Acute Diverticulitis & Hartmann’s Procedure

1. Acute Diverticulitis & Hartmann’s Procedure Nigel A. Scott MD FRCS Hope Hospital, Salford

2. CT diagnosis/ CT intervention

3. Illness and Optimisation A randomised clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high risk patients. Boyd O et al JAMA 1993;270:2699-2707

4. Emergency Admission for Acute Diverticulitis • CT diagnosis/ CT intervention • illness /optimisation What’s the best operation in acute complicated diverticulitis ?

5. Emergency Admission for Acute Diverticulitis Acute Complicated Diverticulitis – Which Operation ? Defunctioning Colostomy Hartmann’s Procedure (HP) Primary Anastomosis (PA) • death • illness • permanent stoma

6. Emergency Admission for Acute Diverticulitis Hinchey stage III & IV – colostomy alone ? Zeitoun et al Br J Surg 2000;87:1366-1374

7. Emergency Admission for Acute Diverticulitis Acute Complicated Diverticulitis – Which Operation ? Defunctioning Colostomy Hartmann’s Primary Anastomosis • death • illness • permanent stoma

8. Emergency Admission for Acute Diverticulitis Q – Primary Anastomosis (PA) or Hartmann’s Procedure (HP) • 15 papers (1997 – 2003)

10. Emergency Admission for Acute Diverticulitis Resection for Acute Diverticular Sepsis n=1620 1 HP:1 PA

11. Emergency Admission for Acute Diverticulitis Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis. 2006 Jan 7;:1-7 [ • 18 studies comparing HP and PA in 884 patients with acute diverticulitis • mortality same • morbidity same (sepsis, wound infection, antibiotic use) • duration of procedure the same Might as well do PA as HP – but are we comparing like with like ?

12. Emergency Admission for Acute Diverticulitis Makela et al Dis Colon Rectum 1998;1523-1528 Hartmann’s Procedure is used in Elderly

13. Emergency Admission for Acute Diverticulitis • ASA I - Normal healthy individual • ASA II - Mild systemic disease that does not limit activity • ASA III - Severe systemic disease that limits activity but is not incapacitating • ASA IV - Incapacitating systemic disease which is constantly life threatening • ASA V - Moribund, not expected to survive 24 hours with or without surgery

14. Emergency Admission for Acute Diverticulitis Blair et al Am J Surg 2002:183:525-528 Biondo et al J Am Coll Surg 2000;191:635-642 Hartmann’s Procedure is used in ASA >III

15. Emergency Admission for Acute Diverticulitis • Hinchey I – pericolic abscess confined to mesentery of colon • Hinchey II – walled off pelvic abscess • Hinchey III – generalised peritonitis • Hinchey IV – faecal peritonitis

16. Emergency Admission for Acute Diverticulitis ** adapted from Hughes staging

17. Emergency Admission for Acute Diverticulitis 6 papers n = 454 Hartmann’s Procedure is used in Hinchey III and IV

18. What’s the best operation in acute complicated diverticulitis ? age sepsis ASA

19. Hinchey I and II If adequate bowel preparation is possible and substantial contamination is not present, a primary anastomosis may be performed, with or without a proximal stoma. Alternatively, Hartmann’s resection is the most appropriate procedure. Hinchey III and IV The procedure of choice in this situation is immediate segmental resection with colostomy.

20. Hartmann’s Procedure • elderly • >ASA III • Hinchey III and IV What are the chances of reversal ?

21. Hartmann’s Reversal • general patient fitness • leave for 6 months - adhesions 1- negligible filmy 2- moderate 3 – dense, difficult 4 – inadvertent enterotomy Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:243-248

22. Hartmann’s Reversal • general patient fitness • leave for 6 months - adhesions Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:243-248

23. Hartmann’s Reversal • general patient fitness • leave for 6 months • informed – autonomic injury, death, morbidity, failure, loop stoma • image/ visualise rectal stump • lose weight

24. Hartmann’s Reversal - Open • Lloyd Davies • ureteric stents • mobilise splenic flexure • TV colon to rectum anastomosis • ? loop stoma

25. Hartmann’s Reversal – Laparoscopic • 38 patients – 70% with diverticular disease • reversal at average of 4 -5 months • adhesions; low 13; moderate 15; dense 10; • 15% conversion – adhesions • los 10 days +/- 4 • 1 death from anastomotic leak Laparoscopic reversal of the Hartmann's procedure Vacher C.; Zaghloul R.; Borie F.; Laporte S.; Callafe R.; Skawinski P.; Leynau G.; Domergue J. Annales de Chirugie Volume 127, Number 3, March 2002, pp. 189-192(4)

26. Hartmann’s Reversal – LaparoscopicH Gallagher Laparoscopic reversal of Hartmann’s can certainly be performed with a significantly low morbidity but incisional herniation from the previous laparotomy is an important rate limiting factor-necessitating conversion when the hernia itself demands repair on its own merit

27. Hartmann’s Reversal Rate – 63%

28. Reversal of Hartmann's Procedure after Surgery for Complications of Diverticular Disease of the Sigmoid Colon Is Safe and Possible in Most Patients. Dig Surg. 2006 Feb 10;22(6):419-425

29. Surgery and Acute Diverticulitis • Common and increasing presentation associated with 30% chance of resection and 10% chance of death after surgery • Hartmanns is used for elderly; >ASA III and Hinchey III and IV • Reversal is possible in 60% - laparoscopic or open Summary

30. The End