Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 2: Operative Versus Non-Operative Management
Clinical Image
Source: Wikimedia Commons - Diverticulitis CT - CC BY-SA 3.0
Case Presentation
A 52-year-old otherwise healthy man presents with 3 days of left lower quadrant pain, low-grade fever, and elevated WBC to 14,000. CT shows sigmoid diverticulitis with a 3 cm localized abscess (Hinchey Stage II). He is hemodynamically stable with no peritoneal signs. The surgery team discusses management options. Option 1: Emergent surgery (sigmoid resection with possible diverting colostomy) carries operative risks and potential for permanent stoma. Option 2: Non-operative management with IV antibiotics and percutaneous CT-guided drainage of the abscess allows the inflammation to resolve; elective sigmoid resection can be considered later if recurrence occurs. Given his stable condition, contained infection, and accessibility of the abscess to percutaneous drainage, the team recommends non-operative management. Interventional radiology places a drain, and 50 mL of purulent fluid is evacuated. He receives IV piperacillin-tazobactam. By day 3, his pain and fever have resolved, WBC normalizes. The drain is removed on day 5 when output is less than 10 mL/day. He is discharged on day 6 with oral antibiotics for 7 more days. At 6-week follow-up, he is well. After discussing recurrence risk (approximately 20-30% for complicated diverticulitis), he elects to proceed with elective laparoscopic sigmoid resection with primary anastomosis 8 weeks later, which is completed uneventfully.
Key Learning Points
- Not all surgical conditions require emergency surgery; stable, contained infections may be managed with antibiotics and drainage, with surgery reserved for failure of conservative management or elective resection later
- Hinchey classification guides diverticulitis management: Stage I (pericolic abscess), Stage II (pelvic abscess amenable to drainage), Stage III (purulent peritonitis - requires surgery), Stage IV (fecal peritonitis - requires surgery)
- Percutaneous abscess drainage allows definitive surgery to be performed electively, often with primary anastomosis rather than colostomy
- Decision to operate electively after complicated diverticulitis considers recurrence risk, patient comorbidities, and patient preference