John Marks MD Chief: Section of Colorectal Surgery Main Line Health System Professor: Lankenau Institute of Medical Research Director: Fellowship in Minimally Invasive Colorectal Surgery and Rectal Cancer Management When to operate for diverticulitis: Acute vs Chronic

50% > 60 years 80% > 80 years 10% of those with diverticulosis may go on to develop diverticulitis – 75% of cases are simple – Very small subset require surgery Incidence of Diverticulosis

Simple Complicated – Abscess – Fistula – Stenosis Perforation Diverticulitis: A Spectrum

Study selection bias Few prospective randomized trials – Patrick Ambrosetti MD Overall Studies are of poor quality overall Studying Diverticulitis

Acute – Free perforation – Peritonitis – Acute abdomen When to Operate

Chronic – Complicated diverticulitis Abscess Fistula Stenosis – Medically refractory – 2 or more hospitalizations – 1 hospitalization < 50 yrs – Immunocompromised When to Operate: Standard Teaching

Hinchey Classification Stage I: Pericolic abscess or phlegmon Stage II: Pelvic, intra-abdominal or retroperitoneal abscess Stage III: Generalized purulent peritonitis Stage IV: Generalized fecal peritonitis

Classic indications called into question Minority of patients develop subsequent attacks Are we justified in telling people that they will avoid life threatening situations with elective resection? What is the effect on QOL? Simple Diverticulitis

Percutaneous drainage of abscess Hartmann’s – Laparoscopic vs. Open Resection with primary anastomosis – proximal diverting stoma – on table lavage Laparoscopic lavage Complicated Diverticulitis Options

Overall Diverticulitis Recurrences N = 502 Timing of first recurrent attack of acute diverticulitis for all patients. Eglinton et al. Br J Surg 2010

Simple Diverticulitis N = 320/502 Timing of first recurrent attack of acute diverticulitis for patients with an uncomplicated first attack. Eglinton et al. Br J Surg 2010

Complicated Diverticulitis N = 165 Timing of first recurrent attack of acute diverticulitis for patients with a complicated first attack. Eglinton et al. Br J Surg 2010

“The timing of elective colectomy in diverticulitis: A decision analysis.” Salem et al. J Amer Coll Surg 2004 – Markov model of clinical pathways – Simulation based on statewide hospital discharge database – Colectomy after 4 th episode lower mortality Fewer colostomy Decreased cost Timing of Elective Colectomy in Diverticulitis

Management Strategies Salem et al. J Amer Coll Surg 2004

“Timing of prophylactic surgery in prevention of diverticulitis recurrence: A cost-effectiveness analysis.” Richards et al. Dig Dis Sci – Markov model as well – Probabilities based on published data – Compared surgery after 1, 2 and 3 episodes – Surgery after 3 rd attack = decreased cost Timing of Elective Colectomy in Diverticulitis

Richards et al. Dig Dis Sci 2002.

Urgent admissions: big increase Urgent surgery: very small increase – Improvement in antibiotics – Interventional procedures Elective surgery: increasing – Laparoscopy Trends in Management 2002 – 2007

Masoomi et al. Arch Surg 2010 Diverticulitis Admissions (2002) 179k210k (2007) Nationwide Inpatient Sample (NIS) database

Masoomi et al. Arch Surg 2010 Elective & Urgent Surgeries

Masoomi et al. Arch Surg 2010 Role of Laparoscopic Resection

Percutaneous drainage of abscess Hartmann’s – Laparoscopic vs. Open Resection with primary anastomosis – proximal diverting ileostomy – on table lavage Laparoscopic lavage Complicated Diverticulitis Options

Gold standard for Hinchey III & IV Significant complications – Wound infection 30% – Stoma complications 10% – Leak rate 30% with reversal – Overall mortality 15-30% Primary resection & anastomosis for Hinchey I & II Resection & anastomosis w/ protective stoma for Hinchey III Hartmann’s Procedure

Alternative for Hinchey I and II – Diverting proximal stoma for Hinchey III Reduced post-operative mortality Avoidance of stoma Lower SSI Studies flawed with selection bias No large randomized trials Hartmann’s vs. Primary Anastomosis

Bauer VP, Clinics in Colorectal Surgery 2009 Hartmann’s vs. Primary Anastomosis N = no. of patients Mortality Stoma Complication Abdominal Abscess Anastomotic Leak Wound Infection Abbas et al, studies HP52619%7-12%8%22.6% HP reversal 8% PRA3589%4%5.5%14% Salem et al, studies HP105118%10.3%24.2% HP reversal %4.3%4.9% PRA5699.9%9.6% Constantinides et al, studies HP %8.7%22.3% HP reversal 3.9% PRA5474.9%3.9%9.6% PRA & stoma 8.3%

Franklin et al. World J Surg, 2008 N = 40 All pts with peritonitis 33% with free air on CXR Hinchey 2b, 3 and 4 (intraop finding) No readmissions for complicated disease – Average f/u 96 months (range 1 – 120 months) 24 patients underwent subsequent elective surgery Laparoscopic Lavage Methods

Described for Hinchey class II, III, & IV Culture of purulent material 4 – 12 L of warm saline reported Drain placement near colonic lesion Adhesions to the colon left untouched Visible perforations closed w/ suture, omental patch, fibrin glue IV antibiotics x 7 days minimum Laparoscopic Lavage Methods

Karoui et al. Dis Colon & Rectum 2009 N = 59 – 35 lavage – 24 resection with anastomosis and diverting ostomy Case matched study Hinchey 3 Laparoscopic Lavage Methods

Laparoscopic Lavage Karoui et al. Dis Colon & Rectum 2009 N = 59

Lavage vs. Resection w/ Ileostomy Laparoscopic GroupOpen GroupP Stage IN = 35N = 24 Mortality00 Morbidity10 (28%)10 (42%)NS Abdominal4 (11%)7 (29%)NS Extra-abdominal6 (17%)3 (12.5%)NS LOS (days, median, ranges)8 (5-18)17 (11-52)< Stage 2N = 25N = 24 Mortality00NS Morbditiy3 (12%)3 (12.5%)NS Abdominal2 (8%) NS Extra-abdominal1 (4%) NS LOS (days, median, ranges)7 (5-11)6 (4-10)NS Stage 1 + Stage 2N = 25N = 24 Mortality00 Morbidity6 (24%)12 (50%)NS Abdominal4 (16%)9 (37.5%) Extra-abdominal3 (12%)4 (17%)NS LOS (days, median, ranges)14 (11-24)23.5 (16-52)< Karoui et al. Dis Colon & Rectum 2009 N = 59

Accuracy of CT Hinchey Class

Alamili et al. Dis Colon & Rectum 2009 Laparoscopic Lavage

Diverticulitis vs IBS Evidence of diverticula only on CT No fever or leukocytosis 88% pain-free at 12 months Histologic evidence of inflammation in 76% Smoldering Diverticulitis N = 47 Horgan et al. Dis Colon & Rectum 2001

N = 46 Patients evaluated had CT documented attack of diverticulitis Multiple validated questionnaires used preop, 3, 6 and 12 months post-op Evaluation of GI, urologic and sexual function – GIQLI – IPSS (international prostate symptom score) - men – EIIF-5 (international index of erectile function) – UDI (urinary distress inventory) - women Quality of Life after Lap Colectomy Forgione et al. Annals of Surgery, 2009

Quality of Life N = 46 *denotes significant difference (P < 0.05). Forgione et al. Annals of Surgery, 2009

Functional results following elective laparoscopic sigmoidectomy after CT-proven diverticulitis. – Ambrosetti et al, J Gastrointest Surg 2007 N = 43 Mean follow up 40 months (3-76) Post operative questionnaire – Recurrent disease – Bowel function – New abdominal pain – Overall satisfaction Overall satisfaction rate 95% Functional Results

Postoperative Results Results Number of Patients (N) Percentage (%) Bowel function Better2456 Unchanged1637 Worse37 New abdominal pain49.3 Degree of satisfaction Excellent2047 Good1740 Mediocre613 Would you go back to surgery 4195 Recurrence0 N = 43 Ambrosetti et al, J Gastrointest Surg 2007

Why the CT appreciation of severity? A. To guide the therapeutic strategies: 1.Mild diverticulitis: conservative ambulatory care (antibiotics?) 2.Stage Ia: conservative care with oral antibiotics 3.Stage Ib and II: hospitalization, iv antibiotics, eventual CT drainage, possible surgery 4.Stage III and IV: surgery B. To evaluate the chances of secondary bad outcome after a first episode of acute diverticulitis susccessfully treated conservatively

So, where is the challenge ? The existence of an associated abscess

Why ? 1. Frequent (between 15 to 20%) rao et al. am j radiol 1998 ambrosetti et al. eur radiol 2002 werner et al. eur radiol Difficult to diagnose bioclinically 3. Therapeutically challenging

Types of acute treatment Should we drain ? « …small pericolic abscess may resolve with antibiotic therapy and bowel rest… » « …today the decision to drain remains to be individualized 1 » 1. The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43:

Secondary treatment 1. « Recently, some surgeons have suggested that surgical resection may not be mandatory in every case after successful percutaneous drainage: however, at present there are insufficient data to support universal endorsement of this concept » The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: « …do a percutaneous drainage where possible, followed later by sigmoid resection in most cases… » European Association of Endoscopic Surgery, Surg Endosc 1999; 13: 430-6

Abscess associated to diverticulitis Between october 1986 to october 1997: – 465 patients had a CT evaluation – 76 (16.3%) had an associated mesocolic or pelvic abscess – 73 patients could be followed-up – Median follow-up: 43 months (2 – 180) – 26 women and 47 men with a mean age of 68 (30 – 94) Ambrosetti et al. Dis colon rectum, march 2005

Abscess associated to diverticulitis Therapeutic principles: – Percutaneous CT drainage of abscess were done only if no bioclinical improvement were noted after 48 hours of parenteral antibiotics – Elective colectomy after successful conservative management of the abscess was not an absolute indication and was adapted for each patient

Associated abscess Location and CT percutaneous drainage n drained not drained (%) (%) Mesocolic (24) 34 (76) Pelvic 28 8 (29) 20 (71)

Surgical vs conservative treatment: no op.: conservative treatment op. 1: surgery during 1st hospitalisation op. 2: surgery later on N No op. (%) Op. 1 (%) Op. 2 (%) mesocolic (49) 7 (15) 16 (36) Pelvic 28 8 (29) 11 (39) 9 (32)

Long-term evolution 1. No patient needed an emergency surgical treatment patients (21%) died during the course of the follow-up. No one died from complications related to the diverticular disease

Essential findings 1. Initial CT is indispensable to confirm the diagnosis and precise the severity of the diverticulitis 2. Patients with a pelvic abscess should be immediately drained 3. Mesocolic abscess ≥ 5 cm should probably be drained immediately 4. Secondary colectomy after pelvic abscess seems highly reasonnable 5. Secondary colectomy after successful conservative treatment of mesocolic abscess is probably not mandatory for all patients

Acute left colonic diverticulitis Prospective study October 1986 – October 1997 University Hospital Geneva

Acute diverticulitis: prospective study 542 patients 290 women and 252 men Mean age: 64 (23-97)

Acute diverticulitis: profile of the study Patients included: 1. Clinical and history compatibility 2. Radiological confirmation (CT and water- soluble contrast enema=GE) 3. Histological diagnosis 4. 1st hospital admission Patients excluded: No radiological or histological confirmation

Acute diverticulitis: radiological criteria (CT and GE) Moderate diverticulitis Severe diverticulitis CT: localized wall thickening (>=5mm) Inflammation of pericolic fat The same + at least one of the following: Abscess Extraluminal air/ contrast GE: segmental lumen narrowing Tethered mucosa +/- mass effect The same + at least one of the following: Extraluminal air/ contrast

Acute diverticulitis Long-term follow-up after a 1st acute episode of left colonic diverticulitis: is surgery mandatory ? R. Chautems, P. Ambrosetti, C. Soravia American Society of Colorectal Surgeons San Diego, June 2001 Dis Colon Rectum 2002; 45:

Acute diverticulitis: aims of the study To evaluate on a long term (9.5 years) the outcome of 118 patients treated medically with success for a 1st episode of diverticulitis To determine risk factors of poor evolution To assess the place of surgery To propose a timing for surgery

Acute diverticulitis: Post hospitalisation evolution No complications: 80 patients (68%) Evolutive complications: 38 patients (32%) 24 deaths (20%) 21 not related to diverticular disease No emergency operation

Identification of initial parameters predictive of evolutive complications Age Severity of the inflammation on CT

Diverticulitis is common Most patients w/ initial episodes of disease will not recur Most patients who undergo surgery in elective circumstances are very satisfied w/ their outcomes Laparoscopic resection for diverticulitis is safe and effective Conclusion

284 patients with diverticulitis treated laparoscopically 143 had previous abdominal surgery Procedures – 256 L colectomy – 1 AR Rectopexy – 3 Hartmann’s Procedures – 12 Hartmann’s Reversal – 12 Other Our Laparoscopic Experience

ASA Class – 11 patients ASA Class I – 143 patients ASA Class II – 121 patients ASA Class III – 4 patients ASA Class IV – 5 patients ASA Class N/A Average OR Time 271 minutes (112 – 894 minutes) Avg EBL 189 cc (10 – 1200cc) Avg largest incision 5.3 cm (1.5 – 15.0 cm) Avg Discharge POD 5.2 days (2 – 43 days) Our Laparoscopic Experience

Morbidity 10.6% – 2 atrial fibrillation – 2 anastomotic leak – 1 anastomotic stenosis – 5 arrhythmia – 2 bowel perforation – 1 DVT – 3 GI bleed – 1 internal hernia – 3 intraabdominal abscess – 2 UTI – 4 wound infection – 2 prolonged ileus – 1 aspiration pneumonia – 1 anemia – 1 sepsis – 1 drug rash – 1 intraabdominal hematoma 1 Mortality 0.3% Our Laparoscopic Experience

Conversion Rate 1.4% – All converted to laparoscopic assisted lower midline incision – Dense adhesive disease Our Laparoscopic Experience