Acute Diverticulitis: Lap , open or conservative?

Savvas Papagrigoriadis MD MSc FRCS

Consultant Surgeon

King’s College Hospital, London

King’s research in diverticular disease Epidemiology

– National UK study on hospital admissions

– Economical analysis Pathogenesis

– Neurotransmitters: serotonin

– Role of smoking in complications

Treatment– RCT Mesalazine for

prevention in diverticulitis– RCT Probiotics

Quality of life Diverticular Disease Clinic

Int J Colorectal Dis. 2012 Dec;27(12):1597-605. doi: 10.1007/s00384-012-1515-6.Epub 2012 Jun 29.A clinicopathological study of serotonin of sigmoid colon mucosa in associationwith chronic symptoms in uncomplicated diverticulosis.Jeyarajah S, Akbar N, Moorhead J, Haji A, Banerjee S, Papagrigoriadis S.

Dig Dis. 2012;30(1):114-7. doi: 10.1159/000335916. Epub 2012 May 3.Differences in early outcomes after open or laparoscopic surgery: what is theevidence?Papagrigoriadis S.

Aliment Pharmacol Ther. 2011 Apr;33(7):789-800. doi:10.1111/j.1365-2036.2011.04586.x. Epub 2011 Feb 9.Review article: the pathogenesis of diverticular disease--current perspectives onmotility and neurotransmitters.Jeyarajah S, Papagrigoriadis S.

Aliment Pharmacol Ther. 2009 Dec 1;30(11-12):1171-82. doi:10.1111/j.1365-2036.2009.04098.x. Epub 2009 Jul 20.Diverticular disease hospital admissions are increasing, with poor outcomes inthe elderly and emergency admissions.Jeyarajah S, Faiz O, Bottle A, Aylin P, Bjarnason I, Tekkis PP, Papagrigoriadis S.

Aliment Pharmacol Ther. 2009 Sep 15;30(6):532-46. doi:10.1111/j.1365-2036.2009.04072.x. Epub 2009 Jun 22.Review article: the current and evolving treatment of colonic diverticulardisease.Tursi A, Papagrigoriadis S.

Int J Colorectal Dis. 2008 Jun;23(6):619-27. doi: 10.1007/s00384-008-0446-8. Epub2008 Feb 15.Diverticular disease increases and effects younger ages: an epidemiological studyof 10-year trends.Jeyarajah S, Papagrigoriadis S.

Int J Colorectal Dis. 2007 Jun;22(6):643-9. Epub 2006 Nov 4.Increased presence of serotonin-producing cells in colons with diverticulardisease may indicate involvement in the pathophysiology of the condition.Banerjee S, Akbar N, Moorhead J, Rennie JA, Leather AJ, Cooper D, Papagrigoriadis S.

Colorectal Dis. 2004 Mar;6(2):81-4.Impact of diverticular disease on hospital costs and activity.Papagrigoriadis S, Debrah S, Koreli A, Husain A.

Colorectal Dis. 2003 Jul;5(4):320-3.Diverticular disease has an impact on quality of life -- results of a preliminarystudy.Bolster LT, Papagrigoriadis S.

Br J Surg. 1999 Jul;86(7):923-6.Smoking may be associated with complications in diverticular disease.Papagrigoriadis S, Macey L, Bourantas N, Rennie JA.

Clinical Scenarios

The Patient with – First timeFirst time acute diverticulitisacute diverticulitis– previous diverticulitis and recurrent symptomsrecurrent symptoms – after recent emergency hospitalisationemergency hospitalisation for DD

• With surgery• With medical management• Admission for bleeding

– atypical abdominal painatypical abdominal pain and diverticulosis on colonoscopy/ radiology

Complications:Free perforation Generalized peritonitis -

septicaemia Free gas in the abdomen Pneumoperitoneum -

abdominal distention Treatment: Urgent

laparotomy High mortality

Complications:Phlegmon or Abscess Most common

complication Localized peritonitis of

left iliac fossa Initial conservative

treatment Percutaneous aspiration

of abscess under CT guidance

Laparotomy if no improvement

Complications:Colovesical fistula Pneumaturia Fecaluria, haematuria,

frequency 25% fever and abdominal

pain Sepsis Gastrografin enema IVP (useful to detect ureter

involvement) Laparotomy (1 or 2 stage)

Complications:Colovaginal fistula It rarely occurs if the uterus is present Vaginal discharge of feces, blood, gas Colposcopy and sigmoidoscopy put the

diagnosis One stage resection of the fistula

Complications:Thigh abscess Not uncommon Suspected if enteric

organisms are isolated Retroperitoneal

perforation Neurovascular bundles

that penetrate the abdominal wall

Inguinal rings Through the pelvic floor

Complications:Bleeding Common acute massive/ not

chronic ? overdiagnosed Urgent colonoscopy

or Angiogram Subtotal colectomy

QuickTime™ and a decompressor

are needed to see this picture.

The “appendicitis model”

When acute pathology presents treat with emergency surgery.

Surgical treatment has minimal morbidity.

The disease does not relapse.

Problems: Emergency treatment of

DD complications has high morbidity.

Without surgery high recurrence rate.

After surgery some relapse of symptoms.

The “peptic ulcer model”

1980s: numerous emergency admissions for peptic ulcer complications

Numerous elective operations aimed to decrease emergency complications…

…then H. Pylori was discovered.

Problem: By performing elective

sigmoid colectomy on DD patients for prevention of complications….

…do we have evidence we are achieving it?

…or are we operating on a different population of patients?

Elective surgery is justified only if it decreases emergency surgery

Etzioni Ann Surg 2009 USA national data on

admissions for diverticulitis 1998 -2005

Emergency admissions rose by 26%

Elective Surgery rose by 29%

0

20000

40000

60000

80000

100000

120000

140000

160000

Emergency AdmissionsElective Surgery

The patient with acute diverticulitis

Treatment with:– Antibiotics (IV or oral)– IV fluids / ressuscitation– 5-ASAs– early CT scan– Some form of colonic imaging at a second stage

when acute inflammation settles

– Evidence for all of the above?

The patient with acute diverticulitis:which antibiotics?

Broad spectrum Gram negative -

anaerobes Non absorbable?

Byrnes MC, Surg Infect 2009 Review of literature for

evidence and guidance on choice of antibiotics in Diverticulitis

No evidence on what is– Best scheme– Optimal duration of

treatment

The patient with acute diverticulitis: outpatient treatment

Martin Gil, Gastronterol Hepatol 2009

Ambulatory treatment of Hinchey 1 & 2 diverticulitis

Ciprofloxacin + metronidazole 8.8 days

70/74 patients treated without admission

13 patients had subsequent elective surgery

Mizuki A, Aliment Pharmacol Ther 2005

Ambulatory treatment of diverticulitis and abscesses up to 2 cms large (US diagnosis)

Oral antibiotics 10 days 68/70 patients treated without

admission 16 recurrences (median fup 30

months)

We may not need IV antibiotics

Ridgway P, Colorectal Dis 2008

RCT 79 inpatients with diverticulitis

Oral v. IV ciprofloxacin & metronidazole

All cases resolved without conversion of oral to IV regime

48 hour rule? Evans J, J Gastrointest Surg

2008 198 inpatients retrospective Drop of WCC & Temperature

within 48 hours predicted discharge with oral antibiotics by day 4

Lack of 48 hour response went on to prolonged stay or surgery

Or even… no antibiotics?

Hjern F, Scand J Gastroenterol 2007

Retrospective 311 inpatients

118 patients received antibiotics

193 patients observation and restriction of oral intake

30 months fup Same recurrence rate

between 2 groups -29% Multivariance analysis did

not show antibiotics ro reduce risk of recurrence

Mild DD does not require antibiotics?

Comment: may indicate that there are many unrecognized episodes of diverticulitis ?

Hinchey II: Do we need drainage?

Brandt D, Dis Colon Rectum 2006 Case control study 66 patients Hinchey

II abscess CT drainage v. antibiotics Outcome identical Questioning whether CT drainage is

necessary

Laparotomy v. Laparoscopy

Is Laparoscopy safer and cheaper? USA national database study Elective surgery only 2002-2007 Total 124,734 patients

– Open 110,172– Laparoscopic 14,562

Lower intra-operative complications in laparoscopic group 0.63% v. 1.15% (p 0.001)

All post-op complications higher for open Laparoscopic had shorter mean stay 5 v. 6.6 days Laparoscopic was cheaper $36k v $39k

Masoomi et al World J Surg 2011

Is Laparoscopy safer and cheaper? USA national database study Elective surgery only 2002-2007 Total 124,734 patients

– Open 110,172– Laparoscopic 14,562

Lower intra-operative complications in laparoscopic group 0.63% v. 1.15% (p 0.001)

All post-op complications higher for open Laparoscopic had shorter mean stay 5 v. 6.6 days Laparoscopic was cheaper $36k v $39k

Masoomi et al World J Surg 2011

Cochrane Meta-analysis – Schwenk 2005

25 RCTs comparing open (OS) with laparoscopic colorectal surgery (LS)

LS longer operative time but less blood loss LS less post op pain LS better pulmonary function Morbidity less in LS Mortality same after OS & LS Post op hospital stay less in LS QoL better with LS Conclusion: clear advantages of LS in most areas

Cochrane systematic review Meta-analysis 11 non randomised, 1

RCT Elective laparoscopic resection safe Laparoscopic: lower overall morbidity

and minor complications Cirrochi 2011

Lap surgery for diverticulitis

Hinchey I, II, III/ chornic diverticulitis, bleeding, stricture

260 operations 5% conversions Average stay 10 -+3 days 11% complications 5 anastomotic leaks 2 deaths

El Zarrok Elgazwi et al JSLS 2010

52 patients diverticulitis Hinchey I-II– 36 Lap– 16 Open

Only 1 conversion Complications

– Lap 16%– Open 43%

Wound infections– Lap 11%– Open 37%

Katsuno 2011

Lap or Hand-Assisted?

361 patients 136 with complicated diverticulitis Lap 36% Hand - assisted Lap 64% Conversion 14% + 11% No difference in complications, hospital stay between Lap and

Hand- assisted Lap

Pendlimari 2011

Risk factors of lap surgery for diverticulitis 526 patients with recurrent diverticulitis - lap sigmoid

colectomy Risk factors for complications

– Anaemia– Myocardial infarction– Heart failure– Surgeon’s experience– Male gender– Age > 75

– Kirchoff 2011

Randomised CT

104 patients either Lap or Open for sigmoid resection for diverticular disease

Conversion 19% Complications

– Lap 9%– Open 23%

QoL better for Lap at 6 weeks (SF36) At 6 months no differences in outcomes Similar financial costs between Lap & Open

Klarenbeek 2011

Meta-analysis

Elective open v Lap sigmoi colectomy for div disease 1991-2009 22 studies, 10,898 patients

– 1538 Lap– 9360 Open

Same mortality Shorter hospital stay in Lap Morbidity higher in open RR = 0.56

Siddiqui 2010

We cannot randomize anymore…

149 recruited patients in multicentre RCT between open and lap surgery for diverticular disease

294 randomized patients Most patients refused randomization Recruitment aborted Patients have formed opinions from internet/

media Raue 2011

Hybrid techniques

15 patients 4 port laparoscopic surgery Operating rectoscope used to extract specimen

trans-anally and do anastomosis No abdominal incision 3/15 patients needed opiates No complications

Saad 2011

Single Port Laparoscopic Surgery

Aim to minimize trauma and improve cosmetics

Right and left hemicolectomy

No significant data yet on outcomes & benefits

SILS for DD

SILS to offer fewer wounds-less pain 10 patients for recurrent diverticulitis 2.5 umbilical incision 9/10 completed Median time 120 minutes Hospital stay 7 days]no complications

Vestweber 2010

Robotic Surgery

Rectal cancer Enough data Safety and outcomes similar

to laparoscopic No advantage to

laparoscopy Bypasses training need for

laparoscopy? Large costs -will have to

show convincing advantages

Robotic surgery for DD

24 patients with recurrent diverticulitis (9 complicated)

Primary anastomosis without stoma No conversion Complications 12.5% No anastomotic leak 324 mins average time (half docking and

console time) Ragupathi 2011

Emergency Surgery: Options of operations

Surgical treatment:Results Reversal of colostomy may be

complicated by anastomotic leak or other complications

One third of the patients with Hartman’s never have the colostomy closed

Reversal of colostomy is not always safe…..

Emergency Surgery : Primary anastomosis with defunctioning better than Hartmann’s

Probability estimates from 6879 patients from 12 studies 6619 Hartmann’s 135 Primary Anastomosis 126 Anastomosis with defunctioning Stoma permanent in 27% of Hartmann’s, 8% of PA with

defunctioning The probability of morbidity and mortality was 55% and 30% for

PRA, 40% and 25% for PADS, and 35%and 20% for HP, respectively.

Primary anastomosis with defunctioning stoma preferred option Constantinides 2007

The role of LPL: Laparoscopic peritoneal Lavage Prospective 100 patients perforated diverticulitis and generalised peritonitis 8 pts Hinchey IV converted to Hartmann’s 92 had LPL 2 pts with pelvic abscess & recurrent intervention Morbidity 4% Mortality 3% Only 2 patients had recurrent diverticulitis (median follow up 36

months) LPL may be adequate treatment of perforated diverticulitis

Myers 2008

Systematic review of LPL (laparoscopic peritoneal Lavage) on Hinchey III

230 patients selected for data extraction. All patients had purulent peritonitis (Hinchey III) and treated with LPL laparoscopic pertoneal lavage. Morbidity was 12.73% overall failure rate of 1.3%. 2.6% patients were readmitted in acute setting only 0.8 % required surgery LPL may be the only treatment required for Hinchey III !

Scarpinata & Papagrigoriadis 2013

Table 1 Study design and patient characteristics

Year Author N Study design Type of study ASA Age (mean)

2005 Mutter et al 15 10 Case series Retrospective I-III 60

2006 Taylor et al 11 10 Case series Retrospective III-IV 57

2008 Bretagnol et al 17 18 Cohort Prospective I-II 56

2008 Myers et al 10 67 Cohort Prospective II-IV 62

2008 Franklin et al 12 32 Case series Retrospective II-III 60

2009 Favuzza et al 14 6 Case series Retrospective III-IV 49

2009 Lam et al 16 5 Cases series Retrospective II-IV 65

2009 Karoui et al 13 35 Cohort Prospective III-IV 56

2010 White et al 22 11 Case series Retrospective III-IV 61

2012 Liang et al 18 36 Cohort Prospective I-IV 63

NR: not reported

Table 2 Authors experience for laparoscopic peritoneal lavage in Hinchey III peritonitis

Authors LOS

(mean) Mortality

(%) Morbidity

(%) Readmission (N.) Secondary resection

(%) Length of follow up

(months) Mutter et al 15 9 0 0 1 67 NR Taylor et al 11 7 0 0 0 73 15 Bretagnol et al 17 12 0 8 0 100 NR Myers et al 10 8 3 8 2 0 36 Franklin et al 12 7 0 20 0 50 96 Favuzza et al 14 8 0 14 1 83 NR Lam et al 16 11 0 33 1 50 6 Karoui et al 13 8 0 28 1 71 21 White et al 22 14 0 12 0 64 20 Liang et al 18 8 0 4.3 0 45 NR

After discharge…

Is there a risk of recurrence? Can we prevent it from happening? Is there a benefit if we diagnose it

early?

Recurrent diverticulitis

– Mueller MH, Eur J Gastroenterol 2005

– 252 patients, 7 years fup

– 34% recurrence of medically treated diverticulitis, 13 patients had surgery, 2 DD related deaths.

Greenberg AS, Aliment Pharmacol Ther 2005

149 young patients <40, 5 years fup

Surgical treatment recurrence 15%

Medical treatment recurrence 55%

Recurrent diverticulitis

Nelson RS Am J Surg 2008 99 inpatients treated medically 46/99 recurrence 20 had surgery

Can we predict recurrence?

Poletti PA, AJR 2004 168 patients, 18 months fup 32% recurrence of diverticulitis CT scan with abscess or pockets of

gas> 5 mm was predictor of recurrence

Conclusions Antibiotics: more evidence needed Antibiotics & CT drainage for Hinchey I-II LPL may be adequate & definitive treatment for

Hinchey III peritonitis Laparoscopic surgery is safe and cost efficient for

all presentations of diverticular disease Laparoscopic surgery may have some

advantages over open surgery Hartmann’s should be avoided if patient fitness

allows for primary anastomosis with defunctioning

Uncertainties

Selection criteria for elective surgery Risk assessment of individual patients

Thank you