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Management of Colonic Diverticulitis

Management of Colonic Diverticulitis. Joint Hospital Surgical Grand Round 24th Oct 2009. Diverticular Disease. The sigmoid colon is most commonly affected (> 90% of cases)  Proximal colonic involvement in 40% of patients. Diverticular Disease. Prevalence

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Management of Colonic Diverticulitis

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  1. Management of Colonic Diverticulitis Joint Hospital Surgical Grand Round 24th Oct 2009

  2. Diverticular Disease • The sigmoid colon is most commonly affected (> 90% of cases)  • Proximal colonic involvement in 40% of patients

  3. Diverticular Disease • Prevalence • ~40% of people by the age of 65 years • ~60% of people by the age of 80 years. • ~10% to 25% of patients with diverticulosis will develop diverticulitis

  4. Diverticulitis • Inflammatory complications result from perforation of diverticula • Sympotms • Usually present within several hours to days • Pain localized to the left lower quadrant • Change in bowel habits • Bloating, nausea, vomiting and anorexia

  5. Diverticulitis • History and Physical examination • Complete blood count (CBC), Urinalysis, and plain abdominal radiographs • CT scan of the abdomen and pelvis with intravenous contrast • Sigmoid diverticula • Peri-sigmoid inflammatory changes • Extraluminal gas or fluid • Pericolic abscess • Adjacent organ involvement

  6. Classification • Hinchey classification is most commonly described • Class I : localized pericolic inflammation • Class II : localized pericolic abscess • Class III : diffuse purulent peritonitis • Class IV : diffuse feculent peritonitis

  7. Uncomplicated ?Young age ?recurrence Complicated Hartmann's procedure Primary resection + anastomosis +/- diverting ileostomy Controversies Indication for surgery Operation Laparoscopic / open

  8. Trend toward nonsurgical conservative management in many presentations of diverticular disease

  9. Uncomplicated Diverticulitis • Absence of complications • Abscess • Free perforation • Fistulization • Stenosis

  10. Uncomplicated Diverticulitis • Abdominal pain, fever, and elevation of white blood cell (WBC) count • Diagnosis by clinical grounds • CT scan • Not mandatory • In severe clinical findings on presentation • Atypical symptoms • Re-evaluate patients

  11. Management • Bowel rest • Antibiotic therapy • Common gram-negative and anaerobic pathogens • Little evidence on selection of specific regimens; no regimen has demonstrated superiority • Paucity of data regarding optimal duration Byrnes et al. Antimicrobial therapy for acute colonic diverticulitis. [Review] Surgical Infections. 10(2):143-54, 2009 Apr.

  12. Uncomplicated Diverticulitis • Complete resolution without recurrence in at least 70% of cases • Colonoscopy to exclude underlying malignancy at a time interval for optimal resolution of the diverticular inflammation.

  13. Uncomplicated Diverticulitis • Immunosuppressed /Immunocompromised patients are more likely to present with perforation or fail medical management • A lower threshold for urgent or elective surgery should apply Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

  14. Uncomplicated Diverticulitis • Younger patients (<50) were previously thought to have more virulent disease • Previous studies have shown misclassification and selection bias • Diagnosis often delayed in younger patients resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated. Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52: 1008-1016

  15. Uncomplicated Diverticulitis • Lack of evidence for elective surgery after a single attack of diverticulitis • Should follow the guidelines for patients of any age • Higher cumulative risk for recurrent diverticulitis Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52: 1008-1016

  16. Uncomplicated Diverticulitis Recurrence • Current practice guidelines recommend that surgery should be offered to patients after two documented episodes of uncomplicated diverticulitis • Factors influencing recommendation include: • Fitness for surgery • Number and severity of attacks • Rapidity and completeness of response to medical therapy • Persistence of residual symptoms after completion of treatment

  17. Uncomplicated Diverticulitis • Large recent multicentric retrospective studies on outcome of patients whose first episode of acute diverticulitis treated conservatively confirmed that the risk ofrecurrent attacks was low Broderick-Villa et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005;140:576–581. • In patients requiring urgent surgery, it is the initial attack in over 80% of cases

  18. Somesakar and colleagues (2002) and Chapman and colleagues (2005) • Patients with perforated diverticulitis and the majority presenting with life-threatening diverticular disease had not had antecedent diverticular events • Salem and colleagues (2004) • Published a decision analysis showing that performing colectomy after the fourth (rather than the second) episode of diverticulitis resulted in fewer deaths, fewer colostomies, and significant cost savings, irrespective of patients’ age The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2004; 199: 904–12.

  19. Uncomplicated Diverticulitis • Surgery should probably be reserved for patients with more recurrent episodes of uncomplicated diverticulitis

  20. Complicated Diverticulitis • Contained Perforation: Pericolic and Pelvic Abscesses (Hinchey Stages I and II) • Intravenous antibiotics and close observation • Image-guided percutaneous catheter drainage

  21. Complicated Diverticulitis • Small pericolic abscesses (<2 cm) and intra-mural abscesses may resolve without intervention Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

  22. Complicated Diverticulitis • Conflicting data • Broderick-Villa and others (2005) support long-term nonoperative management even in patients with abscesses • Several smaller case series suggest that patients with a history of abscess have a higher chance of recurrence

  23. Complicated Diverticulitis • Free Perforation: Purulent and Fecal Peritonitis (Hinchey Stages III and IV) • Aggressive fluid resuscitation and intravenous broad-spectrum antibiotics • Early intensive care unit monitoring with the addition of a central venous catheter

  24. Complicated Diverticulitis • Acutely non-resolving symptoms Hinchey class I-III and patients with Hinchey class IV disease should be offered urgent surgery Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

  25. Complicated Diverticulitis Urgent operative management • Primary resection / primary anastomosis and +/- diverting ileostomy • Hartmann's procedure • Safest option in patients with severe sepsis and generalized purulent or fecal peritonitis is

  26. Hartmann’s vs primary resection anastomosis • Review of eighteen studies between 1966 and December 2003 reported 884 patients with acute complicated diverticulitis • No significant differences were found between primary resection with anastomosis and Hartmann’s procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis (2007) 22: 351–357

  27. Hartmann’s vs Primary Resection Anastomosis • Fifteen Comparative studies (between 1984 and 2004) 963 patients analyzed • Overall mortality was significantly reduced with primary resection and anastomosis • Retrospective nature of the included studies • Considerable degree of selection bias Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review. Dis Colon Rectum 2006; 49: 966–981

  28. Laparoscopic vs Open Resection • When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients Level of Evidence: III; Grade of Recommendation: A • There is no increase in early or late complications • Cost and outcome are comparable • Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with complicated disease. Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

  29. LaparoscopicvsOpen resection • Laparoscopy can be performed safely • benefits in terms of length of stay, less pain and quicker recovery.  • associated with longer operative times and more operative cost • Acceptable alternative to open surgery for an experienced laparoscopic surgeon with an adequate case volume

  30. Laparoscopic vs Open Resection • Laparoscopic sigmoid resection was associated with a 15.4% reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization at the cost of a longer operating time. Klarenbeek et alLaparoscopic Sigmoid Resection for Diverticulitis Decreases Major Morbidity Rates: A Randomized Control Trial Short-term Results of the Sigma Trial. Ann Surg Jan 2009;249: 39–44

  31. Laparoscopic Lavage Acute complicated diverticulitis managed by laparoscopic lavage and drainage with antibiotic Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

  32. Laparoscopic Lavage Outcomes of laparoscopic lavage management in the published studies • Mean length of stay was 9 days Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

  33. Laparoscopic Lavage • Laparoscopic Lavage without sigmoid resection in the acute setting for patients with purulent peritonitis caused by complicated diverticulitis could be considered a valid alternative • Needs to be investigated more thoroughly Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

  34. Laparoscopic Lavage • Primary laparoscopic lavage for complicated diverticulitis may be a promising alternative to more radical surgery in selected patients • Larger studies have to be made before clinical recommendations can be given Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

  35. Summary • Uncomplicated Diverticulitis • Surgery recommended after single attack for immunosuppressed /immunocompromised patients • Young patient should follow the guidelines for patients of any age • Reserved for patients with more recurrent episodes

  36. Summary • Complicated diverticulitis Urgent operation • Primary resection with anastomosis +/- diverting ileostomy • vs Hartmann’s procedure ? Elective operation after non operative management of acute episode

  37. Summary • Elective Sigmoid Resection • Laparoscopic approach is appropriate in selected patients • Laparoscopic Lavage • Could be considered a valid alternative in complicated diverticulitis with purulent peritonitis

  38. Thank you

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