Impact of Laparoscopy on the Management of Right-sided Diverticulitis Dr. CHAN chun-yin, Oliver Department of Surgery, Pamela Youde Nethersole Eastern Hospital 17 th September 2005

Right sided diverticulitis  Acute diverticulitis of the right colon is relatively uncommon  Reported frequency of disease varies 1 in 300 to 1 in 34 appendectomies Oudenhoven et al. Radiology.1998  Prevalence in Western literature 0.9 % - 5% of all diverticulitis Fisher et al. Dis Colon Rectum 1984

Diverticulosis in Asia Oudenhoven et al. Radiology.1998 Chia JG et al. Diseases of the Colon & Rectum Sugihara et al. Annals of the Academy of Medicine, Singapore Chiu et al. J Surg Asso HKSingaporeJapanTaiwan Patient number Prevalence of diverticulosis 25.1%20%13.3%N/A Only Right colon involvement 55%70%68.8%60%

Right sided diverticulitis in Asia  Prevalence 10 to 17% of all diverticulitis Sugihara et al. Annals of the Academy of Medicine, Singapore Lo et al. The Ameriacan Journal of Surgery 1996

Diagnostic dilemma  Clinical features mimic acute appendicitis Almost always misdiagnosis as acute appendicitis Markham et al. Gut 1992 Lo et al. The Ameriacan Journal of Surgery 1996 Chiu et al. ANZ J Surg. 2001

Treatment strategy  Antibiotics alone  Appendicectomy with antibiotics  Diverticulectomy +/- appendicectomy with antibiotics  Ileocolic resection with primary anastomosis with antibiotics  Formal right hemicolectomy with antibiotics Complicated: resection + antibiotics Uncomplicated: Huge controversies !

Greaney and Snyder classification Grade IAcute inflammation Grade IIInflammatory mass Grade IIILocalized perforation over diverticulitis Grade IVPus collection over whole abdominal cavity UNCOMPLICATED COMPLICATED

Background  Ileocolic resection or right hemicolectomy with primary anastomosis was commonly practiced in the era of open surgery for right sided diverticulitis Via midline laparotomy wound Claimed low morbidity and mortality

Background  In the era of laparoscopic surgery Changing management pattern

Objective  To evaluate the impact of laparoscopy on the management of right-sided diverticulitis  In terms of Surgical resection rate Safety of conservative treatment after laparoscopic examination Hospital stay Chance of missing a carcinoma

Setting  A general community hospital

Design  Retrospective evaluation study

Patients and method  All patients who discharged with coding of acute appendicitis, diverticulits or diverticulosis  From August August 2005  Through hospital computer data  Review of case notes  Telephone interview

 Open era From 1993 to 1998  Laparoscopic era Routine laparoscopic appendicectomy started since 1999 in our hospital

Result  Total number of cases with preoperative diagnosis of appendicitis 2569 cases  Number of right sided diverticulitis 135 cases underwent operation 41 cases without operation were excluded  Already underwent appendicectomy before  Previous investigation confirmed presence of right colon diverticulae

2569 patients with preoperative diagnosis of acute appendicitis 135 patients with intraop findings of right diverticulitis Open era 38 cases Laparoscopic era 97 cases Right hemicolectomy 28 cases Appendicectomy 10 cases Right hemicolectomy -open: 14 case -Lap: 2 case Appendicectomy 56 cases Laparoscopy only 25 cases 41 patients diagnosed by CT without operation were excluded 2434 appendicitis

Result  Open era: 38 cases Right hemicolectomy: 28 (73.6%) Appendicectomy alone: 10 (26.4%)  Laparoscopic era: 97 cases Laparoscopy  open right hemicolectomy: 14 Laparoscopic right hemicolectomy  2 Laparoscopy only: 25 Laparoscopic incidental appendicectomy: 56 (16.5%) (83.5%)

Open era vs lap era

Result  Right side diverticulitis : 135 cases Surgical resection: 44 (32.6%)  Open era no…. 28 (63.6%)  Lap era no…. 16 (36.4%) Without resection: 91 (67.4%)  Open era no… 10 (11%)  Lap era no… 81 (89%)

Result

Open groupLaparoscopic group Age, mean Sex (M:F)2:11:1.17 Length of stay (days), median 75 Mortality00 Morbidity Wound infection30 Intra-abdominal collection 10 Readmission00

Reasons for resection Open groupLap group Perforation 812 Inflammatory mass 18- Suspected tumor 24 Total no.2816

Result  Non resection group after laparoscopy Further colonic investigations arranged 4 weeks later

Colonoscopy Ba enema Virtual colonoscopy Defaulted investigation +ve for diverticuli 33 -ve for diverticuli 15 +ve for diverticuli 11 -ve for diverticuli 5 +ve for diverticuli 1 13 Single 9 Single 3 Multiple 24 Multiple 8 Caecal tumor 1

Result  Missed carcinoma: 3 cases year old lady, detected on colonoscopy 4 weeks’ postop, right hemicolectomy performed 1 week later year old gentleman, “prolong ileus” postop, CT revealed caecal tumor, right hemicolectomy performed on Day year old gentleman, persistent pain at 2 weeks’ postop, CT revealed caecal tumor, right hemicolectomy at 3 weeks’ postop

Discussion  Incidence quite high 1 case every 18 cases of appendicitis  Increased use of laparoscopy  Minimally invasive and safe as diagnostic tool  Increased detection of diverticulitis  More conservative trend in laparoscopic era Decreased resection rate  Early detection of uncomplicated diverticulitis  Better assessment by means of laparoscopy

Discussion  Conservative treatment Low morbidity Shorter hospital stay No readmission for second attack Routine follow up colonic investigation  Default rate 16%  Missing carcinoma Early pickup

Discussion  Potential advantages Avoid unnecessary surgical resection and their potential complication Shorter hospital stay  However, Low resection rate really due to laparoscopy or Changing attitude of surgeon towards the management of right-sided diverticulitis

Conclusion  Laparoscopy is a safe procedure in the management of right-sided diverticulitis  Increasing trend of adopting conservative treatment  Rate of missing a carcinoma by laparoscopic examination were low in the present study

Thank you!