Advantages of Laparoscopy for Diverticulitis Steven D. Wexner, M.D., FACS, FRCS, FRCS (Ed) Cleveland Clinic Florida Chairman, Department of Colorectal Surgery Chief of Staff, Cleveland Clinic Florida Professor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic Foundation Clinical Professor of Surgery, University of South Florida College of Medicine

Cleveland Clinic Florida Weston

> Advantages –Operative time –Morbidity –Hospital Length of Stay > Special considerations –Presence of complications –Conversion –Advantages for elderly –Advantages for obese –Cost Advantages of Laparoscopy: Diverticulitis

Laparoscopy: Diverticulitis

Modified Hinchey* Grading System I.Pericolic abscess IIA.Distant abscess amenable to percutaneous drainage drainage IIB.Complex abscess associated with fistula III.Generalized purulent peritonitis IV.Fecal peritonitis *Adv Surg 1978

Author/yearnLap/Open Op time (min) Morbidity (%) Hospital stay (days) Kholer/ Lap Open 165* * 14.3 Dwivedi/ Lap Open 212* * 8.8 Senagore/ Lap Open * * 6.8 Lawrence/ Lap Open 170** 140 9* ** 9.0 *p<0.05**p<0.001 Case-Controlled Series Advantages of less morbidity and shorter hospitalization

Laparoscopy: Diverticulitis Retrospective/prospective results – Hospital Stay Laparoscopy: Diverticulitis Retrospective/prospective results – Hospital Stay Author/yearn Hospital stay (days) Eijsbouts/ Carbajo/ Stevenson/ Bokobza/98 (A) Bouillot/ Smadja/ Sirisier/ Vargas/ Berthou/ Trebuchet/ Bouilott/

Author/yrn Setting surgery Op time Morbidity (%) Hospital stay (days) Sher/97612 Hinchey I Hinchey IIa/b Kockerling/ Chronic Hinchey I/IV Schlachta/ OtherChronicAcute Bergamashi/004034Intracorporeal Lap. assisted 180* * ** 15** Eijsbouts/ Lap. Assisted Facilitated resec Pugliese/ Hinchey I Hinchey II Hinchey III < *p<0.001 **p<0.05 Laparoscopy: Diverticulitis Retrospective/Prospective Results - Morbidity The more complicated the diverticular disease, the tendency for higher morbidity and longer lengths of hospital stay

Author/yearnLSR/OSR Op time (min) Morbidity(%) Bruce/ LSROSR 397** ** Liberman/ LSROSR Kholer/ LSROSR 165* * Dwivedi/ LSROSR 212* 212* Senagore/ LSROSR * 12.6 Lawrence/ LSROSR 170** 170**1409*27 *p<0.05 **p<0.001 Laparoscopy: Diverticulitis - Comparative Studies

Laparoscopy: Diverticulitis > 1/95-1/98: 1118 patients > Laparoscopic colorectal surgery study group > 509 sigmoid colectomies > 304 diverticulitis > 249 (81.9%) –Peridiverticulitis –Recurrent inflammation –Stenosis > 26 Hinchey I > 9 Hinchey II > 2 Hinchey III Köckerling et al., Surg Endosc 1999

Laparoscopy: Diverticulitis StageConversion Mean operative time Morbidity (n (%))(min (range)) (%) Total22/304 (7.2)164 (65-410)17 Chronic12/249 (4.8)159 (65-395)14.8 Hinchey I-IV10/55 (18.2)182 (90-410)28.9 I8/26 (30.7)183 ( )33.3 II1/9 (11.1)198 (90-320)37.5 III/IV0/2 (0)110 ( )50 Köckerling et al., Surg Endosc 1999

Mean age, 59.5 years Mean age, 69.5 years Mean age, 67.9 years Mean age, 54.3 years Mean age, 65.9 years Mean age, 67.7 years #patients Sher et al, Surg Endosc Laparoscopy: Diverticulitis Comparative Study n = 18 Laparoscopy: Diverticulitis Comparative Study n = 18

Morbidity Hinchey IIA and IIB Overall Late experience experience * 13 * P<0.05 Morbidity (%) (%) Laparoscopy: Diverticulitis - Comparative Studies Sher et al, Surg Endosc. 1997

Open vs. Laparoscopy Hospital stay 7* 5 10 † 5 9* Days * p<0.05 † p<0.01 Laparoscopy Laparoscopy: Diverticulitis Sher et al, Surg Endosc. 1997

Results Demographics n1518 Mean age (yrs)69.7(51-91) 62.8(34.-86) Gender (M:F)10:58:10 Operative time (min) Hospitalization (days) Sher et al, Surg Endosc, 1997

Results Hinchey Classification Total (%)(%)(%) Hinchey I10 (66.6)6(33)16(48) Hinchey IIA3(20)7(38)10(30) Hinchey IIB2(13)5(27)7(21) Hinchey III000 Hinchey IV000 Sher et al, Surg Endosc, 1997

Results Morbidity (%)(%) Intraoperative02(11) colotomy01 enterotomy00 Postoperative 2(13.3)1(5.5) Leak (reoperation)11 Bleeding (converted)10 TOTAL2(13.3)3(16.6) TOTAL2(13.3)3(16.6) Sher et al, Surg Endosc, 1997

Results Conversion (13.3)* > 1 extensive adhesions (Hinchey IIB) > 1 bleeding (Hinchey I) (38.9)* > 6 intense inflammatory process (all Hinchey II) > 1 inadvertent enterotomy (Hinchey II) *p<0.04 Sher et al, Surg Endosc, 1997

Laparoscopy: Diverticulitis LaparoscopyLaparotomyp n1414ns Operative time ns (minutes) Blood loss171321<0.04 Postoperative stay6.39.2< (days) Day to P.O fluids2.96.1<0.001 Liberman, Surg Endosc 1996

Laparoscopy: Diverticulitis Retrospective review VariableLaparoscopicOpen n2517 Age (years)5248 Gender (m/f)13/1213/4 Weight (kg) Comorbidity (%)2840 Prior laparotomy (%)5629 Flexure mobilized (%)2424 Left colectomy13 Bruce et al., DCR 1996

Laparoscopy: Diverticulitis VariableLaparoscopicOpen Conversion (%)12--- Operative time (minutes)* Regular diet (days)* Hospital stay (days)* Cost ($)*10,2307,068 Post-discharge817 morbidity Bruce et al., DCR 1996 (* p<0.001)

Laparoscopy: Diverticular disease VariableLaparoscopicOpen Age (years)5952 Weight (pounds) ASA class Perforated75 Abscess1818 Operative time (minutes)* Blood loss (ml) Coogan et al, Surg Endosc 1997 (P<0.001)

Laparoscopy: Diverticular disease VariableLaparoscopicOpen Oral intake (days)* Hospital stay (days)** OR cost ($)15,2007,200 Hospital cost ($)1,7006,800 Total cost ($)17,00015,800 *p<0.0001**p<0.001 Coogan et al, Surg Endosc 1997

Laparoscopy: Diverticulitis VariableLaparoscopyLaparotomyp (n=40)(n=35) Age (mean years)6062ns Gender (m/f)26/1422/13 ns Weight (kg)75 (1.0) 76 (1.1)ns ASA Grade (I:II)22:18 23:12ns Symptoms duration 16 17ns (months) Previous admissions ns Bergamaschi and Arnaud, Surg Endosc 1998

Laparoscopy: Diverticulitis VariableLaparoscopyLaparotomyp (n=40)(n=35) Specimen length (cm) 11 18<0.01 Splenic flexure 29:11 17:18 ns mobilized (no:yes) Anastomosis (CS:CR) 1:3924:11<0.01 Inflammatory cells* 112=0.02 Radiographic leak 00ns * Proximal resection margin (CS- colosigmoid, CR- colorectal) Bergamaschi and Arnaud, Surg Endosc 1998

Laparoscopy: Diverticulitis VariableLaparoscopyLaparotomyp Radiographic leak00ns Follow-up (months)46 63 <0.01 Recurrent ns diverticulitis (%) Bergamaschi and Arnaud, Surg Endosc 1998

Open vs. Laparoscopy Author/yearnLap/OpenOp time (min) Morbidity (%) Hospital stay (days) Bruce/ Lap Open 397** Liberman/9614 Lap Open ** 9.2 Coogan/ Lap Open Kholer/ Lap Open 165* * 14.3 Dwivedi/ Lap Open 212* * 8.8 Senagore/ Lap Open * * 6.8 Lawrence/ Lap Open 170** 140 9* ** 9.0 *p<0.05**p<0.001

Laparoscopy: Diverticulitis Obesity BMI No. of patients Age (yr: mean-range) Gender (M:F) Normal weight Group I (37-78) 16:13 Overweight Group (31-83) 14:13 Obese Group (33-86) 14:13 Tuech et al. Surg Endosc 2001

Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) ASA I ASA II ASA III 123 ASA IV 000 Tuech et al. Surg Endosc 2001 Laparoscopy: Diverticulitis Obesity

Reasons for conversion to laparotomy Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Severe adhesions 221 Unclear anatomy 021 Failure to liberate the splenic flexure 100 Obesity Hemorrhage 100 Total n (%)4 (13.8)4 (14.8)3 (14.3) Tuech et al. Surg Endosc 2001

Laparoscopy: Diverticulitis Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Anastomotic leak (a) 101 Wound infection 223 Pulmonary infection 010 Postoperative ileus 100 Urinary infection 110 TOTAL (%) 5 (17.2) 4 (14.8) (b) 4 (19) (c) Tuech et al. Surg Endosc 2001 a. a.Anastomotic leak resolved with conservative drainage b. b.Group 1 vs. Group 2 – p=0.54 c. c.Group 1 vs. Group 3 – p=0.57

Laparoscopy: Diverticulitis Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Mean hospital stay (d) (a) 9.8 (b) Inpatient rehabilitation 4/29 3/27 (c) 3/21 Tuech et al. Surg Endosc 2001 a. a.Hospital stay Group 1 vs. Group 2: p=0.31 b. b.Hospital stay Group 1 vs. Group 3: p=0.14 c. c.Inpatient rehabilitation Group 1 vs Group 2: p=0.54 d. d.Inpatient rehabilitation Group 1 vs Group 3: p=0.63

Laparoscopy: Diverticulitis > 54 patients- elective after > 2.2 (1-4) attacks > 5 (9.2%) converted > 3/5 (60%) for obesity > Surgery: 298 ( ) minutes > 348 minutes in obese group versus 236 minutes in non-obese group (p 348 minutes in obese group versus 236 minutes in non-obese group (p<0.001) Smadja et al., Surg Endosc 1999

Laparoscopy: Diverticulitis > Ileus: 2.3 (1-6) days > Hospitalization: 6.4 (4-15) days –2 (4.1%) early abdominal complications –4 (8.2%) abdominal wall complications –1 (2%) anastomotic stricture –1.8 (1-3) days use of Morphine Smadja et al., Surg Endosc 1999

> 75 yrs < 75 yrs n= 22n = 63 Mean age (yrs)77.2 (75-82) 53.7 (38-74) Gender (M:F)10:1228:35 Operative time (min) IV analgesia(days) Morbidity (%)1814 Mortality 00 Conversion (%)96 Hospitalization (days)* Teuch et al. Hepatogast 2001 * p=0.003 Laparoscopy: Elderly

Laparoscopic Open p value n= 22 n = 24 Mean age (yrs)77.2 (75-82) 78 (76-84) NS Gender (M:F)10:12 10:14 NS Operative time (min) NS IV analgesia(days) Morbidity (%) Mortality 0 0 NS Inpatient rehabilitation Hospitalization (days) Teuch et al. Surg Endosc 2000 Laparoscopy: Elderly

Laparoscopy: Diverticulitis > 65 patients - single surgeon > 60.1 (28-80) years old > 72.1 (53-97) kg weight > 2.4 (0-15) prior acute attacks > > 2 attacks in 41 (63.1%) patients > 1 attack in 20 patients > 3 patients - chronic disabling pain > 1 colovesicle fistula Siriser F, Surg Endosc 1999

Laparoscopy: Diverticulitis > 179 (95-285) minutes surgery > 26 (40%) pericolic abscesses > 3 (4.6%) conversion - dense inflammatory adhesions in obesity > 9 (17.7%) morbidity - 2 (3.2%) reoperation > No deaths, No leaks > 7.6 (5-19) days in hospital > 11.8 days (+) complications vs. 6.7 days (-) > 2 reoperations for anastomotic stricture at 4 months > (+) 1 asymptomatic (endoscopic) stenosis Siriser F, Surg Endosc 1999

Laparoscopy: Diverticulitis 136 patients - 5 centers - 5 years > 71 females + 65 males > (32-83) years old > 95% had acute infectious diverticulitis > 1 colovesical fistula > 18 (13%) conversions > 12 (67%) 2 o inflammatory adhesions > 173 (80-360) minutes Bokobza et al., Surg Endosc 1998

Laparoscopy: Diverticulitis > 2 (1.5%) postoperative adhesions > 27 (20%) complications > 1 (0.7%) anastomotic fistula > 13 (9.5%) abdominal wall hematoma or abscess > Successful – minutes –17% morbidity –0.58% mortality > Conversion – minutes –37% morbidity –5.6% mortality Bokobza et al., Surg Endosc 1998

Laparoscopy: Diverticulitis Factors predictive of conversion > Tumoral aspect 66% versus 41% > Tumoral aspect and chronic pain 44% versus 18% Conclusion: Need to preselect good candidates and convert early Bokobza et al., Surg Endosc 1998

Laparoscopy: Diverticulitis > 178 sigmoid colectomies > 70 chronic diverticulitis > 22 acute diverticulitis > 86 nondiverticular disease –77 neoplasia –5 rectal prolapse –4 other Schlacta et al., Surg Endosc 1999

Laparoscopy: Diverticulitis VariableAcuteChronicOther n Conversions n (%)3(14)3 (4)17 (20) Median operative time (min) Morbidity n (%)1 (5)6 (9) 1 (1.5) Median full diet (days)334 Median discharge (days)655 Median normal activity (days) (* p<0.05 other vs. chronic) Schlacta et al., Surg Endosc 1999

Laparoscopy: Complications > Prolonged operative time –150 to 255 minutes (p = 0.013) > Increased time to full diet –3.0 to 4.0 days (p < 0.001) > Delayed time to discharge –5.0 days to 9.0 days (p < 0.001) > But not time to normal activity –15 to 16 days Schlacta et al., Surg Endosc 1999

Laparoscopy: Diverticulitis > 110 patients - elective > 63 (36-83) years old > 9 (8.2%) conversion –adhesions, inflammation, obesity > 167 minutes mean operative time Berthou and Charboneau, Surg Endosc 1999

Laparoscopy: Diverticulitis > 2.3 days ileus > 8.2 days hospitalization > No deaths > 7.3% morbidity including trocar site bowel incarceration and small bowel fistula Berthou and Charboneau, Surg Endosc 1999

Laparoscopy: Diverticulitis > Laparoscopic – facilitated feasible for “all forms” of “complicated” diverticular disease > Yields “marked” reductions in: –Operating time –Conversion rate –Operative and general costs Eijsbouts, et al. Surg Endosc 2000

Laparoscopy: Diverticulitis > Facilitated –Mobilization of sigmoid laparoscopically but “practically” no dissection of the “difficult” inflammatory process > Then through a Pfannenstiel incision: –Dissection of inflammatory process –Takedown fistula –Resection –Manual anastomosis Eijsbouts, et al. Surg Endosc 2000

Laparoscopy: Diverticulitis Costs Author/yearnSetting OR ($) Hospital ($) Hospital ($) Eijsbouts/00 Eijsbouts/ Lap assist Facilitated resection 1,6251,2508,1456,095 Bergamashi/ Intracoroporeal procedure (total) Lap assisted 3,0402,8209,25010,050

Laparoscopy: Diverticulitis LaparoscopyLaparotomyp O.R charges ($) 10,5898, Hospital cost ($) 11,50013, Hospital charges ($) 29,98136, Morbidity (%) Mortality 00 Liberman, Surg Endosc 1996

Costs: o pen vs. Laparoscopy Costs: o pen vs. Laparoscopy Author/yearnLap/OpenOR ($)Hospital ($) Bruce/ Lap Open ---10,230* 7,068 Liberman/9714 Lap Open 10,589* 8,207 11,528 13,426 Coogan/ Lap Open 15,200 7,200 17,000 15,800 Dwivedi/ Lap Open 9,566* 7,306 13,953 14,863 Senagore/ Lap Open 1,694* 1,426 3,458* a 4,321* Lawrence/ Lap Open ---17,414 25,700 *p<0.05 a = Total direct cost/case

Laparoscopy: Diverticulitis 18 patients- acute perforation Laparoscopic lavage and suction > + Omental patch closure > 7.5 days in hospital > 4-34 month follow-up > Subsequent elective resection with primary anastomosis possible Franklin et al., Surg Endosc 1997

Laparoscopy: Diverticulitis > 90% Success > Elective resection- 4-5 days in hospital > 5% Morbidity > Better than Laparotomy > Applicable in complex cases as well (Fistula, Abscess, Perforation) Franklin et al., Surg Endosc 1997

Laparoscopy: Diverticulitis > 8 patients - Generalized peritonitis > Laparoscopy + Lavage + Antibiotics > 5-8 days in hospital > month follow-up > No recurrences > No resections O’Sullivan et al, Am J Surg 1996

Laparoscopy: Diverticulitis > 15 patients- Emergency > Generalized peritonitis > 2 o Perforated diverticulitis > Exploration + 10 litre lavage + “biological glue” + drainage > No stoma > 10 days antibiotics Montorsi et al, Surg Endosc 1998A

Laparoscopy: Diverticulitis > Zero mortality > 2 morbidity (lymphangitis, pulmonary) > 8 days hospitalization > 11 elective sigmoid colectomy at 3.5 months (10 successful laparoscopically) Montorsi et al, Surg Endosc 1998A

Laparoscopy: Diverticulitis > There is good evidence (Level 2) that laparoscopy for diverticulitis results in earlier discharge

Laparoscopy: Diverticulitis > Despite longer operative time, the morbidity rate for the laparoscopic approach to diverticulitis in the most recent studies is equivalent or better than the open approach (Level 2 evidence)

Laparoscopy: Diverticulitis Conclusion > Elective laparoscopy for diverticular disease confers many advantages over the traditional approach > Based upon these data, laparoscopy is our preferred approach to the treatment of sigmoid diverticulitis

Rafferty et al, DCR 2006 Practice Parameters for Sigmoid Diverticulitis The Standards Committee of The American Society of Colon and Rectal Surgeons The laparoscopic approach is appropriate in selected patients. Level of Evidence III, Grade of Recommendation A Laparoscopic colectomy may have advantages over open laparotomy, including less pain, smaller scar, and shorter recovery. There is no increase in early or late complications. Cost and outcome are comparable to open resection. Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with complicated disease