Monday, September 10, 2007
Poor Ken Griffey, Jr. Seems like his body keeps letting him down, one thing after another. I was there at the beginning of his career in Seattle, and he was a joy to watch. Now [I began this post a few months ago] he's been having trouble with diverticulitis for the past several months. Guy his age? He's gonna need it out one of these days.
Among the design flaws of the human body (the hemorrhoidal veins and pilonidal dimples are also on the list) is the fact that the blood supply to the colon travels on the outer surface, feeding the inner lining (the mucosa) by sending little branches diving through the muscle layer to get there. Each hole-for-an-artery in the muscle represents a weak spot through which the mucosa can pooch outward, forming a pocket known as a diverticulum. In some people, it happens.
In the US, more than a third -- maybe half -- of people over fifty have at least a few diverticula. Most never know it. For some, it becomes a problem. Unusual in someone his age, Ken Griffey's diverticulitis is likely, according to the odds, to be a recurring problem. Instead of the occasional pocket here and there, I'm guessing his colon shows the typical sawtooth pattern of extensive diverticulosis. (Terminology time: having diverticula is called "diverticulosis, not in and of itself always a problem. Having an infected diverticulum is "diverticulitis. A problem.)
The problems diverticula can cause are in two categories: bleeding, and infection. Because, by developmental definition, each diverticulum abuts an artery, it's easy to understand why inflammation or irritation in one can cause erosion into and bleeding from the vessel. Similarly, infection of a little pocket containing hardened stool isn't hard to figure, either. ("Inspissated" is the medical term for some substance that gets dried out and hardened, and it happens to be among my favorites of words learned in medical school. All those sweet and steamy sibilants, stippled by a percussive "p" and a tensile "t." Inspissated. Great word. And "bezoar." Already wrote about that, but feel like saying it again. Bezoar.)
Surgery for diverticular disease involves navigating numerous grey-zones, and a few of crystal clarity. Seeing someone exsanguinate is a sure signal to swing the scalpel. Bleeding from a diverticulum can be steady and severe. But even when the need to operate is obvious, the target may not be; so the extent of the operation can be in doubt, going in. Less likely nowadays, with better imaging and shorter delays in obtaining it, going to the OR with uncertainty as to which part of the colon contains the bleeder wasn't rare only a few years back. And the nature of diverticular bleeding is that it can stop and start randomly. The stopping, perversely, seems to like to happen just as the patient enters the imaging suite. So, short of unrelenting bleeding, there's a certain degree to which deciding when and if to operate is a crap-shoot. (Pun intended? You decide.)
By far the most common site for diverticula, and for bleeding there-from, is the sigmoid colon. (This probably has to do with pressure generated in having a bowel movement, and is why constipation and diverticulosis have an association; and why high fiber intake is really good for people who have it.) There are times when you find yourself in the patient's belly with a less than clear idea of where the bleeding is coming from: a negative or equivocal imaging study; no time to have gotten one. Then what? It might depend on how localized or extensive that person's diverticula are.
You might resect the sigmoid if it has the dense concentration that one often sees; maybe even send it right to the lab to see if the pathologist can identify the culprit pocket. Some people advocate dividing the colon at about its half-way point, and seeing if blood keeps flowing from the upper half. Having been impressed with how well-tolerated is the removal of most of the colon (as long as there's a decent amount of rectum -- which never has diverticula -- left), I've not been reluctant, when the chips were down, to do a sub-total colon resection.
With diverticulitis, there are lots of decisions as well. It takes a residency and then some to understand the issues and the choices. Some easy (perforation with peritonitis; fistula -- these need surgery for sure, even if the perfect one might be a matter of opinion), some not (mild attacks, repeatedly -- how many, how severe, is enough.) Timing of surgery, and what exactly to do, are decisions into which judgment and experience are at play. For example, after a severe attack which subsides, it's nice to wait several weeks for things to cool down before operating; but recurrent attacks might occur in the interim. The ideal is to be able to do a one-stage operation -- meaning take out the bad part and sew the ends together.
When forced to operate in the middle of a flare-up, it may or may not be necessary to make a temporary colostomy. That's crystal ball stuff. In the really old days, it was three stages: diverting colostomy, followed by resection, followed by a final operation to put everything back together. One of the signs that even surgeons respond -- if reluctantly -- to evidence is that a three-stager almost never is done any more, and many one-stage operations are now considered safe when, not long ago, two would have been the obvious choice.
I should add this: surgery for diverticular disease is gratifying. It's rare to have further problems after having the diseased area removed, and the comparatively small section that's typically taken out leads to no side effects at all. So it's a pretty happy group of patients. It is that for which we surgeons shoot.