Diverticulitis Abscess Tryggvi Stefánsson Centrallasarettet in Västerås and Landspitali University Hospital Reykjavík/Iceland

Perforation Abscess Purulent peritonitis Faecal peritonitis Incidence Hart Cambridge UK 1995-1997 4/100000/year Mäkelä Oulu, Finland 1986-2000 3,8/100000/year

Abscess Diverticulitis abscesses are rare. Individual experience not enough. Incidence Ambrosetti Geneva 1986-1997 1/100000/year

Risk factors for perforated diverticulitis Industrialized countries with high prevalence of diverticulosis Increases with advanced age Men > Women Immune suppression Corticosteroids NSAID Opioids, smoking, alcoholism, red meat, fiber deficiency (??) Morris, Postgrad Med J, 2002 obesity Dobbins, Colorectal dis, 2005 Renal failure

Location Paracolic or Pelvic Retroperitoneal, Retrorectal, Psoas muscle, Hip, Buttock, Flank, Leg, Inguinal region, Scrotum Stabile, Am J Surg, 1990 Neff, Radiology, 1987 Ravo, Am J Gastroenterol, 1985

Bacterias 19 patients: Polymicrobial (E-coli, Bacteroides, Enterococcus, Klebsiella) in 17 E-coli in 1 B Fragilis in 1 Stabile Am J Surg 1990

Abscess

Abscess

Abscess

Treatment Options Bowel Rest Antibiotics PAD (Percutaneous Abscess Drainage) SD (Surgical Drainage) One Stage (Res+ ana +/- ostomy) Two Stages (Hartmanns procedure) Three Stages (Drainage+ostomy)

Results of operations Lahey clinic 1967-1982 Mortality Res and ana 1% Res, ana with stoma 0% Hartmann 16% Three Stages 14% Hackford AW, Dis Colon Rectum, 1985

Results of operations Of 37 patients operated with a 2-stage operation for an abscess 13 patient could have been operated in a single stage operation if they had undergone PAD Mueller PR, Radiology, 1987

Goal of Drainage Downstage-Single stage Patient can recover, Bowel Prep, Clean op field Bacteria culture. Only treatment.

How to drain CT guided Transabdominal, trans sacral (PAD) US guided transabdominal (PAD), transvaginal, transrectal EUS guided through the sigmoid wall Surgical drainage Blind transrectal or transvaginal

Contraindications to PAD Abscess not localized Access not safe Generalized peritonitis Pneumoperitoneum Obstruction Blood dyscrasias/Bleeding diathesis Persistent symptoms after drainage Faeculent Drainage (Immunocompromized and high mortality score) Diverticular disease. Management of the difficult surgical case Williams and Wilkins 1998

Published Results of PAD Neff CC Radiology 1987 16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm 11 single stage op in 10d-6w 3 inop, drainage only. 1 sigm fistula 3 stage 1 resp insuff-died

Published Results of PAD Mueller PR, Radiology 1987: 24 patients, pelvic abscesses 14 single stage op within 10 days 5 two-stage op because of inflammation 2 no initial op but res within 8 months 1 just drain Stabile BE, Am J Surg, 1990: 19 patients with parac or pelvic abscesses (8,9cm) 14 (74%) single stage operation after PAD. 3 Urgent colostomy and surgical drainage. 2 refused operation (one died).

Drainage Drainage Hartmann op Infected part of the colon is left behind. Risk for complications like persistent fistula, DVT, Atelectasis, pneumonia and other infections. If the patient deteriorate in spite of drainage the op risk will be higher. Hartmann op The patient is drained and deviated

Choice of Treatment 1 The Abscess * Size ** Location *** Bacterias 2 The Patient * Morbidity, mortality scoring systems. ** Anastomose healing 3 The Surgeon * Training ** Hospital *** Emergency/Elective

Size of Abscess < 3-5 cm Bowel rest and Antibiotics > 5 cm Bowel rest, Antibiotics and Drainage Ambrosetti Dis Colon Rectum 2005 Siewert AJR 2006

Location Abscesses >5cm: Pelvic: Drainage. Resected when the acute inflammation has faded. Paracolic: Drainage. Conservative treatment. Resection only if symptoms persist. Ambrosetti, Dis Colon Rectum, 2005

Antibiotics Broadspectrum antibiotics (G neg and anaerobes) Cefuroxim, Metronidazol Ciprofloxacin, Metronidazol Tienam Meronem Tacozin

Patient Mortality and Morbidity score ASA, APACHE, POSSUM Anastomose healing Normal: Young and healthy Impaired: Old, Malnourished, Renal failure, AIDS, Steroid dependent, Chemotherapy, Diabetes, Chronic alcoholics, High BMI, Transplant patients

Surgeon Training: In training, General Surgeon, Colorectal Surgeon Hospital: Radiology equipment, Radiologist, ICU, Assistance Emergency/Elective: Rate of complications higher in emergency operations

Team decision Colorectal Surgeon Radiologist Cardiologist Anaesthetist ......

Abscess treatment Normal healing of anastomosis and a favorable mortality score <5 cm: Bowel rest and Broadspectrum antibiotics Those who dont respond: Drainage Persist after drainage: Res and Ana >5cm in pelvis: Drainage with a later res and ana >5cm above the pelvis: Drainage Persist after drainage: Res and Ana Impaired healing of anastomosis 1) Bowel rest, Broadspectrum antibiotics and Drainage 2) Res and Ana + loop Ileost or Hartmanns op Impaired healing of anastomosis and unfavorable mortality score Hartmann operation directly

Summary Young and healthy patients tolerate conservative treatment. Immunocompromized with unfavorable mortality score may not tolerate conservative treatment-need more active surgical treatment.