John Marks MDChief: Section of Colorectal Surgery Main Line Health System

Professor: Lankenau Institute of Medical Research

Director: Fellowship in Minimally Invasive Colorectal Surgery and Rectal Cancer Management

When to operate for diverticulitis: Acute vs Chronic

• 50% > 60 years• 80% > 80 years• 10% of those with diverticulosis may go on to develop

diverticulitis– 75% of cases are simple– Very small subset require surgery

Incidence of Diverticulosis

• Simple

• Complicated– Abscess– Fistula– Stenosis

• Perforation

Diverticulitis: A Spectrum

• Study selection bias• Few prospective randomized trials

– Patrick Ambrosetti MD

• Overall Studies are of poor quality overall

Studying Diverticulitis

• Acute– Free perforation– Peritonitis– Acute abdomen

When to Operate

• Chronic– Complicated diverticulitis

• Abscess• Fistula• Stenosis

– Medically refractory– 2 or more hospitalizations– 1 hospitalization < 50 yrs– Immunocompromised

When to Operate: Standard Teaching

Hinchey Classification

• Stage I: Pericolic abscess or phlegmon

• Stage II: Pelvic, intra-abdominal or retroperitoneal abscess

• Stage III: Generalized purulent peritonitis

• Stage IV: Generalized fecal peritonitis

• Classic indications called into question• Minority of patients develop subsequent attacks• Are we justified in telling people that they will

avoid life threatening situations with elective resection?

• What is the effect on QOL?

Simple Diverticulitis

• Percutaneous drainage of abscess• Hartmann’s

– Laparoscopic vs. Open• Resection with primary anastomosis

– proximal diverting stoma– on table lavage

• Laparoscopic lavage

Complicated Diverticulitis Options

Overall Diverticulitis RecurrencesN = 502

Timing of first recurrent attack of acute diverticulitis for all patients.

Eglinton et al. Br J Surg 2010

Simple DiverticulitisN = 320/502

Timing of first recurrent attack of acute diverticulitis for patients with an uncomplicated first attack.

Eglinton et al. Br J Surg 2010

Complicated DiverticulitisN = 165

Timing of first recurrent attack of acute diverticulitis for patients with a complicated first attack.

Eglinton et al. Br J Surg 2010

• “The timing of elective colectomy in diverticulitis: A decision analysis.” Salem et al. J Amer Coll Surg 2004– Markov model of clinical pathways– Simulation based on statewide hospital discharge

database– Colectomy after 4th episode

• lower mortality• Fewer colostomy • Decreased cost

Timing of Elective Colectomy in Diverticulitis

Management Strategies

Salem et al. J Amer Coll Surg 2004

• “Timing of prophylactic surgery in prevention of diverticulitis recurrence: A cost-effectiveness analysis.” Richards et al. Dig Dis Sci 2002.– Markov model as well– Probabilities based on published data– Compared surgery after 1, 2 and 3 episodes– Surgery after 3rd attack = decreased cost

Timing of Elective Colectomy in Diverticulitis

Timing of Elective Colectomy in Diverticulitis

Richards et al. Dig Dis Sci 2002.

• Urgent admissions: big increase• Urgent surgery: very small increase

– Improvement in antibiotics– Interventional procedures

• Elective surgery: increasing– Laparoscopy

Trends in Management2002 – 2007

Masoomi et al. Arch Surg 2010

Diverticulitis Admissions

(2002) 179k 210k (2007)

Nationwide Inpatient Sample (NIS) database

Masoomi et al. Arch Surg 2010

Elective & Urgent Surgeries

Masoomi et al. Arch Surg 2010

Role of Laparoscopic Resection

• Percutaneous drainage of abscess• Hartmann’s

– Laparoscopic vs. Open• Resection with primary anastomosis

– proximal diverting ileostomy– on table lavage

• Laparoscopic lavage

Complicated Diverticulitis Options

• Gold standard for Hinchey III & IV• Significant complications

– Wound infection 30%– Stoma complications 10%– Leak rate 30% with reversal– Overall mortality 15-30%

• Primary resection & anastomosis for Hinchey I & II• Resection & anastomosis w/ protective stoma for

Hinchey III

Hartmann’s Procedure

• Alternative for Hinchey I and II– Diverting proximal stoma for Hinchey III

• Reduced post-operative mortality• Avoidance of stoma• Lower SSI• Studies flawed with selection bias• No large randomized trials

Hartmann’s vs. Primary Anastomosis

Bauer VP, Clinics in Colorectal Surgery 2009

Hartmann’s vs. Primary Anastomosis

N = no. of patients

MortalityStoma

ComplicationAbdominal

AbscessAnastomotic

LeakWound

Infection

Abbas et al, 2007

18 studies

HP 526 19% 7-12% 8% 22.6%

HP reversal 8%PRA 358 9% 4% 5.5% 14%

Salem et al, 2004

54 studies

HP 1051 18% 10.3% 24.2%

HP reversal 787 0.8% 4.3% 4.9%PRA 569 9.9% 9.6%

Constantinides et al, 2006

15 studies

HP 416 15.1% 8.7% 22.3%

HP reversal 3.9%PRA 547 4.9% 3.9% 9.6%PRA & stoma 8.3%

• Franklin et al. World J Surg, 2008• N = 40• All pts with peritonitis • 33% with free air on CXR• Hinchey 2b, 3 and 4 (intraop finding)• No readmissions for complicated disease

– Average f/u 96 months (range 1 – 120 months)

• 24 patients underwent subsequent elective surgery

Laparoscopic Lavage Methods

• Described for Hinchey class II, III, & IV• Culture of purulent material• 4 – 12 L of warm saline reported• Drain placement near colonic lesion• Adhesions to the colon left untouched• Visible perforations closed w/ suture, omental patch,

fibrin glue• IV antibiotics x 7 days minimum

Laparoscopic Lavage Methods

• Karoui et al. Dis Colon & Rectum 2009• N = 59

– 35 lavage– 24 resection with anastomosis and diverting ostomy

• Case matched study• Hinchey 3

Laparoscopic Lavage Methods

Laparoscopic Lavage

Karoui et al. Dis Colon & Rectum 2009

N = 59

Lavage vs. Resection w/ IleostomyLaparoscopic Group Open Group P

Stage I N = 35 N = 24 Mortality 0 0 Morbidity 10 (28%) 10 (42%) NS Abdominal 4 (11%) 7 (29%) NS Extra-abdominal 6 (17%) 3 (12.5%) NSLOS (days, median, ranges) 8 (5-18) 17 (11-52) <0.0001Stage 2 N = 25 N = 24 Mortality 0 0 NS Morbditiy 3 (12%) 3 (12.5%) NS Abdominal 2 (8%) 2 (8%) NS Extra-abdominal 1 (4%) 1 (4%) NSLOS (days, median, ranges) 7 (5-11) 6 (4-10) NSStage 1 + Stage 2 N = 25 N = 24 Mortality 0 0 Morbidity 6 (24%) 12 (50%) NS Abdominal 4 (16%) 9 (37.5%) 0.0507 Extra-abdominal 3 (12%) 4 (17%) NSLOS (days, median, ranges) 14 (11-24) 23.5 (16-52) < 0.0001

Karoui et al. Dis Colon & Rectum 2009

N = 59

Accuracy of CT Hinchey Class

Alamili et al. Dis Colon & Rectum 2009

Laparoscopic Lavage

• Diverticulitis vs IBS• Evidence of diverticula only on CT• No fever or leukocytosis• 88% pain-free at 12 months• Histologic evidence of inflammation in 76%

Smoldering DiverticulitisN = 47

Horgan et al. Dis Colon & Rectum 2001

• N = 46• Patients evaluated had CT documented attack of diverticulitis• Multiple validated questionnaires used preop, 3, 6 and 12 months

post-op• Evaluation of GI, urologic and sexual function

– GIQLI – IPSS (international prostate symptom score) - men– EIIF-5 (international index of erectile function)– UDI (urinary distress inventory) - women

Quality of Life after Lap Colectomy

Forgione et al. Annals of Surgery, 2009

Quality of LifeN = 46

*denotes significant difference (P < 0.05).

Forgione et al. Annals of Surgery, 2009

• Functional results following elective laparoscopic sigmoidectomy

after CT-proven diverticulitis. – Ambrosetti et al, J Gastrointest Surg 2007

• N = 43• Mean follow up 40 months (3-76)• Post operative questionnaire

– Recurrent disease– Bowel function– New abdominal pain– Overall satisfaction

• Overall satisfaction rate 95%

Functional Results

Postoperative Results

Results Number of Patients(N)

Percentage(%)

Bowel function Better 24 56 Unchanged 16 37 Worse 3 7New abdominal pain 4 9.3Degree of satisfaction Excellent 20 47 Good 17 40 Mediocre 6 13Would you go back to surgery 41 95

Recurrence 0

N = 43

Ambrosetti et al, J Gastrointest Surg 2007

Why the CT appreciation of severity?

A. To guide the therapeutic strategies:1. Mild diverticulitis: conservative ambulatory care

(antibiotics?)2. Stage Ia: conservative care with oral antibiotics3. Stage Ib and II: hospitalization, iv antibiotics, eventual CT

drainage, possible surgery4. Stage III and IV: surgery

B. To evaluate the chances of secondary bad outcome after a first episode of acute diverticulitis susccessfully treated conservatively

So, where is the challenge ?

The existence of an associated abscess

Why ?

1. Frequent (between 15 to 20%)

rao et al. am j radiol 1998ambrosetti et al. eur radiol 2002werner et al. eur radiol 2003

2. Difficult to diagnose bioclinically 3. Therapeutically challenging

Types of acute treatment

Should we drain ?« …small pericolic abscess may resolve with antibiotic therapy and bowel rest… »« …today the decision to drain remains to be individualized 1 »

1. The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: 289-97

Secondary treatment

1. « Recently, some surgeons have suggested that surgical resection may not be mandatory in every case after successful percutaneous drainage: however, at present there are insufficient data to support universal endorsement of this concept »

The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: 289-97

2. « …do a percutaneous drainage where possible, followed later by sigmoid resection in most cases… »

European Association of Endoscopic Surgery, Surg Endosc 1999; 13: 430-6

Abscess associated to diverticulitis

• Between october 1986 to october 1997:– 465 patients had a CT evaluation– 76 (16.3%) had an associated mesocolic or

pelvic abscess– 73 patients could be followed-up– Median follow-up: 43 months (2 – 180)

– 26 women and 47 men with a mean age of 68 (30 – 94)

Ambrosetti et al. Dis colon rectum, march 2005

Abscess associated to diverticulitis

• Therapeutic principles:– Percutaneous CT drainage of abscess were done

only if no bioclinical improvement were noted after 48 hours of parenteral antibiotics

– Elective colectomy after successful conservative management of the abscess was not an absolute indication and was adapted for each patient

Associated abscess

Location and CT percutaneous drainage

n drained not drained (%) (%)

Mesocolic 45 11 (24) 34 (76)Pelvic 28 8 (29) 20 (71)

Surgical vs conservative treatment:no op.: conservative treatment

op. 1: surgery during 1st hospitalisationop. 2: surgery later on

N No op. (%)

Op. 1 (%)

Op. 2 (%)

mesocolic 45 22 (49) 7 (15) 16 (36)

Pelvic 28 8 (29) 11 (39) 9 (32)

Long-term evolution

1. No patient needed an emergency surgical treatment

2. 15 patients (21%) died during the course of the follow-up. No one died from complications related to the diverticular disease

Essential findings

1. Initial CT is indispensable to confirm the diagnosis and precise the severity of the diverticulitis

2. Patients with a pelvic abscess should be immediately drained

3. Mesocolic abscess ≥ 5 cm should probably be drained immediately

4. Secondary colectomy after pelvic abscess seems highly reasonnable

5. Secondary colectomy after successful conservative treatment of mesocolic abscess is probably not mandatory for all patients

Acute left colonic diverticulitis

Prospective study October 1986 – October 1997 University Hospital Geneva

Acute diverticulitis: prospective study

542 patients290 women and 252 men

Mean age: 64 (23-97)

Acute diverticulitis: profile of the study

Patients included:1. Clinical and history compatibility2. Radiological confirmation (CT and water-soluble contrast enema=GE)3. Histological diagnosis4. 1st hospital admission

Patients excluded:No radiological or histological confirmation

Acute diverticulitis: radiological criteria (CT and GE)

Moderate diverticulitis Severe diverticulitis

CT: localized wall thickening (>=5mm)

Inflammation of pericolic fat

The same + at least one of the following:Abscess

Extraluminal air/ contrast

GE: segmental lumen narrowing

Tethered mucosa+/- mass effect

The same + at least one of the following:

Extraluminal air/ contrast

Acute diverticulitisLong-term follow-up after a 1st acute episode

of left colonic diverticulitis:is surgery mandatory ?

R. Chautems, P. Ambrosetti, C. SoraviaAmerican Society of Colorectal Surgeons

San Diego, June 2001

Dis Colon Rectum 2002; 45: 962-966

Acute diverticulitis: aims of the study

• To evaluate on a long term (9.5 years) the outcome of 118 patients treated medically with success for a 1st episode of diverticulitis

• To determine risk factors of poor evolution• To assess the place of surgery• To propose a timing for surgery

Acute diverticulitis:Post hospitalisation evolution

No complications: 80 patients (68%)

Evolutive complications: 38 patients (32%)

24 deaths (20%)

21 not related to diverticular diseaseNo emergency operation

Identification of initial parameters predictive of evolutive complications

Age

Severity of the inflammation on CT

• Diverticulitis is common• Most patients w/ initial episodes of disease will not

recur• Most patients who undergo surgery in elective

circumstances are very satisfied w/ their outcomes• Laparoscopic resection for diverticulitis is safe and

effective

Conclusion

• 284 patients with diverticulitis treated laparoscopically• 143 had previous abdominal surgery• Procedures

– 256 L colectomy– 1 AR Rectopexy– 3 Hartmann’s Procedures– 12 Hartmann’s Reversal– 12 Other

Our Laparoscopic Experience

• ASA Class– 11 patients ASA Class I– 143 patients ASA Class II– 121 patients ASA Class III– 4 patients ASA Class IV– 5 patients ASA Class N/A

• Average OR Time 271 minutes (112 – 894 minutes)• Avg EBL 189 cc (10 – 1200cc)• Avg largest incision 5.3 cm (1.5 – 15.0 cm)• Avg Discharge POD 5.2 days (2 – 43 days)

Our Laparoscopic Experience

• Morbidity 10.6%– 2 atrial fibrillation– 2 anastomotic leak– 1 anastomotic stenosis– 5 arrhythmia– 2 bowel perforation– 1 DVT– 3 GI bleed– 1 internal hernia– 3 intraabdominal abscess– 2 UTI– 4 wound infection

– 2 prolonged ileus– 1 aspiration pneumonia– 1 anemia– 1 sepsis– 1 drug rash– 1 intraabdominal hematoma

• 1 Mortality 0.3%

Our Laparoscopic Experience

• Conversion Rate 1.4%– All converted to laparoscopic assisted lower

midline incision– Dense adhesive disease

Our Laparoscopic Experience