Yair Edden, MD Department of Surgery Shaare-Zedek Medical Center The Hebrew University School of Medicine Jerusalem, Israel Sigmoid Diverticular Disease

Yair Edden, MD

Department of Surgery

Shaare-Zedek Medical Center

The Hebrew University School of Medicine

Jerusalem, Israel

Sigmoid Diverticular Disease

Nomenclature

• Diverticulum = sac-like protrusion of the colonic wall

• Diverticulosis = describes the presence of diverticuli

• Diverticulitis = inflammation of diverticuli

Nomenclature

• True Diverticulum = all layers of the GI wall (mucosa to serosa) e.g. Appendix, Meckel, Congenital

• False/Pseudo Diverticulum = Mucosa-submucosa herniates through the muscle layer (muscularis propria)

and then is only covered by serosa e.g. Acquired pathology

• Before the 20th century, diverticular disease was rare

• Prevalence has increased over time– 1907 First reported resection of complicated diverticulitis by Mayo– 1925 5-10%– 1969 35-50%

Epidemiology- Sigmoid diverticulosis

Increases with age:• Age 40 <5%

• Age 60 30%

• Age 85 65%

Younger patients are diagnosed frequently

Epidemiology- Sigmoid divericulosis

Endoscopic appearance

Double contrast Barium enema

CT Scan

CT Scan

From out side…

“Westernized” nations have predominantly left sided diverticulosis

– 95% diverticuli are in sigmoid colon

– 35% can also have proximal diverticuli

– 4% have only right sided diverticuli

Anatomic location of diverticuli varies with the geographic location

Asia and Africa diverticulosis in general is rare and usually right sided

– Prevalence < 0.2%

– 70% diverticuli in right colon in Japan

Anatomic location of diverticuli varies with the geographic location

Pathophysiology

• Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

Pathophysiology

• Law of Laplace:• Pressure = K x Tension / Radius

• Sigmoid colon has the smallest diameter resulting in highest pressure zone

Pathophysiology

• Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers

• Segmentation increased intraluminal pressure mucosal herniation Diverticulosis

May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

Pathophysiology

Lifestyle factors associated with diverticular disease

Low fiber diverticular disease

Not absolutely proven in all studies but strongly suggested

Western diet is low in fiber with high prevalence of diverticulosis

In contrast, African diet is high in fiber with a low prevalence of diverticulosis


• Obesity associated with diverticulosis – particularly in men under the age of 40

• Lack of physical activity


Do patients need to avoid foods with seeds or nuts?


NO!

In most cases diverticular disease is a-

symptomatic

A-symptomatic diverticulosis

• Considered ‘a-symptomatic’ • However, some patients will complain of

cramping, bloating, irregular BMs, narrow caliber stools

• Confused with IBS• Recent studies demonstrate motility

abnormalities in patients with ‘a-symptomatic’ uncomplicated diverticulosis

Diverticulitis

• Diverticulitis = inflammation of diverticuli

• Most common complication of diverticulosis

• Occurs in 10-25% of patients with diverticulosis

Diverticulitis

• Micro or macroscopic perforation of the diverticulum

• Subclinical inflammation to generalized peritonitis

• Previously thought to be due to fecaliths causing

increased diverticular pressure; this is really rare

Diverticulitis

• Erosion of diverticular wall from increased

intraluminal pressure

• Inflammation

• Focal necrosis

• Perforation

• Usually inflammation is mild and microperforation is

walled off by peri-colonic fat and mesentery

Diagnosis of Diverticulitis

• Classic history: increasing, constant, LLQ abdominal

pain over several days prior to presentation with fever

• Crescendo quality – each day is worse

• Constant – not colicky

• Fever occurs in 57-100% of cases


• Previous episodes of similar pain

• Associated symptoms• Nausea/vomiting 20-62%

• Constipation 50%

• Diarrhea 25-35%

• Urinary symptoms (dysuria, urgency, frequency) 10-15%


• Diagnosis can be made with typical history and

examination

• Radiographic confirmation (CT) is often… (100%)

performed

• Rules out other causes of an acute abdomen

• Determines severity of the diverticulitis

CT Scan

CT Scan

Simple vs. Complicated Diverticulitis

• Complicated diverticulitis = Presence of

macroperforation, obstruction, abscess or fistula

• Simple diverticulitis = Absence of the above

complications





complications

Simple Diverticulitis

Hospitalization !?


• IV Antibiotics

• Bowel rest, clear liquids for 2-3 days

• Based on clinical findings advance diet (low residue)

and PO antibiotics


After resolution of attack - high fiber diet

with supplemental fiber


• Follow-up: Colonoscopy in 4-6 weeks• Purpose

• Exclude neoplasm

• Evaluate extent of the diverticulosis


Prognosis after resolution

• 30-40% of patients will remain asymptomatic

• 30-40% of patients will have episodic abdominal

cramps without frank diverticulitis

• 20-30% of pts will have a second attack





complications

Complicated Diverticulitis

Hinchey classification1. Pericolic abscess

2. Distal abscess

3. Purulent peritonitis

4. Fecal peritonitis

Hinchey EJ et al. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978


Hinchey classification1. Pericolic abscess

2. Distal abscess

CT guided drainage


Hinchey classification3. Purulent peritonitis

4. Fecal peritonitis

Surgery


Hartman’s Procedure


Other clinical presentation

1.Bleeding

2.Stricture

3.Fistula



Bleeding




• Most only have symptoms of bloating and diarrhea but no significant abdominal pain – Painless hematochezia– Start – stop pattern; “water faucet”

• Diverticulitis rarely causes bleeding• Right > Left



Stricture


• Chronic inflammation

• Bloating

• Constipation



Stricture

Surgery



Fistula


• Chronic inflammation• Small Bowel

• Bladder

• Vagina (s/p Hysterectomy)

• Retro – peritoneum



Fistula

Surgery

Re-operative Surgery for Crohn’s Disease

Open vs. Lap?.

WhatWill Be Your

Approach?

Re-operative Surgery For Crohn’s Disease

Re-operative Surgery For Crohn’s DiseaseRe-operative Surgery For Crohn’s Disease


Sometimes it looks like this:


Less pain

Shorter stay

Less morbidity compared with open ?!

Faster return to normal activity

Immunologic & metabolic benefits

Adhesion formation, reduced SBO

Lower recurrence in Crohn’s ?

Cosmesis

So, Why Bother?

Port of entry & pneumoperitoneum

Adhesions & limited exposure

Anatomical orientation due to previous

resection / procedure

Anticipated Problems 1

Identification of pathology

Potential Intra-operative complications

(bleeding, enterotomies, adjacent organs i.e.

ureter)

Anticipated Problems 2

Get complete information & understanding

of the previous procedure

Plan surgical strategy: Port sites position,

complete Lap, Lap assisted, hand assisted

How to Avoid the Pitfalls

Positioning: both arms tucked in,

Lithotomy - team positioning flexibility

Room setup: 2 TV monitors!


Open technique for insufflation

First port placement away from scars

(a-traumatic Trocars / Visual ports)

Finger adhesiolysis (to create initial work space)

Angled scope – only!

A-traumatic intestinal graspers & dissectors

(Technical Considerations)


Adhesiolysis and additional port placement

Reestablish / confirm Anatomy

Identify pathology (tattoo in CRC, IOUS for solid

organs)

Urethral stents (depending procedure)

HALS?

Sound judgment & low threshold for conversion

How to Avoid the Pitfalls(Technical Considerations)

1443 Lap. Colorectal procedures

Oct. 2002 - Oct. 2010

42 Reop (2.8%) :

31 IBD (27 Rec Crohn’s, 4 UC)

7 Rec. CRC

4 Benign disease

26M, 16F, 21-79y old

1-13y - time from last procedure

Re-operative Laparoscopic Colorectal Surgery

Our Experience

37 prev. open procedure (5 pts. 2-4)

5 prev. lap. procedure

Procedures: Ileocolic resection 22

Small bowel resection 11

Strictureplasty 5

Segmental colectomy 9

Comp. proctectomy IAP 4


Our Experience

Conversion rate 12% (n=6)

exposure & adhesions - 5

bleeding - 1

Morbidity 19% (n=8):

prolonged ileus - 6

post op intestinal bleeding - 2 (1 relaparotomy)

LOS mean 9 (6-21) days

Results:


Our Experience

Literature Review

The Role of Re-operative Laparoscopic Surgery

Anti reflux

Colorectal (IBD mostly Crohn’s disease, CRC)

Morbid obesity

SBO (adhesion related)

Re-operative Laparoscopic Surgery

70 – ileocolic resection

28/70 – previous ileocolic resection

1 – conversion ( in redo group)

7- complications (leak, stricture, hemorrhage, PE,

SBO, line sepsis, UTI) all in primary group

Canin J, Salky B, Edye M 1999 Surg Endosc

Re-operative Laparoscopic Surgery For Crohn’s Disease

Conclusion:

Experience required for successful laparoscopic

management in complicated Crohn’s

Canin J, Salky B, Edye M 1999 Surg Endosc

Re-operative Laparoscopic Surgery For Crohn’s Disease

23 patients underwent laparoscopic reoperation

for recurrent Crohn’s.

Conversion rate - 69% (n=16(

Complication, length of operation

were the same

Re-operative Laparoscopic Resection for Crohn’s Disease

Uchikoshi et al, Surg Endosc October 2004

168 laparoscopic-assisted ileocolic resections.

78.4% (n=124) redo

Previous resection was not a predictor

of conversion to laparotomy

Laparoscopic Assisted Ileocolic Resectionfor Crohn’s Disease

Edden Y. et al. JSLS 2008

Laparotomy vs. Laparoscopy?

Major Complication post

Laparoscopic Surgery

Requiring

Re-Exploration

510 patients

5.2% reoperation (n=27)

65% anastomotic leak (n=15)

Lap. approach 17 pts. (13/17 anast leak)

Open approach 10 pts. (2/10 anast leak)

Is a Laparoscopic Approach Useful for Treating Complication

After Primary Laparoscopic Colorectal Surgery?

Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

Results: LOS 12d vs. 18d (P=NS)

Complications 1/17 vs. 3/10 (P=NS)

Is a Laparoscopic Approach Useful for Treating Complication

After Primary Laparoscopic Colorectal Surgery?

Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

Trocar sites are the most common cause of bowel

obstruction in the early post operative period

Reoperation Following Minimally Invasive Surgery:

Are the ‘Rules’ Different?

McCormick JT.& Simmang CL. Clin Colon Rectal Surg 2006

Results comparable/similar to primary

laparoscopic resection

Late in the learning curve, experienced team

Patients selection

Concluding Comments

Expect higher conversion and longer OR time

Surgeon’s sound judgment to ensure

patients safety

Concluding Comments

LAP HAND ASSISTED RIGHT COLECTOMY

Angled scope

Intestinal Graspers & Dissectors

Tissue and Vascular division:

Harmonic Scalpel (LCS)

Ligasure

Endo Staplers

Endoclips

SURGICAL INSTRUMENTS AND EQUIPMENT

• 46 pts. lapGroup 1 : 14 inlam mass

Group 2 : 10 recurrence after prev resection

Group 3 : 22 none of above

• Group 4 :70 pts. Open

Conclusion: inlam mass, prev resection – not contraindication

Gr 4 Gr 3 Gr 2 Gr 1

245 cc

195 cc

131 cc

151 cc

blood loss

21% 15% 10% 0% morbidity

2 2 1 conversion

Lap assisted ileocolic resection in Crohn’s dis :.are phlegmons, abscess or recurrent disease a

contraindication?

Wu J, Fleshman J, 1997 Surgery

61 laparoscopic procedures,26.2% (n=16)

redo

No differences in the rate of postoperative

complications

Hasegawa H. et al. Br J Surg 2003

LAPAROSCOPIC SURGERY FOR RECURRENT CROHN’S DIS.

Documents

Yair Edden, MD Department of Surgery Shaare-Zedek Medical Center The Hebrew University School of Medicine Jerusalem, Israel Sigmoid Diverticular Disease