DIVERTICULITIS Management Dilemmas

Diverticulitis Common in Western and industrialised societies ~ 300,000 hospitalisations yearly in the United States 1.5million days of inpatient care + 1.5million OPD visits M≈F Increases with age, ~ 10% in adults < 40 years to 50 to 70% among those ≥80 years 80% of patients are ≥ 50 years Affects the sigmoid and descending colon in >90% of patients ~20% of patients with diverticulosis will develop diverticulitis over their lifetime

First to describe three stage procedure defunction, resection, closure stoma WJ Mayo & LB Wilson, SGO 1907 ‘Appendicitis on the left side’

Aetiology Exact cause is unknown Associations with diets low in fibre and high in refined carbohydrates Low fibre – diminished stool bulk – slower GI transit time and changes in colonic motility – elevated intraluminal pressures – herniations at areas of weakness Other factors include physical inactivity, constipation, obesity, smoking, and treatment with NSAIDs

Hinchey Classification Stage I: small, confined pericolic or mesenteric abscesses Stage II: pelvic/retroperitoneal abscess Stage III: purulent peritonitis Stage IV: faecal peritonitis Mortality: <5% for Stage I+II, 13% for Stage III and 43% for Stage IV with permission; Jacobs D. N Engl J Med 2007;357: , Copyright© 2007 Massachusetts Medical Society, all rights preserved

Current Guidelines ACPGBI ACPGBI ACPGBI Position Statement on Elective Resection for Diverticulitis WGO 2007 – Diverticular Disease (used by NICE) ASCRS Practice Parameters for Sigmoid Diverticulitis

Investigations Diagnosis based solely on clinical findings will be incorrect in 33% of cases Diagnosis based solely on clinical findings will be incorrect in 33% of cases CT abdomen with contrast is the investigation of choice (WGO,ASCRS,ACPGBI) (sensitivity %; specificity %; level of evidence III; Grade A recommendation) CT abdomen with contrast is the investigation of choice (WGO,ASCRS,ACPGBI) (sensitivity %; specificity %; level of evidence III; Grade A recommendation) Other modalities such as ultrasound scan, MRI or contrast enema can be performed if CT not available Other modalities such as ultrasound scan, MRI or contrast enema can be performed if CT not available

Management of Acute Diverticulitis The debate continues

“ sigmoid colitis with an acute component in the presence of diverticulosis likely to represent diverticulitis. No perforation or collection”

Acute Uncomplicated Diverticulitis Admit or discharge home.....?? Admit or discharge home.....?? Recommendations: OPD management of uncomplicated diverticulitis with 7-10 days PO antibiotics Pt to be reviewed within hours Resolution of acute diverticulitis in 85% ~1/3 will have a recurrent attack often within one year

Antibiotic Therapy – Is IV Therapy Needed? RCT – 79 patients with acute, uncomplicated diverticulitis 41 patients received oral therapy, 38 received IV Regimens included ciprofloxacin and metronidazole Complete resolution of symptoms in both groups No patient had to be converted to IV from the oral group

Antibiotic Therapy – Is IV Therapy Needed? RCT 132 pts – 66 pts received PO antibiotics, 66 pts received IV antibiotics (co-amoxiclav) No statistical difference in treatment failure between the groups *Biondo et al 2013 Ann Surg Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis

The Debate – How Long Is Really Needed? Uncomplicated sigmoid diverticulitis (Hinchey 1) Used ertapenem 123 patients assigned to treatment arms After 4 days, treatment successful on clinical grounds in 98% After 7 days, treatment deemed successful in 98.2% of cases

The Controversy – Are Antibiotics Really Needed At All? All major guidelines recommend antibiotic treatment however......

Prospective, multicentre, randomised trial in Sweden and Iceland between 2003 and patients were enrolled 309 no antibiotics, 314 antibiotics 1 year follow-up No significant difference in complication rates, length of hospital stay or readmission rates *Chabok et al 2012 BJS Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis

Diverticular Abscess Radiologically guided percutaneous drainage is usually the most appropriate treatment for patients with a large diverticular abscess (ASCRS, level of evidence: III; Grade B recommendation) ~15% of patients with acute diverticulitis will develop a pericolonic or intramesenteric abscess Hospitalisation and IV antibiotics are indicated Abscesses <2 cm in diameter may resolve without further intervention (some say <4cm) Larger abscesses are candidates for percutaneous catheter drainage; the majority of patients can avoid an emergency operation by using this intervention

136 pts 19: localised free air, 45: abscess 4 cm/distant free air >2 cm, 6: distant free air + free fluid 38 patients (28%) percutaneous abscess drains 5 patients (3.7%) urgent surgery on admission 7 (5%) urgent surgery for failed non-operative management Overall success rate of non-operative management: 91% 25/27 (92.5%) patients with free air remote from the perforation site were successfully treated non-operatively *Dharmarajan et al 2011 DCR The Efficacy of Nonoperative Management of Acute Complicated Diverticulitis

To Scope or Not To Scope? After resolution of an initial episode of acute diverticulitis, the colon should be adequately evaluated to confirm the diagnosis (ASCRS level of evidence: 1C; grade of recommendation: strong) Investigation of the colonic lumen by endoscopic means or barium enema after the acute attack is mandatory (ACPGBI, Grade C)

Recent papers and meta-analysis question the need for colonoscopy; especially after uncomplicated diverticulitis Recent papers and meta-analysis question the need for colonoscopy; especially after uncomplicated diverticulitis To Scope or Not To Scope?

458 patients – 249 (54%) underwent colonosocpy within 1 year 458 patients – 249 (54%) underwent colonosocpy within 1 year 77 (31%) polyps, 19 (7.6%) advanced adenomas, 4 (1.6%) invasive malignancy = 23 (9.2%) had clinically significant neoplasia 77 (31%) polyps, 19 (7.6%) advanced adenomas, 4 (1.6%) invasive malignancy = 23 (9.2%) had clinically significant neoplasia Patients with complicated diverticulitis had higher incidence of adenoma (p=0.001) and invasive malignancy (p=0.007) than uncomplicated diverticulitis Patients with complicated diverticulitis had higher incidence of adenoma (p=0.001) and invasive malignancy (p=0.007) than uncomplicated diverticulitis Incidence of significant neoplasia in uncomplicated diverticulitis was similar to average risk patient Incidence of significant neoplasia in uncomplicated diverticulitis was similar to average risk patient

292 patients – 205 had colonic evaluation 292 patients – 205 had colonic evaluation 50 (24.4%) polyps; 20 (9.8%) hyperplastic polyps; 19 (9.3%) adenomas; 11 (5.4%) colonic neoplasia (10 advanced adenomas and 1 CRC); 1 pt had IBD 50 (24.4%) polyps; 20 (9.8%) hyperplastic polyps; 19 (9.3%) adenomas; 11 (5.4%) colonic neoplasia (10 advanced adenomas and 1 CRC); 1 pt had IBD The yield of advanced colonic neoplasia was equivalent to that detected in screening pts The yield of advanced colonic neoplasia was equivalent to that detected in screening pts

11 studies from 7 countries included Risk of malignancy pooled proportional risk 1.6% (CI %) (22/1970 pts) 1497 uncomplicated diverticulitis PPR 0.7% (CI %) 79 complicated diverticulitis PPR 10.8% (CI %) Risk of malignancy low in uncomplicated diverticulitis but significant risk in those with complicated diverticulitis

Surgical Intervention <10% of patients admitted with acute diverticulitis require surgical treatment during the same admission <10% of patients admitted with acute diverticulitis require surgical treatment during the same admission Indications include: Indications include: generalised peritonitis, uncontrolled sepsis, uncontained visceral perforation, the presence of a large, undrainable abscess and lack of improvement or deterioration within 3 days of medical management generalised peritonitis, uncontrolled sepsis, uncontained visceral perforation, the presence of a large, undrainable abscess and lack of improvement or deterioration within 3 days of medical management characteristic of Hinchey stage III or IV disease. characteristic of Hinchey stage III or IV disease.

Widely perceived as the ‘safe’ option Performed on patients with adverse features Co-morbidities Hinchey III & IV General surgeons ‘on call’ ~40% never closed Closure > 40% morbidity with permission; Jacobs D. N Engl J Med 2007;357: , Copyright© 2007 Massachusetts Medical Society, all rights preserved Aydin et al, Dis Colon Rectum, 2005 Hartmann’s Procedure

Experienced surgeon Stable patient, less contamination + defunctioning stoma + intra-operative bowel lavage with permission; Jacobs D. N Engl J Med 2007;357: , Copyright© 2007 Massachusetts Medical Society, all rights preserved Primary Resection and Anastomosis

62 pts (Hinchey III + IV) – 30 Hartmanns (HP), 32 Primary anastomosis + ileostomy (PA) Overall complication rates comparable (80% vs 84%) Similar morbidity and mortality rates Secondary endpoints significantly different: Stoma reversal rate 90% vs 57%, Grade IIIb-IV complications 0% vs 20%, operating time 73mins vs 183 mins, LOS 6 days vs 9 days and lower in hospital costs all favoured PA group

Hinchey III The Debate Continues.....

Am J Surg 1996, patients over 37 months ( ) Mean age 57 (30-67) Generalised peritonitis – 1 had free air on CXR (CT abdomen not readily available) Laparoscopy Purulent peritonitis (Hinchey 3) Lavage & drainage Outcome Mortality =0; Morbidity =2/8 Hospital stay = 10 days

Morbidity = 4% Mortality = 4% Hospital stay = 8 days (7 -19) 8% conversion 2% re-operation

DCR December 2014

The Final Issue Elective Resection Indicated or Not?

Elective Resection ASCRS Guidelines Recommend elective resection after one episode of complicated diverticulitis treated non-operatively

Elective Resection ASCRS Guidelines ‘The decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticultits should be indivualized. Grade of recommendation: Strong based on moderate-quality evidence, 1B’

Elective Resection ACPGBI Guidelines “Majority of evidence for elective resection is... of poor quality” “Decision on whether to resect should be made in conjunction with the radiologist, pathologist... and patient themselves”

When To Operate? 210 patients underwent laparoscopic resections for acute sigmoid diverticulitis Group 1 were operated on early (5-8 days after admission) Group 2 were operated on late (4-6 weeks or later) 10 conversions (9 in Group 1) 8 anastomotic leaks (all in Group 1) Concluded that delaying surgery significantly decreased post-operative morbidity

Many papers, both in support of elective resection... BJS, 2005 –   MEDLINE Literature review   After one episode, one-third recur   Of those, a further third have another episode

...and favouring more cautious elective resection BJS, Retrospective chart review of all (502) patients admitted with diverticulitis between 1997 – % will recur, 4.7% will have two or more episodes Recurrence usually occurred within 12 months of the initial presentation, a pattern more consistent with failure of the index episode to settle Subsequent elective surgery to prevent recurrence and the development of symptoms should be used judiciously

In summary, there are no guidelines that cover the treatment of every patient with diverticulitis – treatment must be tailored to the individual patient

Case Discussions

Case 2

Mildly thickened sigmoid in an area of diverticular disease with no evidence of perforation or obstruction

What now? Diverticulitis with pericolic free gas Small blebs free gas over liver

What next? Surgery Surgery Laparoscopy and Lavage ? Laparoscopy and Lavage ? Resection? Resection? Hartmanns? Hartmanns? Primary anastomosis? Primary anastomosis? Defunction? Defunction?

2 months post Hartmann

6 months post Hartmanns Endoscopic assessment of rectal stump and colon normal. Inflammatory markers normal Improvement of CT images, mildly dilated left ureter

Case 3

66yo female, crampy abdominal pain, loose stool, Flexi sig to distal desc colon normal

Surgery Mass palpable in LIF Mass palpable in LIF Midline laparotomy Midline laparotomy Multiple odematous loops sm. bowel adherent to sigmoid and dome of bladder Multiple odematous loops sm. bowel adherent to sigmoid and dome of bladder Sharp dissection of sm. bowel loops to identify abscess cavity at dome of bladder with sigmoid perforation which fed into it Sharp dissection of sm. bowel loops to identify abscess cavity at dome of bladder with sigmoid perforation which fed into it “raggedy” sm. bowel, 2 serosal tears, 1 enterotomy proximal jejeunum “raggedy” sm. bowel, 2 serosal tears, 1 enterotomy proximal jejeunum

Hartmanns procedure Hartmanns procedure Oversew serosal tears Oversew serosal tears Repair enterotomy Repair enterotomy Robinson drain x 2 to pelvis Robinson drain x 2 to pelvis High jejeunostomy High jejeunostomy

Prolonged hospital stay Prolonged hospital stay Hickmann line, TPN Hickmann line, TPN Restricted oral intake Restricted oral intake Cystogram Cystogram When to reverse jejeunostomy? When to reverse jejeunostomy?

Water soluble contrast exam

Started feed down distal limb of jejeunostomy Started feed down distal limb of jejeunostomy Continued TPN Continued TPN No abdominal pain, no rise in inflammatory markers No abdominal pain, no rise in inflammatory markers Effluent came out end colostomy Effluent came out end colostomy What now? What now?

Case 4