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

2. Perforation Abscess Purulent peritonitis Faecal peritonitis Incidence
Hart Cambridge UK /100000/year
Mäkelä Oulu, Finland ,8/100000/year

3. Abscess Diverticulitis abscesses are rare.
Individual experience not enough.
Incidence
Ambrosetti Geneva /100000/year

4. 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

5. 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

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

7. Abscess

8. Abscess

9. Abscess

10. 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)

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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).

18. 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

19. 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

20. 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

21. 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

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

23. 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

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

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

26. 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

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