SURGICAL UPDATES-FROM MOUTH TO ANUS Colonic diverticulitis-Minimising Interventions, maximising outcomes A/Prof. Christopher J. Young 1,2,3 1 Royal Prince Alfred Hospital, Colorectal Unit, Camperdown, NSW 2050 2 Concord Hospital, Colorectal Unit, Concord, NSW 2139 3 University of Sydney Thank you giving me the opportunity to present my work. No Disclosures

Diverticular disease Sigmoid diverticulosis rate in western society 33-66% Acute diverticulitis occurs in 10-25% of the above More common among elderly BUT ↑ incidence observed in younger age groups ↑ Incidence of right sided diverticultis

Definitions: Interventions and Outcomes Outcomes/Maximise ↑ Outpatient treatment ↓ LOS for those admitted ↓ Use of IV and oral A/B’s ↓ Investigations -CT/US/MRI ↓ Colonoscopy post acute diverticulitis ↓ Elective resection rate ↓ Emergency surgery rate ↑or↓(? Percutaneous drainage rate) ↓ Stoma formation rate ↑ Stoma closure rate ↑ QOL INCL ↓ time off normal ADL Interventions/Minimise Investigations- CT/US/MRI Hospital admission Antibiotics: Nil A/B’s vs. oral A/B’s vs. IV A/B’s Percutaneous drainage Surgery- lap vs. open Stoma- permanent/temporary Colonoscopy

Definitions: Hinchey classification Hinchey EJ et al, Adv Surg, 1978 Sher ME et al, Surg Endosc, 1997 Hughes ES et al, MJA, 1963

Definitions: Hinchey classification Kaiser AM et al, Am J Gastroenterol, 2005 Klarenbeek et al, IJCD, 2012 Wasvary H et al, Am Surg, 1999

Uncomplicated vs. Complicated Evolving Management Complicated disease includes perforation, obstruction, abscesses, fistula and stricture formation. With a greater understanding of the pathophysiology of diverticulitis and the advancement of technology, the management of diverticulitis has been evolving in recent times. There is a significant push towards the outpatient management of simple diverticulitis and less aggressive initial management for complicated cases. As well as, a change in surgical management options including laparoscopic versus open approach and primary anastomosis versus Hartmann’s procedure for Hinchey Grades 3 and 4. An attempt has been made by several societies to condense some of this into guidelines and practice parameters based on the level of evidence

Correlating guidelines with clinical practice in diverticulitis management 100 CSSANZ Members, average 14years practice 22 hypothetical scenarios, 19 guideline based Siddiqui J, Zahid A, Hong J, Young CJ, 2017 Colorectal Disease in review.

Colonic diverticultis-Minimising Interventions, maximising outcomes Consensus and disagree with guideline recommendations Management of simple diverticulitis, 75% of respondents would admit for bowel rest and IV antibiotics as opposed to 18% who would treat as an outpatient on oral antibiotics ± modified diet. Following recovery from an episode of complicated diverticulitis, 91% elected for no operative intervention at follow-up, compared to 5% who would offer an elective laparoscopic resection and 2% who were divided between both options.

Colonic diverticultis-Minimising Interventions, maximising outcomes Equipoise and disagree with guideline recommendations Imaging when computed tomography (CT) scan was contraindicated, e.g. patient with renal failure, the majority (56%) opted for CT, with some stating without contrast. Only 21% agreeing to the alternative of ultrasound (US) or magnetic resonance imaging (MRI). Choosing CT was more likely if the surgeon was younger than 50 years-old (p=0.04) or practicing less than 10 years (p=0.03). Failed conservative therapy for uncomplicated sigmoid diverticulitis, 70% would opt for a repeat CT scan (more likely if working in a city [tertiary/quaternary] center – 75% vs. 52%, p=0.03 or practicing for more than 10 years – 80% vs. 58%, p=0.02) and only 11% would proceed to an emergency sigmoid colectomy (more likely if working in a rural/regional center – 50% vs. 9%, Fisher’s exact test p=0.02). In the case of an elective colectomy, 58% would use oral, mechanical bowel prep before the procedure and intravenous (IV) antibiotics on induction of general anesthesia (GA). This was more likely to be the case if the surgeon was aged over 50 years-old (68% vs. 48%, p=0.04). Those with an ASU in their practice were more likely to choose none of these options (39% vs. 14%, p=0.006).

Colonic diverticultis-Minimising Interventions, maximising outcomes Equipoise and agree with guideline recommendations 62% of respondents agreed to image guided percutaneous drainage for a 3cm mesocolic abscess not responding to conservative management. Univariate analyses demonstrated that a significantly greater number of those practicing in a non-city (tertiary/quaternary) setting (87% vs. 55%, p=0.005), practicing for more than 10 years (70% vs. 48%, Fisher’s exact test p=0.047) and being European sub-specialty trained (79% vs. 56%, p=0.04) was associated with this. For Hinchey Grade 3 diverticulitis, 57% opted for Hartmann’s procedure with 33% choosing on-table colonic lavage and colorectal anastomosis with diverting loop ileostomy. A greater proportion of North American sub-specialty trained surgeons (87% vs. 51%, Fisher’s exact test p=0.01) and non-Australasian trained surgeons (77% vs. 45%, p=0.002) would perform a Hartmann’s procedure in this case, as well those practicing for more than 10 years (67% vs. 33%, p=0.002) and older than 50 years old (70% vs. 41%, p=0.004). In considering the proximal extent of resection for sigmoid diverticulitis, 58% would remove colon only where there is thickened, inflamed and hypertrophic tissue and resect the entire sigmoid colon (63% of Australian based vs. 35% of New Zealand based surgeons, p=0.03), whereas 13% would only do the former, and 23% would only do the latter.

Colonic diverticultis-Minimising Interventions, maximising outcomes Equipoise

Colonic diverticultis-Minimising Interventions, maximising outcomes Future directions/ evidence/ literature Changing demographics: Vather R et al ANZJS 2015; 25,167 admissions for acute DD from 2000-2012 (NZ), mean age decreased (66 vs. 64 years), mean age lower in men (61 vs. 67 years), more younger men 18-44 years (69% vs 31%). LOS increased with age and deprivation. Unrestricted diet effect for uncomplicated diverticulitis: Stam MAW et al Colorectal Dis 2016, 86 pts Hinchey 1a/b, no antibiotics, 6 months follow-up. Readmissions: 5 readmissions for pain, one recurrent diverticulitis, 3 surgery (2 symptoms, 1 Hinchey III). 20% continuing symptoms 6 months later and 5% recurrent diverticultis.

Colonic diverticultis-Minimising Interventions, maximising outcomes Future directions/ evidence/ literature Treatment of uncomplicated diverticultis: Mali JP et al DCR 2016; 161 pts Uncomplicated diverticulitis treated without antibiotics (Finland). 30 day follow-up. No control group. 87% treated as outpatients. 3% admitted. 9% given antibiotics after 2 days. 3% misdiagnosis. 9% pericolic air. Conclusion: symptomatic treatment is safe and effective. Multicentre/International RCT of Uncomplicated diverticulitis; Bissett I et al (NZ/AUS). All patients admitted. To determine whether the administration of a placebo regimen results in ≥24 hours prolongation of hospital admission when compared with a standard intravenous and oral antibiotic regimen. Diagnosed with uncomplicated acute diverticulitis on CT scan within 24 hours of admission. Does not exhibit systemic inflammatory response syndrome

Colonic diverticultis-Minimising Interventions, maximising outcomes Future directions/ evidence/ literature Laparoscopic lavage: Vennix S et al Lancet 2015; LADIES, DIVA (hartmann’s vs. sigmoidx/anast), LOLA (2 Lap Lavage vs. Sigmoidx(1 hartmanns/1 anastomosis) (Belgium, Italy, Netherlands). Hinchey Grade III. 90 pts 2010-2013, terminated due to increased event rate in Lap lavage group, I.e. major M&M within 12 months, 67% vs. 60%, mortality 4 vs. 6. Conclusion: Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis. Di Saverio S IJOS 2016; LOLA ? (Italian arm) Inter-hospital and inter-operator variability? Gehrman J et al BJS 2016; DILALA, Hinchey Grade III, 43 pts laparoscopic lavage vs. 40 Hartmann’s procedure (Denmark, Sweden). Significant decreased costs Lap Lavage group.

Colonic diverticultis-Minimising Interventions, maximising outcomes Future directions/ evidence/ literature Surgical Intervention: What is being done?: Hong M et al ANZJS 2015; 2829 emergency acute diverticulitis (VIC), 724 complicated. 10.4% emergency procedure. 72% resections Hartmann’s procedure. Who does the surgery?: Gibbons G et al 2015 ANZJS; CRSx vs. ASU (WA), similar M&M, Primary anastomosis 86% vs. 29%, Stoma rate 40% vs. 89% Hartmann’s reversal: Brathwaite S et al 2015 SLEPT; 19 Lap vs 62 open reversals (USA), Lap shorter LOS, M&M equivalent

Colonic diverticultis-Minimising Interventions, maximising outcomes Conclusion: Diverticulitis is common Many areas of understanding of the disease process and treatment are uncertain Ongoing trials will help to resolve some of these questions Minimising interventions and maximising outcomes is an aspiration, not an absolute goal