of the drain. You know, if they're clinically doing great and the drain drop output, you know, drops off and it's minimal. Yeah, plus or minus on repeat imaging. But I would do complete a course of antibiotics and pull the drain if it's low output. If it's higher output, I'm gonna get some, get some studies, maybe a repeat scan, make sure that that everything's adequately drained. If it's the output is.

Looking questionable. If it's looking like maybe it's developing into a fistula, I may want to get a drain study. I may wanna leave that drain for a longer period of time and you know, go back to my principles of fistula management. But all in all, follow the patient clinically, continue antibiotics, repeat interval imaging at some interval, and then management of the drain, depending on the output and quality of the output. Fantastic. Patrick. I don't routinely image them, so I'd follow 'em clinically like Jay said. See what the character of the output is, see how much is coming out, and then obviously how they're feeling, how their exam is, et cetera. We'll check a, oftentimes we'll check, get a get a C, B, C on their return visit. And if they're clinically doing well, the drain comes out. And if there's any question repeat scan, and if the drain is feculent, then that's a different story. I think that leads you down a different pathway. So this is one of my favorite questions to ask out there, and I would say that, you know, like many things in medicine, there's just not a whole lot of data to support exactly how you deal with a drain. I love when I sit in panels to ask people how to do, and I've had everything from

saying, Hey, I get a drain study in every single person. Because if it connects with the colon, then they have a higher rate of an abscess. Haven't seen that particular data out there. And then I would not pull the drain or I'd keep it in until the time of the operation to, I never image anything. I just follow and see what it looks like and I pull it in. I think that, you know, no matter what this is, this is something that you kind of have to stick to your plan, understand what's going on, understand the risk, and kind of go back with the patient. But there's really is no right or wrong answer in this. I think it's important to understand what are the options, and in general, exactly what you guys said. We're following our drainage output. We're gonna go ahead and consider if they're getting worse that potentially we're gonna be able to re-image them. And, and, and along those same lines, Patrick, what in general are, how often do, how often do drains do they not work in and of themselves? Do you have any any idea about that? The drain drainage procedure itself

not working. Yeah. Yeah. So you stick a drain in there and you think, Hey, I'm gonna kind of roll through this particular patient, put 'em on IV antibiotics and make them quote unquote cool. Down about roughly in some of the larger series, do you have any idea how often that drains themselves fail that you gotta proceed right away at the time? No, I don't actually. It's about a third of the time, and that's a number to kind of keep in mind. And there's certainly a lot of different factors that go into that. Where is, you know, do you get a good drain in there? Is it a kind of a tricky window that you can't be able to, does the drain get blo clogged in there? You know, how thickened and how bad is that? Is that initial attack that we're talking about right there? So, mm-hmm. I try to let everybody know that just because, you know, they successfully go on to get a drain. Everybody seems to think, whoa, I get a drain, so I'm done. I don't know how to worry about this in a while. I can give 'em antibiotics. And remember about two thirds of the time, maybe even on a high point, 75% of the time, it could work, but upwards of 25%. To 33%. Those drains won't

work and the patient will experience problems. You might have to upsize the drain, you know, you might have to maneuver the drain or the drain fails completely altogether and you gotta go a different route for those patients. Are you doing any lap drain placements? So like the situation that we'll see sometimes is they have a six centimeter abscess. IR says there's no window, can't get to it. And other, these are always the worst. Possible patients. They're always BMI 60, you know, poorly controlled diabetes, you know, all everything. What are you doing in that situation? Are you taking 'em to resection or are you doing lap drain placement? Yeah, in general, no, I don't do lap drain placement. If I gotta take out an a colon, I'm gonna take out the colon. I You do bring up a good point though. There are certain factors that are dependent about how we. Take care of certain patients. You know, what are your skill sets? What is the skill sets? You know, if you're in a, a small hospital, someone that doesn't have IR drainage, you know, and you can't transfer that, you might be more AP to do something else. BMI is certainly a factor, especially when you're thinking about,

hey. I'm going to divert the patient, I'm gonna be fine. And all of a sudden you got a foot and a half Yeah. Abdominal wall that you're gotta be able to deal with for you know, either a prime anastomosis and a proximal ileostomy or even a colostomy. That, that might be a very, very difficult challenge that might need to steer you in another direction. You know, in general, if you talk about, Hey, I'm going to. Be able to take that patient in the operating room. I, in general, I'm gonna try to resect that particular one. It's a little bit like the laparoscopic lavage that we talked about without, you know, necessarily having to find the hole or anything, it, you're just trying to get in there safely and kind of break up of those adhesions. But let's face it, when you have a six centimeter abscess, everything's stuck to everything. And sometimes that can be, depending on the time these patients come in. It could be hard as a rock if you get to it early, you might be able to, you know, do a kind of a wash on a drain placement. But many of these patients, they've kind of already walled off. And what's preventing you from getting a drain in is oftentimes the small bowel. Mm-hmm.

That's preventing what the window is. And so with everything kind of stuck, now what are you gonna do? Are you gonna, you know, lice that small bowel and maybe get an atomy and have to deal with that and all quickly how the dominoes may tumble. And so it's important to kind of think that through. So, back to our patient. So Patrick, you see the patient in clinic, you remove the drain. She says to you, do I have to have an operation? Yeah. So that's a great question. And that depends. It depends on the patient mostly. And how many flares have they had? How severe are those flares? How big of an impact is it on their life? What's their. Appetite for surgical risk. What are their other risk factors? In terms of having an operation? All those things play in. And so this patient, she was 40 something healthy. This is her first

flare. She did have perforation, had a drain placed. And so the risk of recurrence in a patient with perforation, with a, with an abscess is something to the tune of 30 to 40%. And so you can start with that number, and this requires a little bit of time in clinic, you know, sit, you sit down and you say, this, this, let's play all this out. And the patient, if they're amenable, this would be a reasonable patient to operate on, certainly because they're up to a 40% risk of re recurrence, and she's a good operative candidate. On the flip side, if this doesn't fall in line with that patient's values after a legitimate risk benefit, rationale discussion, you don't have to have to operate on them either. So this is a, it is an inter, it's every patient's unique and that comes to clinic with this. Yeah. You know, the interesting thing about these patients that re recover after, specifically after an abscess or maybe even in a big bout, and you're starting to talk to, saying,

Hey, we wanna have an operation from our standpoint as surgeons, you know, one of the things we want is we want them to be feeling as good as possible, and then from their standpoint, they're typically like, I feel good, so why do I want to have an operation now? Right. So that's a conversation that I go through these patients and say, you know, it's a little bit like the, as the tread on your tire starts to kind of wear down, you know, we want to get it to the point before it kind of, you, it pops or you, you know, it's way down and you're kind of skidding off the road. We want you to get into pretty good shape and to make sure that, you know, you feel as good as possible. So it's just a quick tire change, if you will. And and we don't have to be able to go through and have this be a major ordeal, Patrick. Scott, if you were in, in clinic with this patient and you know, you do your whole thing, you talk about the rationale, risk, benefits, et cetera, of surgery specifically for her, would you recommend you say, I'm, you know, as a surgeon, I say, I think you should have surgery, or do you leave it open to say I would certainly offer you surgery and then do you let the

patient decide? How do you. You know, certainly the patient always decides, but you get my, my question, so this is a conversation that I kind of use some overall points over and over and over again. The first thing I tell the patient is, do you have an indication to go to the operating room? And the answer to that is yes. Do you have to go. To the operating room, the answer is no. And I start there so that they understand first and foremost, that if we're sitting here and we get to the point where you go to the operating room, right? Let, let's think about it. Think about any case you wanna be able to, do you wanna have an indication go to the operating room, right? And and certainly patients like, you know, do we have to go to the operating room? Do you have an indication? Yes, you absolutely do. Do you have to? Not necessarily. And with those as our building blocks, what I tend to do is I walk a patient through exactly what both you and Jason just talked about. You have a relatively healthy person, fairly, you know, normal BMI, that we can handle. You look at your own skillset. That's something that we don't talk a whole lot

about, right? What are our outcomes? What do we feel comfortable with? Do we truly have the minimally invasive skills, robotically, laparoscopically, hand assisted, whatever it may, that you can limit some of the morbidity associated with that. What is your leak rate? We can talk about a leak rate associated with sigmoid resection for diverticulitis all along being less than 5%. What is yours as a surgeon, right? We don't talk about that a lot. And if yours is 15%, that maybe that may sway your opinion. Similarly, we talk a little bit about, you know, has this patient, had prior operations, has this patient on Eliquis, they have a heart attack. All of those other things that you both mentioned that I think go into play regarding this specific patient. Somebody that has you know. No prior bouts, they've had an ability to have, you know, a successful drain placement to the point where it's out in clinic, they're otherwise healthy. You know, I think that the data would suggest and to lead me in a situation where if they're truly kind of pinning me down, I'd take 'em to the operating room and I

would be able to take out the Sigma colon. 'cause I think that the risks associated with that operation are lower than maybe some of the other the risks that go along with this disease or. Unplanned need to have, you know, quality of life or intervention. Jay kind of go to that same point. She asks you, she says is her risk of perforation in the need for an urgent colostomy if she elects not to undergo an operation? When, when do they typically perforate? Well, what you always taught me when I was your resident was the, your first bout is typically your your worst bout. So, it's typically that first episode. I don't know if that, that's as far as I'm aware that's what the data shows. Unless that's changed in the recent years. No, absolutely. It is the case. Now, here's the tough thing about diverticulitis though. So there's data that you would read out there, or textbooks that you would read out there that would say that. Every B diverticulitis is a perforation, right? That you have these micro perforations that cause it to be thickened and inflamed. But so

when we talk about perforation, it's important to talk about an abscess or talk about a free perforation. But remember in the old days, what we used to think of is that. Diverticulitis was a progressive disease so that if you had one bout the next time you were gonna have another bout, it was sure to be worse and then worse and then worse. And then if you look at it all, you're apt to have a perforation on your first time more than anything else. So, Kevin, the patient comes back to you and they said, I'll think about that. I'm not quite so sure. Is there anything else that I should do in the interim while I'm thinking about this? So you have somebody that got. A you know, it's a, it's a younger woman. I'm 52, so you know, she's younger to me and she had a successful drain place. She's feeling a lot better the drain's now out in clinic as she's waiting around anything else you would do prior to proceeding with surgery. Yeah. I appreciate you tailoring these questions to me. I think she needs a colonoscopy in the meantime. Yeah, that's fantastic.

So you wanna clear that colon, you wanna make sure there's no other concurrent disease. So let's switch up the scenario just a little bit now and say that the patient presented with no abscess, thickened colon, no fistula. She responds to antibiotics and back in your office. But, but Patrick, instead of this being the first bout, now she, this is her third bout, how do you go about in these patients that have you know, a little bit about. Elective resection or observation, especially with the patients that have had multiple bounce through. Yeah. So this just moves your, moves your starting place more towards the the surgery end game, right? This is what we talked at the beginning. You gotta add these things up, and it's good to know about these episodes, how severe they were. You know, we went to the beginning. I always put in all of my attestations for these notes to say, how many flares does, has the patient had, or how much they think had, how many times have they received antibiotics? How many times have they admitted, been admitted to a hospital? Have they had a colonoscopy? When was it, what did

it show? And did they have a personal family history of colon cancer? What's their past abdominal surgical history? Every single time it, it, a lot of times you see IBD templates, right from GI and surgery too. But those things are listed, so I put those in there 'cause I always forget. And then if they come back to clinic, I can remember those things. And so this person's closer to surgery. We wanna make sure that those flares were actually diverticulitis flares. We wanna see if she's ever fully recovered from 'em. And is this the quote unquote smoldering diverticulitis? And. We wanna know all about the patient and their lifestyle and you know how active they are and are they traveling a bunch? And what other, other comorbidities when it comes to their health, their BMI, et cetera. I think that's great. I lots to unpack there and we'll get to in a little bit. Jay, I'll come to you, I'll give you a pre-read to think about. I'm gonna ask you about what smoldering diverticulitis is. But Patrick, you brought up a great point and that point is about, you know, were these bouts. Truly diverticulitis or not. If you talk to some patients, we've all talked to 'em. They're like, I've had, you know, 5,000 bouts. But what they're really experience is a lot of

times just spasm associated with that colon. That's become, as we all know, when you operate on some of these patients, what do you see? You see a fibrotic. Thickened colon that nothing passes through and you know, and essentially they may experience pain and even spasm and associate and attribute that to the fact that, hey, I'm having another bottle diverticulitis. And it's not, so, it is important, as you said, to say, what is CT proven what's not, what's they, they been admitted for how many times they've been on antibiotics, although. We certainly know patients that are like, as soon as they feel that they don't want to go through it again so that they They're on the antibiotics. Yeah. Yeah. They keep the antibiotics or, you know, they have the outstanding prescription that they can kind of fill anytime they need, be from their primary care doc because they've been so burned in the past. So, Jay, patrick mentioned something that's that doesn't get a whole lot of press out there, but it's certainly something that we see and that's those patients that have kind of a smoldering diverticulitis. Can you delve in a little bit there and talk about what that is? Yeah, so those are patients

that kind of have a. I mean, it's exactly what it sounds like. It's smoldering, you know, so it's this low grade chronic inflammation that maybe never really gets better. They don't really have breaks between their episodes. You know, maybe they'll go on antibiotics, they'll get a little bit better, but as soon as they come off antibiotics or, you know, their symptoms return. So it's, it's those patients that have that low grade chronic inflammation that just kind of goes on for weeks and weeks. And on those patients, are you more or maybe less apt to recommend surgery? Yeah, those patients are somebody who just needs the disease part of their colon out, so it would be definitely more apt to offer that patient surgery. Yeah. Fantastic. So. Patrick, let's take a step up. Let's, let's just go up one level, and this is something we could have started with a little bit, and that's the idea of complicated versus uncomplicated diverticulitis. So how do you kind of classify complicated versus uncomplicated diverticulitis? Yeah, so,

complicated diverticulitis. Something happened that complicated it. So in this case, there's a handful of different things that can happen. An abscess, like in this patient. Stricture or fistula are the three kind of biggest big ticket items that would make a diverticulitis episode complicated. So I think the important point here is that many patients, when they hear the terms complicated and uncomplicated, they immediately think, well, I had severe symptoms. It was a really bad bout. And it's important to understand that the severity of the symptoms doesn't necessarily. Talk about the classification of complicated or not? Yeah, exactly what you said. That if you got a strict abscess perforation, fistula understanding that micro perforations can be in both, it's really. Those are the ones that make up a complicated diverticulitis. So the very bad thickened sigmoid colon, it could be a flag mon there, it could be, you know, really, really nasty, really thickened. That could be an uncomplicated diverticulitis. You just don't have the narrowing that

comes in from the repeated bouts of fibrosis. You don't have that fistula to nearby organs, co vesco, cova, even colac, cutaneous or small bowel trying to wear it off. Or, or that abscess that's in her free perforation. So, Jason, you know, if we talked a little bit about the fact about patients in general, it seems like everybody gets a CAT scan. You know, they come in, they have any sort of belly pen and they go from there. Can you stratify, if you will, kind of degree or bouts or even complicated versus uncomplicated on ct? Yeah. Yeah. So this is, if you're an intern out there, you better memorize this because if you have to present up at the podium a diverticulitis case, you're definitely getting asked about the, the Hinchey classification. So, you know, stage one hinchey is inflammation combined to the, the colon or the pericolonic area. Stage two is a pelvic, or, you know, di distal inflammation abscess, basically a pelvic abscess. Stage three is perent peritonitis, and then stage four is

feculent peritonitis. Be Before we move on though, I wanted to ask you, you know, we were talking about this complicated uncomplicated. What do you make of the, you know, I know there is some data that says that we can, we don't even need to give antibiotics at all for uncomplicated diverticulitis. What, what do you make of that data and are you incorporating that at all into your practice? Is that just a European thing? Yeah, it's, it's an interesting balance. So there's actually a Cochrane review about diverticulitis treated with antibiotics versus not. And there's a large trial that we hope to be able to see here in, in the US that it's gonna be done. We'll get some good data on that. I still believe that Dave flma at the University of Washington is leading that particular trial. Now I think it's important to understand that in most cases. The no antibiotics is not for complicated because what we know is that for complicated diverticulitis, most of these patients, not, not necessarily urgently, right? We've for sure seen patients in clinic that have a colovesical fistula and, and they're doing

just fine. Yeah. They have, you know, urinary tract symptoms that go from there or have an abscess, but those patients that definitely have uncomplicated diverticulitis, even if it's pretty severe, can be treated as effectively some of the data would show. With having antibiotics? No, just IV fluids and bowel rest. And they can kind of get through and, and go from there. The the analogy is, I got a strained muscle. I'm gonna put it at rest. I'm not gonna do any more bicep curls to be like Patrick's biceps. And the reality is, is that it can go better alone. Now the hard part is it is an absolute knee jerk reaction, especially in the us to you come in, you get diverticulitis. You're on antibiotics. Mm-hmm. As a matter of fact, as you all know, by the time oftentimes you're consulted that you go see 'em in the emergency department or if they're admitted they've already gotten a course of IV antibiotics and you know, it's kind of starting from there. Sure. That's what I would like if I come in with it. Please to

shake Kevin. So the reality is, is that even though that the data is out there, part of this is, there's no question. Part of this is just the culture of what we've been all trained by. The other part of it is I would, I would. I guess is a little bit of, maybe a little bit of worrisome if the patient has a bad outcome mm-hmm. That, you know, medically, legally are they doing the wrong thing by not giving antibiotics. But there's certainly data to support that you don't necessarily for uncomplicated diverticulitis. This griping again, not with stricture, not with fistula, or not with a free perforation that you can treat with IV fluids and bowel rest alone. You know, as we talk about these particular patients though in practicality, how often does that occur? That's certainly the minimum, but I think that as we get more data, I. That the patients are gonna, you know, there's certainly some patients that would do just fine with that. Patrick, on his initial a answer to this entire scenario, remember what he said

was, you know, there are certain patients that don't need to come in, don't need IV antibiotics, they can just get an outpatient course of PO antibiotics and do just fine. On that note, have you, have you ever treated a truly uncomplicated case without antibiotics? Or do you typically I have not. No. That's a great question. I have not. And oftentimes it's just easier to get antibiotics and they do fine. Now the question that does come up is, you know, what's the downside of antibiotics? And we talk about super bacteria, we talk about c diff, we talk about all that. We've published at the Cleveland Clinic about c diff following, about a diverticulitis, and it certainly is a real. Thing. We actually found that you can actually get c diff after a colonoscopy. And, but you know, so these things can happen. But in general, I think antibiotics are pretty tried and true, but there is data there to support them. I think Kevin's question is good. Like, Patrick, if you have, if you get acute on complicated diverticulitis, do you want antibiotics? Yeah. Yeah. The question I would have though too is what I would, I would say yes as well. Yeah. What are you giving either Jay or Scott, what are you guys

giving and for how long? Let's say for a truly uncomplicated course and they're gonna leave the ED or this patient who goes, does great with the drain and goes home. Are you doings Cipro Flagel? You doing Augmentin? Are you doing seven days, 10 days, 14 days? I know there's some recommendations out there, but, okay. Go ahead. Well, we'll typically do 10, 14 days of Augmentin. Yeah. And I typically give Cipro and flag. I think it's, you know, it's. Pretty decent coverage flag certainly doesn't taste the best, gives the patients that awful taste in their mouth and they go from there. But it's been tried and true and I'll do 10 to 14 days. It kind of really depends. And you say, well, which one, 10 or 14? And I would say, you're, you're looking at the patient and seeing how they're doing. There's no question that. There are gonna be certain patients that will transition over to more of a smoldering diverticulitis that might need to have a little bit longer course or might need to have that imaging that we talked about before to make sure that they're not developing an abscess. Remember we talked about in this patient, the patient had three centimeter abscess.

They started to get worse. Kevin said, go ahead and give a repeat CAT scan, and now it's a bigger abscess. There's certainly those patients who present with just. Thicken sigmoid, colon, very same scenario. They do a little bit better on the antibiotics. And then day three, day four, increased pain, increased white count, or maybe some fevers. You scan them and they've actually got an abscess now that you can be able to deal with. So it kind of goes both ways. And in that case, your antibiotics may be around a little bit longer. Okay, let's, let's jump back to a couple of intern level questions, and with that we'll bring back in our vascular surgeon. So Kevin, pretty straightforward. Classic pimp question, what are your boundaries for resection? Doesn't matter if you do it open or robotic or whatever. What are your boundaries for resection? For bout of sigmoid diverticulitis? Okay, so, we want to just take the sigmoid colon from what I remember. So, do the boundaries involve the rectum? Where the. 10

coalesce. If you wanna gimme some hints here. Yeah, that's fantastic. So that's the, that's the best one. So we used to say all the time that recurrent diverticulitis for sigmoid diverticulitis occurs in about 2%. And of those 2%, the vast majority of 'em, 'cause you didn't get on the rectum and so you left some diverticulitis behind or diverticulum behind. In that particular case, it's important to go past the point where the tinia splay or coalesce as you're talking about right there and then approximately. Jason, what's your proximal point of resection? So you just wanna, you wanna feel the bowel, so you want it to be that soft, supple not underrated, you know, healthy bowel. You're not going to try to rid them of all their diverticula. You just want soft, supple, healthy bowels, your proximal resection margin. Yeah. Fantastic. And I, and I know that we talked about it before, but. If you have diverticular disease throughout the entire colon, that's not the point where you're gonna say, I'm gonna do a completion colectomy and take it all out. We wanna really focus on where it is and, and again, that diverticulitis,

recurrence is still an issue. They, they don't all go away, and in many cases though, it is like we talked about before, you know less than 3%. So should be able to go from there. Patrick, you're sitting there and the colon itself. Won't reach, you've resected that bout, what are some maneuvers that you can do to get the get the, get a nice tension for anastomosis between the colon and the rectum? Yeah, you gotta be able to to mobilize it. And so you can start with the lateral to medial dissection, going along the white line of tilt and seeing what that gets you typically won't be enough. So you wanna follow that around and. Do a splenic flex mobilization that requires coming all the way around past the spleen to those more tenuous connections to even the pancreas there, and really dropping that transverse colon down that will typically get you to where you need to be but not always. You can also work along the, by

releasing the soro or the peritoneal coverage covering the mesentery, that'll get you a little bit of release. You can pick away at the corners of the Mez and you can take in IMV vein as well will be kinda your last, your last trick to getting things to drop down for a standard. I colo rectal anastomosis. That's fantastic. So, I couldn't have said it better myself, right outta the textbook. Those are all the keys in order to be able to make it reach. And then I would say the last thing maybe you could do is mobilize the rectum a little bit in that presacral vascular space. Get a couple additional centimeters up there and it'll go well. So guys, we've been at this for a while. Let's go ahead and put a bow on it. So, Jason, complicated. Uncomplicated. What do we tell the listeners? Complicated is anything that so, stricture, obstruction, perforation fistulas are all complicated disease. Fantastic. Patrick, rules of thumb about a drain, how often do they fail? What are your thoughts and how do you deal with them? Is there any good data there?

Yeah. They drink fail about a third of the time. You gotta be prepared to deal with that. And we talked about taking a look at output character, the output effect then or otherwise, although we didn't dive into that too much. And typically wanna get those out in clinic and get that patient over the hump to either not operate or operate and do a nice minimally invasive resection with anastomosis without an ostomy. And I will say just in general, since you mentioned if somebody does have truly cullan output for the drain, that's gonna be somebody that I'm gonna try to quiet them down, keep the drain in all the way to the point of the time of the operation. I don't, I don't deal with it at all. Just let it drain. I say, listen, you form fistula. We'll deal with this at the time of the operation. We're not gonna remove the drain. We'll keep you on some antibiotics. So we'll go from there. Kevin, is there an exact number of. Repeated bouts of uncomplicated diverticulitis that you would say you have to have an operation. The

answer rhymes with no. Yeah, no. This is a a personal decision with each individual patient. Fantastic. And then finally, just for the last thing, Patrick, boundaries of resection for left sided diverticulitis. Just and get down to the rectum and get back up about the healthy colon on the left side. Hey fellas, open mic to you. What things didn't we cover before we kind of sign off of this one with diverticulitis? We didn't cover the best thing. The best thing is what do you, when do you put a patient together and when you don't? I'm a acute care surgeon and this is the always the question is how do you make that decision? And so I'd love to hear from Jason and Scott on, on their thoughts on this. Go ahead, Jay. I'm a bariatric surgeon, so, I divert them. I'll push it over to Scott. Yeah. So I, I would say in general that there's a couple of things that we'll kind of. Important to know on that particular topic. The first thing is,

is that you can find plenty of literature out there that would suggest that you can put a patient together in the setting of perforated diverticulitis or, or fairly significant disease. I don't, you didn't gimme a true scenario, but I'm guessing that. The patient's bad enough that you're urgently taking 'em into the operating room. So we'll say in this particular case that it is free perforation for there. 'cause that's something that, you know, as an EGS surgeon, acute care surgeon, you're gonna probably take 'em for that. There's also data that would suggest that, again, that you can put them to together and they can get a a proximal diverting ostomy and leave all that stool that's in between. And they do just fine. I. I think the important points that I try to teach my trainees about is that all sounds good, but you gotta look at a couple of things, right? Because this is not cookbook medicine. The first thing is just what we were talking about before, and that's factors to consider with therapy. And that goes into, I. What's the patient's

comorbidities? We all know that. Let's just say that one of you developed a complication following an emergent surgery for diverticulitis. By and large you might get sick, but if, if you leaked or you did something, you could do fairly well if the person that you're dealing with has all sorts of comorbidities, you know, there. Ability to, to tolerate that subsequent complication, you know, you have to consider and have to go to play. And that might be somebody that you're more apt to be able to, you know, do a diversion on the other thing that is, you know, probably one of the most important things is technically how did that operation go and what is the current status of the bowel? So you get in there and you know, in general, as we all know, especially for diverticulitis, the rectum itself, the important reason to go on the rectum is the rectum. No matter how bad that left-sided diverticulitis is, the rectum tends to be soft and supple. But there's certainly patients that have a pelvic abscess

or have, have had stool depending on how long before they presented, you know, in, you know, in extremists or anything that that inflammatory cascade has gone down the rectum and, and all of us here on this call have probably had one way or another. Had to extend your distal resection margin, mid rectum, 'cause things are just so bad and now you're halfway down. And remember if you're in that situation, you know, now you're mid rectum. You know, especially on a male, it could be a smoker heavy BMI, you're gonna divert that patient. You know you're gonna in one ear or another. But when the bowel is very. Thickened and you're looking at, you know, your stapled anastomosis and your donuts are, you know, true just giant donuts that have a hard time, and you have some of that tissue that's squeezing out in between your ea stapler. That's somebody that's, you're kind of setting up for not to have a good situation. So my rules of thumb are this. Look at the patient in front of you and see are they healthy or they're not. If they have a lot of comorbidities or they're. Not

doing well at the time of the operation. You know, they're hypotensive, you know, really tachycardic, things like that. That's the time to fight the fight another day. And certainly I'm not advocating that they're necessarily the patients that you have to have a damage control procedure on. There is some data I. That is out there to full disclosure about damage control operations in the setting of diverticulitis. And again, all you're doing is pushing it to the right and you're like, Hey, just very similar to trauma. Like, I'm gonna see what they're in now. I'm just gonna get this thing out. I'm gonna leave it open. But and it's very interesting and they show that they wind up with less of a chance to have permanent ostomies. The thing that you're trying to avoid is that we know there is data out there that would suggest that if you give a person a colostomy. And compare that with a person who has an ileostomy. The person who has a colostomy is much more apt. To have a permanency to that colostomy than if they're gonna have an ileostomy. And there's one paper out there that suggests that

in patients over 70, there's a greater than 75% chance that they're gonna live with that permanent colostomy for the rest of their lives. So that's important to know 'cause you're kind of bound and churn them. We wrote a paper at the Cleveland Clinic that looked at the scenario that I gave before. So you have a person that had left sided diverticulitis, you put them back together and you did a diverting ileostomy. So the question that comes up is, especially if they have a column of stool that is all throughout there, right? Are they going to have more of a problem by giving 'em a diverting ostomy? And what we found was no, that they did, it was a, that it was safe. So what does a diversion do? I don't, you know, it's a great question and it's something that I can't explain the mechanics behind it. But it is certainly something that we found and we're worried about it. So I'll be much more apt if I'm gonna divert, assuming that I can get healthy ball the healthy bowel, but I'm still like, it just didn't go quite right. I'm gonna give him a diverting ostomy. I will not give him a colostomy. And that's how I

think about it. That's great. I have two, I have two short questions that I still have. One with smoldering diverticulitis. How long do you wait? If I can get 'em through, I mean, the classic thing is to say I want to kind of get you through six, eight weeks, do a colonoscopy, and then operate on you right away and go from there. The reality is, is by definition, the smoldering diverticulitis is something that you can't quite get 'em through. That just, it's the little engine that couldn't, just can't get up over the hump. You know, they get up there and they continue to have problems, so sometimes you have to bite the bullet and just take 'em from there. So. I don't have a set thing, but I, I try to see if they're truly just really, truly smoldering and they can be semis stable. If I can get that colonoscopy, I, what I do is I'd scope 'em on a Friday and then just let 'em chill out and then just go ahead and do the, a case on a, on a. On a Monday, or you know, if you got scopes on one day and doing the next one, so they only have to have one bowel prep. I think that'd be great. And I figured the question would come in and say, are you still bowel prepping your colons? And I

would say the answer's pretty clear that oral antibiotics plus a mechanical bowel prep is probably the best way to go to just give them mechanical bowel prep in the absence of oral antibiotics. I, I wouldn't do that. We're not doing that. My last question is, we'll see sometimes that a patient comes in clinically hemo, apically, stable, tender, but not diffusely peritoneal, and, but they got a pretty significant amount of free air. Without free fluid, how, how are you managing? And everybody kind of freaks out. They see that scan with all that free air and they say we we're calling the OR Right Now how do you manage those patients? Yeah. I'll tell you a funny story. I was on call once when I was living in Washington State and I got a pager at this particular one that said they wanted to have a consult for. Free air for perforated diverticulitis. It's lots of it. And so I was expecting to do the exact same thing that you said in, you know, take him right to the or called the or said, be ready to go. And when I walked up to the ward, I opened the door and there was this woman sitting there eating a subway

sandwich. I will never forget it like it was yesterday. And I said, oops, sorry, wrong room. Nice to see you. And I closed the door and I looked at my pager again and I looked at the door number and I was like. They must have moved. The patient asked the nurse, do you know where Mrs Blank is? And they were like, yeah, that's her right there. I'm like, but she's eating a subway cell. I opened the door, I'm like, Hey, I'm Dr. Steele. I, I am a surgeon. And she's like, get out. And, and I was like, okay. So we, we know that we don't operate, we always say we don't operate on a radiographic, we operate on patients. And it's cliche, but it, it, the, the point does come, the thing that worries me when I see a bunch of free air. If I see associated free fluid, yeah. Mm-hmm. I'm just, if I'm seeing a bunch of just free air, then oftentimes if the patient is stable, what's happened is that they perforated, they didn't have much in their colon. They probably perforated let out, you know, if you will a giant fart in their abdomen. The, the all internal fart. Yeah. Yeah. And then it kind of w walled itself off

and they look pretty good. And I'll be, you know, I'll be up to have a lower that, that, that to me is not an emergency. But if they have a bunch of fluid in there that, that's worrisome and that would be something that I'm more AP to take the operating room. Yeah. I'll just, I just want to end by saying well first off, just for Kevin, next time we're running carotid disease. And he gets to pimp Scott on the next one. So everybody be sure to tune in, tune in for that. But I remember one of my very first calls as a staff first year out, like first month outta residency. I was on call and my chief resident was Dr. Kevin Can. And we got a perforated diverticulitis that we had to take to the or. And I think we called you, Scott for, for your advice. So here we are eight years, almost, almost a decade later, still asking you questions about what we should do. So full circle. I remember that case. I do. Yeah. What comes around goes around fellas. And it's it's good to have the crew back together. And with that, we'll turn it back to Patrick to wrap things up. Alright, that's all we got. Thanks for listening. We'll be back for more in the near future carotid disease

next time. In the meantime, dominate the day.