Management of Colonic Diverticulitis Joint Hospital Surgical Grand Round 24th Oct 2009

Management of Colonic Management of Colonic DiverticulitisDiverticulitis

Joint Hospital Surgical Grand Round

24th Oct 2009

Diverticular DiseaseDiverticular Disease

• The sigmoid colon is most commonly affected (> 90% of cases)

• Proximal colonic involvement in 40% of patients

Diverticular DiseaseDiverticular Disease

• Prevalence – ~40% of people by the age of 65 years – ~60% of people by the age of 80 years.

• ~10% to 25% of patients with diverticulosis will develop diverticulitis

DiverticulitisDiverticulitis

• Inflammatory complications result from perforation of diverticula

• Sympotms– Usually present within several hours to days – Pain localized to the left lower quadrant – Change in bowel habits– Bloating, nausea, vomiting and anorexia

DiverticulitisDiverticulitis• History and Physical examination

• Complete blood count (CBC), Urinalysis, and plain abdominal radiographs

• CT scan of the abdomen and pelvis with intravenous contrast

• Sigmoid diverticula• Peri-sigmoid inflammatory changes• Extraluminal gas or fluid• Pericolic abscess• Adjacent organ involvement

ClassificationClassification

• Hinchey classification is most commonly described

• Class I : localized pericolic inflammation

• Class II : localized pericolic abscess

• Class III : diffuse purulent peritonitis

• Class IV : diffuse feculent peritonitis

ControversiesControversies

• Uncomplicated– ?Young age– ?recurrence

• Complicated– Hartmann's procedure– Primary resection +

anastomosis• +/- diverting ileostomy

Indication for surgery

Operation

Laparoscopic / open

• Trend toward nonsurgical conservative

management in many presentations of

diverticular disease

Uncomplicated DiverticulitisUncomplicated Diverticulitis

• Absence of complications– Abscess

– Free perforation

– Fistulization

– Stenosis


• Abdominal pain, fever, and elevation of white blood cell (WBC) count

• Diagnosis by clinical grounds

• CT scan– Not mandatory– In severe clinical findings on presentation– Atypical symptoms– Re-evaluate patients

ManagementManagement

• Bowel rest

• Antibiotic therapy – Common gram-negative and anaerobic

pathogens – Little evidence on selection of specific

regimens; no regimen has demonstrated superiority

– Paucity of data regarding optimal duration

Byrnes et al. Antimicrobial therapy for acute colonic diverticulitis. [Review] Surgical Infections. 10(2):143-54, 2009 Apr.


• Complete resolution without recurrence in

at least 70% of cases

• Colonoscopy to exclude underlying

malignancy at a time interval for optimal

resolution of the diverticular inflammation.


• Immunosuppressed /Immunocompromised patients are more likely to present with perforation or fail medical management

• A lower threshold for urgent or elective surgery should apply

Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)


• Younger patients (<50) were previously thought to have more virulent disease

• Previous studies have shown misclassification and selection bias

• Diagnosis often delayed in younger patients resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated.

Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52: 1008-1016


• Lack of evidence for elective surgery after a single attack of diverticulitis

• Should follow the guidelines for patients of any age

• Higher cumulative risk for recurrent diverticulitis

Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52: 1008-1016

Uncomplicated DiverticulitisUncomplicated DiverticulitisRecurrence• Current practice guidelines recommend that

surgery should be offered to patients after two documented episodes of uncomplicated diverticulitis

• Factors influencing recommendation include:– Fitness for surgery

– Number and severity of attacks

– Rapidity and completeness of response to medical therapy

– Persistence of residual symptoms after completion of treatment


• Large recent multicentric retrospective studies on outcome of patients whose first episode of acute diverticulitis treated conservatively confirmed that the risk of recurrent attacks was low Broderick-Villa et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005;140:576–581.

• In patients requiring urgent surgery, it is the initial attack in over 80% of cases

• Somesakar and colleagues (2002) and Chapman and colleagues (2005) – Patients with perforated diverticulitis and the majority

presenting with life-threatening diverticular disease had not had antecedent diverticular events

• Salem and colleagues (2004) – Published a decision analysis showing that

performing colectomy after the fourth (rather than the second) episode of diverticulitis resulted in fewer deaths, fewer colostomies, and significant cost savings, irrespective of patients’ age

The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2004; 199: 904–12.


• Surgery should probably be reserved for patients with more recurrent episodes of uncomplicated diverticulitis

Complicated DiverticulitisComplicated Diverticulitis

• Contained Perforation: Pericolic and Pelvic Abscesses (Hinchey Stages I and II) – Intravenous antibiotics and close

observation

– Image-guided percutaneous catheter drainage

Complicated DiverticulitisComplicated Diverticulitis• Small pericolic abscesses (<2 cm) and

intra-mural abscesses may resolve without intervention



• Conflicting data– Broderick-Villa and others (2005)

support long-term nonoperative management even in patients with abscesses

– Several smaller case series suggest that patients with a history of abscess have a higher chance of recurrence


• Free Perforation: Purulent and Fecal Peritonitis (Hinchey Stages III and IV)

– Aggressive fluid resuscitation and intravenous broad-spectrum antibiotics

– Early intensive care unit monitoring with the addition of a central venous catheter


• Acutely non-resolving symptoms Hinchey class I-III and patients with Hinchey class IV disease should be offered urgent surgery



Urgent operative management

• Primary resection / primary anastomosis and +/- diverting ileostomy

• Hartmann's procedure – Safest option in patients with severe sepsis

and generalized purulent or fecal peritonitis is

Hartmann’s vs primary resection Hartmann’s vs primary resection anastomosisanastomosis

• Review of eighteen studies between 1966 and December 2003 reported 884 patients with acute complicated diverticulitis

• No significant differences were found between primary resection with anastomosis and Hartmann’s procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure

Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis (2007) 22: 351–357

Hartmann’s vs Primary Hartmann’s vs Primary Resection AnastomosisResection Anastomosis

• Fifteen Comparative studies (between 1984 and 2004) 963 patients analyzed

• Overall mortality was significantly reduced with primary resection and anastomosis

• Retrospective nature of the included studies – Considerable degree of selection bias

Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review. Dis Colon Rectum 2006; 49: 966–981

Laparoscopic vs Open Resection

• When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patientsLevel of Evidence: III; Grade of Recommendation: A

• There is no increase in early or late complications• Cost and outcome are comparable• Laparoscopic surgery is acceptable in the elderly and

seems to be safe in selected patients with complicated disease.


LaparoscopicLaparoscopic vs Open resectionOpen resection

• Laparoscopy can be performed safely – benefits in terms of length of stay, less pain

and quicker recovery. – associated with longer operative times and

more operative cost

• Acceptable alternative to open surgery for an experienced laparoscopic surgeon with an adequate case volume

Laparoscopic vs Open Resection

• Laparoscopic sigmoid resection was associated with a 15.4% reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization at the cost of a longer operating time.

Klarenbeek et al Laparoscopic Sigmoid Resection for Diverticulitis Decreases Major Morbidity Rates: A Randomized Control Trial Short-term Results of the Sigma Trial. Ann Surg Jan 2009;249: 39–44

Laparoscopic LavageLaparoscopic Lavage

Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

Acute complicated diverticulitis managed by laparoscopic lavage and drainage with antibiotic


Outcomes of laparoscopic lavage management in the

published studies


• Mean length of stay was 9 days


• Laparoscopic Lavage without sigmoid resection in the acute setting for patients with purulent peritonitis caused by complicated diverticulitis could be considered a valid alternative

• Needs to be investigated more thoroughly



• Primary laparoscopic lavage for complicated diverticulitis may be a promising alternative to more radical surgery in selected patients

• Larger studies have to be made before clinical recommendations can be given


SummarySummary

• Uncomplicated Diverticulitis– Surgery recommended after single attack for

immunosuppressed /immunocompromised patients

– Young patient should follow the guidelines for patients of any age

– Reserved for patients with more recurrent episodes

SummarySummary

• Complicated diverticulitisUrgent operation

– Primary resection with anastomosis +/- diverting ileostomy

– vs Hartmann’s procedure

? Elective operation after non operative management of acute episode

SummarySummary

• Elective Sigmoid Resection

–Laparoscopic approach is appropriate in selected patients

• Laparoscopic Lavage – Could be considered a valid alternative

in complicated diverticulitis with purulent peritonitis

Thank youThank you

Documents

Management of Colonic Diverticulitis Joint Hospital Surgical Grand Round 24th Oct 2009