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Updated Management of Colonic Diverticulitis

A comprehensive overview of the latest management strategies for colonic diverticulitis, including surgical techniques, percutaneous drainage, and the role of peritoneal lavage.

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Updated Management of Colonic Diverticulitis

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  1. Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND ROUND

  2. Diverticulosis • False diverticulum • Herniation of mucosa and submucosa via weak point of muscular wall where vasa recta penetrate Colonic wall weakening Age related changes Intraluminal pressure Segmentation Dietary fibre deficiency

  3. Diverticulosis • Prevalence • 30% by age 60 • 60% by age 80 • Presentation • Asymptomatic: 70% • Diverticulitis: 10-25% • Bleeding: 5-10%

  4. Modified Hinchey Classification

  5. Uncomplicated diverticulitis • 70-80% of all diverticulitis • Absence of • Abscess • Perforation • Fistula • Stricture / obstruction • Management • Bowel rest • Antibiotics • Colonoscopy 6-8 weeks after acute episode to exclude underlying malignancy [1] • Feingold et al. Dis Colon Rectum 2014;57:284-294

  6. Uncomplicated diverticulitis • Elective colectomy in an individualized basis [1] • Low risk of recurrence [1,2] • 13-23% risks of subsequent uncomplicated attacks • 6% risks of subsequent complicated attacks • Mortality and morbidity not increased after >2 uncomplicated attacks [1,3] • Routine elective surgery for <50years not recommended [1] • Feingold et al. Dis Colon Rectum 2014;57:284-294 • Salem et al. Dis Colon Rectum 2007;50:1-5 • Wieghard et al. Ann Gastroenterol 2015;28:25-30

  7. Complicated diverticulitis • Percutaneous drainage? • Surgery • Peritoneal lavage? • Stoma vs primary anastomosis? • Laparoscopic?

  8. Percutaneous drainage • For Hinchey II disease [1] • Size of abscess >5cm: likely not successful with antibiotics alone [2,3] • Feasibility of drainage • Availability of expertise • Successful rate ~70-80% [1] • Soumian et al. World J Gastroenterol 2008;14:7163-7169 • Siewart et al. Am J Roentgenol 2006;186:680-686 • Ambrosetti et al. Dis Colon Rectum 2005;48:787-791

  9. Surgery • Indication • Unstable haemodynamics • Hinchey III / IV on CT scan • Failure to respond conservative therapy • Complications

  10. Hartmann’s operation • Gold standard since 1980’s • For quick and efficient sepsis control • High mortality ~20% • Significant morbidities • > 1/3 of patient never have stoma reversed • Reversal of stoma also has significant morbidities

  11. Peritoneal lavage • Possible alternative for selective group of patient [1] • Expected benefit [2] • Avoid urgent laparotomy and colostomy • Reduced morbidity and mortality • Significantly reduced inflammatory environment  minimize complications from subsequent colonic resection • Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 • Corocci et al. Medicine (Baltimore) 2015;94:e334

  12. Peritoneal lavage • Systematic review • 19 papers from 1996 to 2013 • Total 871 patients Cirocchi et al. Medicine (Baltimore) 2015;94:e334

  13. Peritoneal lavage • Overall success rate: 24.3% (212/871) • Alive without surgical treatment for recurrent diverticulitis or complication • Overall conversion rate to open: 3.8% (17/444) (for Hinchey I-IV) [45% for Hinchey IV] • 30-day mortality rate: 4.8% Cirocchi et al. Medicine (Baltimore) 2015;94:e334

  14. Peritoneal lavage • Hospital readmission rate: 6.9% (29/419) • Recurrent diverticulitis (16/29) • Peritonitis (6/29) • Fistula (3/29) • Undetected Ca colon (2/29) • Abscess (1/29) • Intestinal obstruction (1/29) • 69% of readmitted patients required surgical treatment Cirocchi et al. Medicine (Baltimore) 2015;94:e334

  15. Peritoneal lavage • No histological diagnosis - ?underlying Ca colon • Leaving septic foci with persistent / recurrent infection / inflammation [1] • Recurrence • Not an appropriate alternative to colectomy [1] Validated? • Feingold et al. Dis Colon Rectum 2014;57:284-294

  16. Peritoneal lavage • Mainly for Hinchey III • Absolutely contraindicated for Hinchey IV (high risk of treatment failure) [1-3] • Experienced laparoscopic surgeon • Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 • White et al. Dis Colon Rectum 2010;53:1537-1547 • Rogers et al. Dis Colon Rectum 2012;55:932-938

  17. Anastomosis or not? • Effective alternative [1,2] • Primary anastomosis not worse than stoma in terms of mortality and morbidity [1-3] • Small-scale retrospective studies with selection bias [1,3,4] • Feingold et al. Dis Colon Rectum 2014;57:284-294 • Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 • Abbas. Int J Colorectal Dis 2007;22:351-357 • Cirocchi et al. Int J Colorectal Dis 2013;28:447-457

  18. Anastomosis or not? • Lower mortality rate for anastomosis (P < 0.02) • Shorter hospital stay (P < 0.001) Cirocchi et al. Int J Colorectal Dis 2013;28:447-457

  19. Anastomosis or not? • Selection bias and heterogeneity • Age, sex, ASA scale, co-morbidity • Hinchey stage • Faecal diversion in anastomosis group • Critically ill patients in Hartmann’s group Validated?

  20. Laparoscopic • After complicated attacks…

  21. Laparoscopic Gaertner et al. World J Surg 2013;37:629-638

  22. Laparoscopic • Short-term outcomes [1-3] • Less blood loss / postoperative ileus [1-3] • Less postoperative pain [1-3] • Similar complication rate [2,3] • Shorter hospital stay [1-3] • Improved quality of life [1-3] • Feingold et al. Dis Colon Rectum 2014;57:284-294 • Klarenbeek et al. Ann Surg 2009;249:39-44 • Gervaz et al. Ann Surg 2010;252:3-8

  23. Laparoscopic • Long-term outcomes • Comparable quality of life and morbidity [1-3] • Laparoscopic approach preferred when expertise available [4] • Klarenbeek et al. Ann Surg 2009;249:39-44 • Klarenbeek et al. Surg Endosc 2011;25:1121-1126 • Gervaz et al. Surg Endosc 2011;25:3373-3378 • Feingold et al. Dis Colon Rectum 2014;57:284-294

  24. Summary • Uncomplicated vs complicated • Percutaneous drainage – for large abscess • Peritoneal lavage? • Controversial (NOT for free perforation) • Expertise in laparoscopic surgery • Anastomosis? • Hartmann’s operation – gold standard • Primary anastomosis with proximal diversion in selected group • Laparoscopic? • Expertise in laparoscopic surgery

  25. End

  26. Age-related changes • Increased elastin deposition in taenia coli • Increased type III collagen synthesis • Increased collagen crosslinking  Irreversible state of contracture and reduced resistance of colonic wall

  27. Segmentation Diverticulum Contraction Contraction

  28. Dietary fiber deficiency • Longer transit time • Increases intraluminal pressure

  29. Uncomplicated diverticulitis • Low threshold of surgery for immunocompromised [1] • E.g. transplant, long-term steroid, renal failure • Medical treatment more likely to fail [2] • Higher mortality rate for medical treatment alone [2] • Higher risks of complicated attacks [3] • Feingold et al. Dis Colon Rectum 2014;57:284-294 • Hwang et al. Dis Colon Rectum 2010;53:1699-1707 • Klarenbeek et al. Ann Surg 2010;251:670-674

  30. Percutaneous drainage • Potential benefit • Reducing pain, fever, leukocytosis [1] • Avoid emergency operation and stoma • Facilitate elective single-stage laparoscopic colectomy [2] • Beckham et al. Clin Colon Rectal Surg 2009;22:156-160 • Dharmarajan et al. Dis Colon Rectum 2011;54:663-671

  31. Heterogeneity for lavage • Hinchey stages • Amount of lavage • Indications for lavage • Failed conservative treatment with antibiotics • Failed percutaneous drainage • Treatment for failed lavage • Colectomy +/- anastomosis or stoma • Percutaneous drainage • Medical treatment • Primary repair for colonic perforation

  32. Laparoscopic surgery Klarenbeek et al. Ann Surg 2009;249:39-44

  33. Laparoscopic surgery Laparoscopic surgery • Gervaz et al. Ann Surg 2010;252:3-8 • Klarenbeek et al. Ann Surg 2009;249:39-44

  34. Laparoscopic surgery • Gervaz et al. Ann Surg 2010;252:3-8 • Klarenbeek et al. Ann Surg 2009;249:39-44

  35. Laparoscopic surgery • Scarce data on emergency setting • Mainly retrospective reviews • Comparable in morbidity and mortality • Selection bias • Latarte et al. Am J Surg 2015;209:992-998

  36. Conservative for Hinchey Ib / II • Lamb et al. Dis Colon Rectum 2014;57:1430-1440

  37. Conservative for Hinchey Ib / II • Lamb et al. Dis Colon Rectum 2014;57:1430-1440

  38. Right-sided diverticulitis • More common in Asian population • Often misdiagnosed as acute appendicitis • More indolent compared with left-sided disease with usually mild severity [1-4] • More long-term remission and disease control solely with medical treatment +/- drainage only [1,2] • Similar treatment algorithm as left-sided disease • Law et al. Int J Colorectal Dis 2001;16:280-284 • Telem et al. Gastroenterol Res Pract 2009;359485 • Kim et al. J Korean Soc Coloproctol 2010;26:402-406 • Tan et al. Int J Colorectal Dis 2013;28:849-854

  39. Right-sided diverticulitis • Diverticulitis found during surgery (esp during appendicectomy) without prior imaging • If obviously perforated with contamination  colectomy • If mild  no role for colectomy [1]; proceed to appendicectomy • Tan et al. Int J Colorectal Dis 2013;28:849-854

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