Diverticulitis:HowManyAttacksareTooMany?
RahulNarang,MDColorectalSurgeonAssistantProfessorofSurgery
BASICS
PathophysiologyDiverticularDisease
• Increasedintraluminalpressure
• Sigmoidcolonmostcommonlyinvolved(95%)• Smallestdiameter• Laplace’slaw:generates
highestpressure
• Incidenceofdiverticulardiseaseincreaseswithage:– 30%atage60– 60-80%atage80
RiskFactors
• LowfiberDiet
• Smoking
• Constipation
• Obesity
• NSAIDS
Complications
• Obstruction
• Bleeding
• Fistula
• Sepsis,Perforation
• Mayco-existwithIBD Specimen showing blood in diverticulae
ClinicalClassification• Uncomplicatedvs.Complicated• Uncomplicated• Pericolicsoft-tissuestranding,colonicwallthickening,phlegmon
• Complicated:Acutediverticulitis+• Abscess• Obstruction• Perforation• Fistula
SignificanceofDiverticulitis
• SignificantprobleminWesternCountries
• Oneofthemostcommoncausesofacutesurgicaladmission
• 152,000yearlyhospitalizations
• Annualcostsofdiverticulardiseaseestimatedat$2.7billionperyear
Sandler RS et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1511.
• NationwideInpatientSampleduringtheperiod1991-2005:
– Ratioofhospitaldischargesfordiverticulitisincreasedfrom5.1to7.6casesper1000inpatients.
– Patientsunderwentsurgeryforuncomplicateddiverticulitisdeclinedfrom17.9%to13.7%(P <0.001).
• Imaging:CTScan
Management:AcuteUncomplicatedDiverticulitis
• ConservativeManagement• Nonoperative:Bowelrest,Antibiotics
• POorIVdependingonseverity:Anaerobic/GNcoverage
• OutpatientorInpatient
• Successfulin>70%pts
Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44.
ANTIBIOITICSANDFAILURESREQUIRINGEMERGENCYSURGERY
Long-termoutcomein445PatientsafterDiagnosisofDiverticularDisease.
• Retrospectivecohortstudy,DanishPatientRegisterandNationalRegister
• M/F=30/70,medianage75years
Moreno AM et al. Colorectal Dis 2007
• 73%receivedconservativetreatmentprimarily
• 35.3%hadsufferedclinicalrecurrenceofDD,ofthese15.9%weresubsequentlyoperated.
• 3.6%ofthepatientsdiedofcausesrelatedtodiverticulitis.– Possiblehigh-riskgroupsforrecurrenceweremalesandtheirageabove70years.
Moreno AM et al. Colorectal Dis 2007
Long-termoutcomein445PatientsafterDiagnosisofDiverticularDisease.
•DIVERTrial:MulticenterRCT
•132Patients,5HospitalsinSpain
•Outpatientvs.HospitalTreatmentofUncomplicatedDiverticulitis(CTConfirmed)+Abx
•Samerateoftreatmentfailure
•Overallhealthcarecostperepisodewas3timeslowerinoutpatientgroup
•NodifferenceinQOL
•ImportantcostssavingwithoutnegativeinfluenceonQOL
Blondo S, Ann Surg 2014
RiskofEmergencyColectomyandColostomyinPatientswithDiverticularDisease.
• Retrospectivecohortstudy
• 25,058patients
• Only5.5%ofpatientshadrecurrenthospitalizationsduringwhichanemergencycolectomy/colostomywasperformed
Anaya, D et al. Ann Surg 2005
SOHOWMANYATTACKSISTOOMANY?
ElectiveSurgeryfortheTreatmentofAcuteUncomplicatedDiverticulitis
• In1999PracticeParametersoftheASCRSandEAESrecommendedelectivesurgery– After2episodesofuncomplicatedacutediverticulitis– After1episodeinyoungpatients
ASCRS = American Society of Colon and rectal Surgeons EAES = European Association for Endoscopic Surgery
Stollman NH. Am J Gastroenterol. 1999;94(11):3110-3121; Kohler L. Surg Endosc. 1999;13: 430-436; Rafferty J. Dis Colon Rectum. 2006; 49: 939–944
• In2006theASCRS recommendedthatelectivesurgeryshouldbemadeonanindividualbasisafterafavorableresponsetoconservativetreatment
ASCRS = American Society of Colon and rectal Surgeons EAES = European Association for Endoscopic Surgery
Stollman NH. Am J Gastroenterol. 1999;94(11):3110-3121; Kohler L. Surg Endosc. 1999;13: 430-436; Rafferty J. Dis Colon Rectum. 2006; 49: 939–944
ElectiveSurgeryfortheTreatmentofAcuteUncomplicatedDiverticulitis
• ClinicalPracticeGuidelineTaskForceofASCRS(2014):
“Thedecisiontorecommendelectivesigmoidcolectomyafterrecoveryfromuncomplicatedacutediverticulitisshouldbeindividualized.“
• Uncomplicateddiverticulitistreatednonoperatively
– reportlowerrecurrenceratesrangingfrom13%to23%
– lowratesofsubsequentcomplicateddisease
– needforemergencyoperation(<6%)
Hall JF, Dis Colon Rectum 2011Eglinton, Br J Surg 2005Broderick – Villa G, Arch Surg 2005Anaya DA, Arch Surg 2005
• Afterrecoveringfromaninitialepisodeofdiverticulitis,theestimatedriskofneedingemergencysurgerywithstomaformation:– 1in2000patient-yearsoffollow-up.
– Whichmeans - 18ptswouldundergoelectivecolectomytoprevent1emergencysurgeryforrecurrentdiverticulitis.
• Thepracticeofrecommendingelectivecolectomytopreventafuturerecurrencerequiringstomaformationisnotsupportedshouldbediscouraged
Janes S, Br J Surg 2005Anaya DA, Arch Surg 2005
2ormoreattacks?• Patientswithmorethan2episodesarenotatanincreasedriskformorbidityandmortalityincomparisonwithpatientswhohavehadfewerepisodes
• Theimpactofdeclineinelectivesurgeryfordiverticulardiseasedemonstrated– Increaseinabscessformation– Noriseintherateofemergencycolectomy
Chapman JR, Ann Surg 2006Ricciardi R Dis Colon Rectum 2009
SpecialConsiderations
• Transplantpatients,patientsmaintainedonchroniccorticosteroidtherapy,immunosuppressedpatients,patientswithchronicrenalfailureorcollagen-vasculardisease– Morelikelytohavefailureofmedicalmanagement– Greaterriskofrecurrencedisease– Highmortalityratewithmedicaltherapyalone
• Surgeonsshouldmaintainalowthresholdtorecommendoperativeinterventionasdefinitivetreatmentwiththefirsthospitalizationforacutediverticulitisinthesepatients
Hwang SS, Dis Colon Rectum 2010Klarenbeek BR, Ann Surg 2010
ComplicatedDiverticulitis
• Electivecolectomyshouldtypicallybeconsideredafterthepatientrecoversfromanepisodeofcomplicateddiverticulitis
ComplicatedDiverticulitis
• Neitherphlegmonnorextraluminalgasaloneseenonimagingisconsideredcomplicateddisease
• Mesocolicabscessesof≥5cmorpelvicabscesseswithorwithoutpercutaneousdrainageà electivecolectomyshouldtypicallybeadvised– retrospectivedata(smallnumbers)haveshowsrecurrenceratesashighas40%
Ambrosetti P, Dis Colon Rectum 2000Kaiser AM, Ann J Gastroenterol 2005
ComplicatedDiverticulitis
• Diverticulitisiscomplicatedbystrictureorfistulaformationà electiveorsemi-electiveresectionisgenerallynecessarytoprovidesymptomaticrelief
Klarenbeek BR, Ann Surg 2010
DiverticulitisinYoungPatients
• <Age50
• Noclearconsensus
Nelson et al. Management of Diverticulitis in Younger Patients. Dis Colon Rectum 2006; 49:1341-45. Guzzo J, Hyman N. Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum 2004;47:1187-91.
DiverticulitisinYoungPatients• Longerlifespan– highercumulativeriskforrecurrent
attacks– However, overallrateofrecurrenceremainedrelativelylowà27%
– After1st attackinyoungpatientsà only7.5%requiredsubsequentemergencysurgery• AnayaDA,ArchSurg 2005
– RetrospectivedatacollectedonyoungpatientswithCT-confirmedinitialepisodesofdiverticulitisdemonstrated• Low2.1%rateofemergencysurgeryatsubsequentattacks
– NelsonRS,DisColonRectum2006
Treatment
FIBER• Highfiberintakeusedtotreatincreasedspasmand
increasedsegmentalcontractionsbyBritishin1970s
• DietaryAllowancesnowrecommend22-28gofdietaryfiberascorrectintakeinwomenand28to34ginmen–varieswithsize
• Butwesterndietaryfiberstudyrevealsintakevariesbetweenaveragesof8-10ginmost
• Invegandietsasmuchas40-50g/day
Burkitt DP, Phil. Dietary Guidelines2010.
IndicationforElectiveSurgery
• 291patients111(38%)treatedconservatively,180(62%)underwentsurgery(108acuteand72elective)
• Conservativelygroupdiverticulitisrecurrencerate48%(88patients).
Klarenbeek BR, Ann Surg, 2010.
• Indicationsforelectivesurgerywere:– recurrentattacksofdiverticulitiswithpersistentcomplaints(36%)
– complaintsofstenosis(40%)– fistula(14%)– persistentabscesses(3%)– recurrentdiverticularbleeding
• Usingimmunosuppressiontherapy,chronicrenalfailure,collagen-vasculardiseases:have5-foldgreaterrisk(36%vs.7%)ofaperforationinrecurrentepisodesofdiverticulitis.
Klarenbeek BR, Ann Surg, 2010.
ElectiveSigmoidResection
• Open,Lap,Robotic
• SigmoidResection– ProximalMargin:compliantbowel
• Includethickened,woodyorgrosslydiseasedbowel•Notalldiverticulabearingcolonmustberemoved
– Distal:upperrectum
•Open vs. LaparoscopyAuthor/year n Lap/Open Op time
(min)Morbidity
(%)Hospital stay
(days)
Bruce/96 25 17
Lap Open
397**115
12 1
4.2 6.8
Liberman/96 14 14
Lap Open
192 183
14 14
6.3**9.2
Coogan/97 59 52
Lap Open
190 108
- 3.8 9.3
Kholer/98 27 34
Lap Open
165*121
16 61.7
7.9*14.3
Dwivedi/02 66 88
Lap Open
212*143
18 23.8
4.8*8.8
Senagore/02 61 71
Lap Open
109 101
1.6*12.6
3.1*6.8
Lawrence/03 56 215
Lap Open
170** 140
9* 27
4.1**9.0
•*p<0.05 •**p<0.001
Laparoscopy:Diverticulitis
Laparoscopy Laparotomy pO.Rcharges($) 10,589 8,207 0.05Hospitalcost($) 11,500 13,400 0.29Hospitalcharges($)29,981 36,745 0.11Morbidity(%) 14 14 0.11Mortality 0 0
•Liberman, Surg Endosc 1996
EmergentSurgicalIntervention• AccordingtocurrentASCRSguidelines• Sigmoidresection,endcolostomy,closureofdistalstump• OverallMorbidityupto29%• Mortality10-20%• LongLOS(20+days)• Colostomyclosuretechnicallydifficult• “Temporary”colostomiesoftenneverclosed(30%-75%)
• ThishasbeenchallengedbyEuropeanAssociationforEndoscopicSurgeryrecommendations+severalstudies
• AlternativetoHPinclude:PA+/-Diversion&LapLavage
Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44
Rafferty et al, DCR 2006
•Practice Parameters for Sigmoid Diverticulitis
•The Standards Committee of The American Society of•Colon and Rectal Surgeons
•The laparoscopic approach is appropriate in selected patients. Level of Evidence III, Grade of Recommendation A
•Laparoscopic colectomy may have advantages over open laparotomy, including less pain, smaller scar, and shorter recovery. There is no increase in early or late complications.
•Cost and outcome are comparable to open resection. Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with complicated disease
BottomLine!
• Mostperforationsandcomplicationsdonotoccurafterrecurrences,happenatfirstattack
• ConservativemanagementofrecurrentnonperforateddiverticulitisassociatedwithlowratesofMorbidity&Mortalitywithmildcourse
Chapman J, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005;242:576–581. Chapman JR, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg. 2006;243:876–880
TakeHomeMessage•Asfewpatientswillactuallyrequireurgentsurgery,shouldlimitdiscussionregardingthisuncommoncomplication
•Insteadshouldfocusondiscussionofrisksandbenefitsofsurgery,QOLimplications,andthehigherlikelihoodofsimilarepisodesasthereasonto,ornotto,considersurgery
•Potentialpoorfunctionaloutcomesandpersistentabdominalsymptomsafterelectivesigmoidcolectomyfordiverticulitisshouldbeconsideredaswell.
ThankYou
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