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

2. Perforation Abscess Abscess Purulent peritonitis Purulent peritonitis Faecal peritonitis Faecal peritonitisIncidence HartCambridge UK1995-19974/100000/year MäkeläOulu, Finland1986-2000 3,8/100000/year

3. Abscess Diverticulitis abscesses are rare. Individual experience not enough. Incidence AmbrosettiGeneva 1986-19971/100000/year

4. Risk factors for perforated diverticulitis Industrialized countries with high prevalence of diverticulosis Industrialized countries with high prevalence of diverticulosis Increases with advanced age Increases with advanced age Men > Women Men > Women Immune suppression Immune suppression Corticosteroids Corticosteroids NSAID NSAID Opioids, smoking, alcoholism, red meat, fiber deficiency (??) Opioids, smoking, alcoholism, red meat, fiber deficiency (??) Morris, Postgrad Med J, 2002 obesity obesity Dobbins, Colorectal dis, 2005 Renal failure Renal failure

5. Location Paracolic or Pelvic Paracolic or Pelvic Retroperitoneal, Retrorectal, Psoas muscle, Hip, Buttock, Flank, Leg, Inguinal region, Scrotum 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: 19 patients: Polymicrobial (E-coli, Bacteroides, Enterococcus, Klebsiella) in 17 Polymicrobial (E-coli, Bacteroides, Enterococcus, Klebsiella) in 17 E-coli in 1 E-coli in 1 B Fragilis in 1 B Fragilis in 1 Stabile Am J Surg 1990

7. Abscess

8. Abscess

9. Abscess

10. Treatment Options Bowel Rest Bowel Rest Antibiotics Antibiotics PAD (Percutaneous Abscess Drainage) PAD (Percutaneous Abscess Drainage) SD (Surgical Drainage) SD (Surgical Drainage) One Stage (Res+ ana +/- ostomy) One Stage (Res+ ana +/- ostomy) Two Stages (Hartmanns procedure) Two Stages (Hartmanns procedure) Three Stages (Drainage+ostomy) Three Stages (Drainage+ostomy)

11. Results of operations Lahey clinic 1967-1982 Mortality Res and ana1% Res and ana1% Res, ana with stoma0% Res, ana with stoma0% Hartmann16% Hartmann16% Three Stages14% Three Stages14% Hackford AW, Dis Colon Rectum, 1985

12. Results of operations Of 37 patients operated with a 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 Downstage-Single stage Patient can recover, Bowel Prep, Clean op field Bacteria culture. Bacteria culture. Only treatment. Only treatment.

14. How to drain CT guided Transabdominal, trans sacral (PAD) CT guided Transabdominal, trans sacral (PAD) US guided transabdominal (PAD), transvaginal, transrectal US guided transabdominal (PAD), transvaginal, transrectal EUS guided through the sigmoid wall EUS guided through the sigmoid wall Surgical drainage Surgical drainage Blind transrectal or transvaginal Blind transrectal or transvaginal

15. Contraindications to PAD Abscess not localized Abscess not localized Access not safe Access not safe Generalized peritonitis Generalized peritonitis Pneumoperitoneum Pneumoperitoneum Obstruction Obstruction Blood dyscrasias/Bleeding diathesis Blood dyscrasias/Bleeding diathesis Persistent symptoms after drainage Persistent symptoms after drainage Faeculent Drainage Faeculent Drainage (Immunocompromized and high mortality score) (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 Neff CC Radiology 1987 16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm 16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm 11 single stage op in 10d-6w 11 single stage op in 10d-6w 3 inop, drainage only. 3 inop, drainage only. 1 sigm fistula 3 stage 1 sigm fistula 3 stage 1 resp insuff-died 1 resp insuff-died

17. Published Results of PAD Mueller PR, Radiology 1987: 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: 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 Drainage 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 Hartmann op The patient is drained and deviated

19. Choice of Treatment 1The Abscess * Size **Location ***Bacterias 2The Patient *Morbidity, mortality scoring systems. ** Anastomose healing 3The 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 TienamMeronemTacozin

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

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

26. Abscess treatment Normal healing of anastomosis and a favorable mortality score Normal healing of anastomosis and a favorable mortality score <5 cm: Bowel rest and Broadspectrum antibiotics <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 in pelvis: Drainage with a later res and ana >5cm above the pelvis:Drainage >5cm above the pelvis:Drainage Persist after drainage:Res and Ana Impaired healing of anastomosis 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 Impaired healing of anastomosis and unfavorable mortality score Hartmann operation directly

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