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Dr. Carlo Augusto Sartori Castelfranco V.to (TV)

“Quando e come operare la malattia diverticolare del colon”. “Possibilità di trattamento chirurgico laparoscopico”. Dr. Carlo Augusto Sartori Castelfranco V.to (TV). Laparoscopic colonic resections for diverticular disease Results of a single center series of 105 pts.

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Dr. Carlo Augusto Sartori Castelfranco V.to (TV)

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  1. “Quando e come operare la malattia diverticolare del colon” “Possibilità di trattamento chirurgico laparoscopico” Dr. Carlo Augusto Sartori Castelfranco V.to (TV) sartori@ulssasolo.ven.it

  2. Laparoscopic colonic resections for diverticular disease Results of a single center series of 105 pts. Surgical strategy and technique Osp. Ital. Chir. 9: 111-120; 2003 sartori@ulssasolo.ven.it

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  4. Laparoscopic left colon resections for diverticulitis. Personal experience: 105 cases 44 m Cases N°:105 61 f Mean age : 68.3 (min.30, max.81) Left colectomies:84 Segmental resections :21 sartori@ulssasolo.ven.it

  5. Laparoscopic left colon resections for diverticulitis. Personal experience: 105 cases Hinchey Classification I pericolic abscess II pelvic abscess III purulent peritonitis IV fecal peritonitis ASA 1 48 (45,7%) ASA 2 50 (47,7%) ASA 3 7 (6,6%) ASA 4 0 (0%) sartori@ulssasolo.ven.it

  6. Indications for surgery Recurrent diverticulitis or severe in young patients • 2 or more diverticulitis episodes 56,2% • 1 severe diverticulitis episode in patients < 50 years 10,5% • Stenosis 5,7% • Fistula with urinary bladder 2,9% • Ileo-colic fistula 1,9% • Hinchey I Peridiverticular abscess 14,3% • Hinchey II Pelvic abscess 1,9% • (percutaneous drainage and surgery) • Hinchey III Previous peritonitis 1,9% • (laparoscopic lavage and resection after 6-8 weeks ) • Perforation 3,8% • Acute bleeding (embolization and surgery) 0,9% Stenosis Abscess and fistula Urgency Patients affected by stercoral peritonitis (Hinchey IV) were excluded from present study. sartori@ulssasolo.ven.it

  7. Surgical strategy - Primary identification of embryonary planes and ligation of the vessels with dissection from right to left and from up to bottom sartori@ulssasolo.ven.it

  8. Diffuse diverticular diseaseStandard left colectomyDiverticular disease localized in the sigmoid colon Sigmoid resection with preservation of the origin of IMA and left colic artery sartori@ulssasolo.ven.it

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  11. Diverticular disease with fistulaleaving the treatment of the fistula at the end • Ileo-colic fistula • Colo-vaginal or colo-vescical fistula sartori@ulssasolo.ven.it

  12. - Small pericolic abscess (Hinchey I) Diverticular disease with abscess • Antibiotic therapy • TPN • Elective laparoscopic colectomy - Voluminous abscess (over 5 cm.) (Hinchey II) • Percutaneous drainage US or CT-guided • Antibiotic therapy and TPN • Elective laparoscopic colectomy sartori@ulssasolo.ven.it

  13. Diverticular disease with peritonitis Localized peritonitis Diffuse purulent peritonitis Fecal peritonitis sartori@ulssasolo.ven.it

  14. EMICOLECTOMIA SINISTRA T 1 T 2 T 3 T 4 T 5 sartori@ulssasolo.ven.it

  15. Surgical technique 1 • Preparation of the patient • Preparation of the operating field • Position of the surgeons • Exposure of the operating field • Identifying Gerota’s fascia and sectioning the vessels sartori@ulssasolo.ven.it

  16. Surgical technique 2 • Lowering of the splenic flexure • Sectioning of the mesorectum and the rectum • Service minilaparotomy, extraction of the operative specimen and execution of the colo-rectal anastomosis sartori@ulssasolo.ven.it

  17. Results: 105 cases - Operating time 163,3 min (range 80-300 min) - Conversion rate 0,9% (1 case cirrhosis, severe diverticular disease) - I.op blood loss 66 ml (range 30-150 ml) - Post-op blood loss 0,9% (1 case 2 units of blood) sartori@ulssasolo.ven.it

  18. Results: - I.op. complications 0 - Average lenght of specimen 25,05 cm. - Histological examination: - Deaths 2 (1,9%) adenocarcinomas 1 (0,9%) villous adenoma withsevere displasia 1 (0,9%) pulmonary embolism on the 4th postoperative day sartori@ulssasolo.ven.it

  19. Results • Post-operative complications 12 pts 11,4% • - bleeding from anastomosis 1 0,9% • - ileal perforation (reoperated) 1 0,9% • - intraperitoneal bleeding 1 0,9% • - wound infections 6 5,7% • - abdominal fluid collection 3 2,8% sartori@ulssasolo.ven.it

  20. Results - Anastomotic leaks 0% - Restoring intestinal function 2,1 days - Oral liquid diet 2,4 days - Average hospital stay 9,2 days (range 7-18) Last 50 cases: average number of days effectively required for hospital treatment: 5,2 days (range 4-12) sartori@ulssasolo.ven.it

  21. Results: monocentric studies sartori@ulssasolo.ven.it

  22. Results: multicentric studies sartori@ulssasolo.ven.it

  23. Average operative time for colectomy for diverticulitis sartori@ulssasolo.ven.it

  24. Conversions: 17 (4,7%) % sartori@ulssasolo.ven.it

  25. TIPI DI CONVERSIONE Conversioni “precoci” Conversioni “tardive” sartori@ulssasolo.ven.it

  26. CAUSE DI CONVERSIONE Di principio Laparoscopia esplorativa Di necessità Per impossibilità tecnica di proseguire in LAPS Per una complicanza intra-operatoria sartori@ulssasolo.ven.it

  27. Conversione di necessità • tempi operatori • morbilità • costi sartori@ulssasolo.ven.it

  28. Cause di conversione Conversion rates in laparoscopic colorectal surgery A predicitive model with 1253 patients PP Tekkis, AJ Senagore, CP Delaney Departement of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation Surg. Endosc. 2005 19:47-54

  29. Risk factors for conversion * Diagnosed at BE or colonoscopy Le Moine, Br J Surg, 2003 sartori@ulssasolo.ven.it

  30. Laparoscopy: Diverticulitis Gonzalez et al, Surg Endosc 2004 sartori@ulssasolo.ven.it

  31. Laparoscopy: DiverticulitisResults * (p< 0.05) - n (%) Gonzalez et al, Surg Endosc 2004 sartori@ulssasolo.ven.it

  32. Results-Open versus LaparoscopyMorbidity Morbidity (%) 43 29* 29 13 0 0 Hinchey IIA and IIB Overall Late experience experience * P<0.05 sartori@ulssasolo.ven.it Sher et al, Surg Endosc, 1997

  33. 10§ 9 * 7* 5 5 * p<0.05 § P<0.01 Results-Open versus LaparoscopyHospital stay Days sartori@ulssasolo.ven.it Sher et al, Surg Endosc, 1997

  34. Laparoscopy: Diverticular disease Variable Laparoscopic Open Age (years) 59 52 Weight (pounds) 165 172 ASA class 2.3 2.1 Perforated 7 5 Abscess 18 18 Operative time (minutes)* 190 108 Blood loss (ml) 340 308 (P<0.001) Coogan et al, Surg Endosc 1997 sartori@ulssasolo.ven.it

  35. Laparoscopy: Diverticular disease Variable Laparoscopic Open Oral intake (days)* 0.8 5.1 Hospital stay (days)** 3.8 9.3 OR cost ($) 15,200 7,200 Hospital cost ($) 1,700 6,800 Total cost ($) 17,000 15,800 *p<0.0001 **p<0.001 Coogan et al, Surg Endosc 1997 sartori@ulssasolo.ven.it

  36. Laparoscopy: Diverticular disease Costs a= Total direct cost/case *p<0.05 sartori@ulssasolo.ven.it

  37. Laparoscopy: DiverticulitisObesity Tuech et al. Surg Endosc 2001 sartori@ulssasolo.ven.it

  38. Laparoscopy: DiverticulitisObesity • Anastomotic leak resolved with conservative drainage • Group 1 vs. Group 2 – p=0.54 • Group 1 vs. Group 3 – p=0.57 Tuech et al. Surg Endosc 2001 sartori@ulssasolo.ven.it

  39. Laparoscopy: DiverticulitisObesity • Hospital stay Group 1 vs. Group 2: p=0.31 • Hospital stay Group 1 vs. Group 3: p=0.14 • Inpatient rehabilitation Group 1 vs Group 2: p=0.54 • Inpatient rehabilitation Group 1 vs Group 3: p=0.63 Tuech et al. Surg Endosc 2001 sartori@ulssasolo.ven.it

  40. Laparoscopy: Elderly > 75 yrs< 75 yrs n= 22 n = 63 Mean age (yrs) 77.2 (75-82) 53.7 (38-74) Gender (M:F) 10:12 28:35 Operative time (min) 234 183 IV analgesia (days) 5.4 5.2 Morbidity (%) 18 14 Mortality 0 0 Conversion (%) 9 6 Hospitalization (days)* 13.1 8.8 *p=0.003 Teuch et al. Hepatogast 2001 sartori@ulssasolo.ven.it

  41. Laparoscopy: Elderly Laparoscopic Open p value n= 22 n = 24 Mean age (yrs) 77.2 (75-82) (76-84) NS Gender (M:F) 10:12 10:14 NS Operative time (min) 234 136 NS IV analgesia (days) 5.4 8.2 0.001 Morbidity (%) 18 50 0.02 Mortality 0 0 NS Inpatient rehabilitation 6 15 0.01 Hospitalization (days) 13.1 20.2 0.003 Teuch et al. Surg Endosc 2000 sartori@ulssasolo.ven.it

  42. Laparoscopy: DiverticulitisEmergency 18 patients- acute perforation Laparoscopic lavage and suction • + Omental patch closure • 7.5 days in hospital • 4-34 month follow-up • Subsequent elective resection with primary anastomosis possible Franklin et al., Surg Endosc 1997 sartori@ulssasolo.ven.it

  43. Laparoscopy: DiverticulitisEmergency • 90% Success • Elective resection- 4-5 days in hospital • 5% Morbidity • Better than Laparotomy • Applicable in complex cases as well (Fistula, Abscess, Perforation) Franklin et al., Surg Endosc 1997 sartori@ulssasolo.ven.it

  44. Conclusions • Surgical treatment of complicated diverticular disease carried out laparoscopically gives good results in terms of morbidity and mortality and confers many advantages over the traditional approach sartori@ulssasolo.ven.it

  45. Conclusions • Laparoscopy requires its own specific surgical strategy • The surgical team must be expert in laparoscopic surgery and in colo-rectal surgery • Emergency cases should be performed only by experienced laparoscopic surgeons sartori@ulssasolo.ven.it

  46. Conclusions • The technique must be standardized so that the incidence of complications, operating time and the rate of conversions to open surgery can be minimized sartori@ulssasolo.ven.it

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