1. Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND ROUND

2. Diverticulosis  False diverticulum  Herniation of mucosa and submucosa via weak point of muscular wall where vasa recta penetrate Colonic wall weakening Intraluminal pressure Age related changes Segmentation Dietary fibre deficiency

3. Diverticulosis  Prevalence  30% by age 60  60% by age 80  Presentation  Asymptomatic: 70%  Diverticulitis: 10-25%  Bleeding: 5-10%

4. Modified Hinchey Classification StageDescription 0Mild clinical inflammation 1aConfined pericolic inflammation 1bConfined pericolic abscess 2Pelvic, distant intraabdominal or retroperitoneal abscess 3Generalised purulent peritonitis (no open communication with bowel lumen) 4Faecal peritonitis (free open perforation) Fistula Obstruction

5. Uncomplicated diverticulitis  70-80% of all diverticulitis  Absence of  Abscess  Perforation  Fistula  Stricture / obstruction  Management  Bowel rest  Antibiotics  Colonoscopy 6-8 weeks after acute episode to exclude underlying malignancy [1] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294

6. Uncomplicated diverticulitis  Elective colectomy in an individualized basis [1]  Low risk of recurrence [1,2]  13-23% risks of subsequent uncomplicated attacks  6% risks of subsequent complicated attacks  Mortality and morbidity not increased after >2 uncomplicated attacks [1,3]  Routine elective surgery for <50years not recommended [1] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294 2.Salem et al. Dis Colon Rectum 2007;50:1-5 3.Wieghard et al. Ann Gastroenterol 2015;28:25-30

7. Complicated diverticulitis  Percutaneous drainage?  Surgery  Peritoneal lavage?  Stoma vs primary anastomosis?  Laparoscopic?

8. Percutaneous drainage  For Hinchey II disease [1]  Size of abscess >5cm: likely not successful with antibiotics alone [2,3]  Feasibility of drainage  Availability of expertise  Successful rate ~70-80% [1] 1.Soumian et al. World J Gastroenterol 2008;14:7163-7169 2.Siewart et al. Am J Roentgenol 2006;186:680-686 3.Ambrosetti et al. Dis Colon Rectum 2005;48:787-791

9. Surgery  Indication  Unstable haemodynamics  Hinchey III / IV on CT scan  Failure to respond conservative therapy  Complications

10. Factors for consideration Patient factors Surgeon factors Intraoperativ e conditions

11. Hartmann’s operation  Gold standard since 1980’s  For quick and efficient sepsis control  High mortality ~20%  Significant morbidities  > 1/3 of patient never have stoma reversed  Reversal of stoma also has significant morbidities

12. Peritoneal lavage  Possible alternative for selective group of patient [1]  Expected benefit [2]  Avoid urgent laparotomy and colostomy  Reduced morbidity and mortality  Significantly reduced inflammatory environment  minimize complications from subsequent colonic resection 1.Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 2.Corocci et al. Medicine (Baltimore) 2015;94:e334

13. Peritoneal lavage  Systematic review  19 papers from 1996 to 2013  Total 871 patients Cirocchi et al. Medicine (Baltimore) 2015;94:e334

14. Peritoneal lavage  Overall success rate: 24.3% (212/871)  Alive without surgical treatment for recurrent diverticulitis or complication  Overall conversion rate to open: 3.8% (17/444) (for Hinchey I-IV) [45% for Hinchey IV]  30-day mortality rate: 4.8% Cirocchi et al. Medicine (Baltimore) 2015;94:e334

15. Peritoneal lavage  Hospital readmission rate: 6.9% (29/419)  Recurrent diverticulitis (16/29)  Peritonitis (6/29)  Fistula (3/29)  Undetected Ca colon (2/29)  Abscess (1/29)  Intestinal obstruction (1/29)  69% of readmitted patients required surgical treatment Cirocchi et al. Medicine (Baltimore) 2015;94:e334

16. StudyNo. Desi gn Hinchey Conve rsion (%) Hospi tal stay (Day) Amou nt of lavage (L) Complic ation (%) Readm ission Death (%) Electi ve colect omy IIIIII IVIV Swank 2013 38 Retr o 053 0310432350 Edeiken 2013 10Pros0181204NR40402 Rogers 2012 42 7 Retr o 00427NR10NR14NR4 Liang 2012 47 Retr o 004726NR40021 White 2010 35 Retr o 201 2014154808 Lam 20099 Retr o 015333N/ANRN/A303 Karoui 2009 35Pros00 3535 00815281025 Favuzza 2009 7 Retr o 016007NR 104 Mazza 2009 25Pros2896014NR12NR016 Lippi 200913Pros05710N/ANRN/A320 Myers 2008 10 0 Pros0 2525 6767 88844330 Bretagnol 2008 24Pros05 1818 10121080024 Franklin 2008 40 Retr o 05 3232 30815200024 Galleano 2007 4Pros0220010 0004 Mutter 2006 10 Retr o 00 1010 008NR0106 Taylor 2006 14 Retr o 02 1010 206321008 Da Rold 2004 7 Retr o 115014N/ANR0000 Faranda 2000 18Pros00 1616 20815170015 O’Sullivan 1996 8Pros0080010NR25200

17. Peritoneal lavage  No histological diagnosis - ?underlying Ca colon  Leaving septic foci with persistent / recurrent infection / inflammation [1]  Recurrence  Not an appropriate alternative to colectomy [1] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294

18. Peritoneal lavage  Mainly for Hinchey III  Absolutely contraindicated for Hinchey IV (high risk of treatment failure) [1-3]  Experienced laparoscopic surgeon 1.Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 2.White et al. Dis Colon Rectum 2010;53:1537-1547 3.Rogers et al. Dis Colon Rectum 2012;55:932-938

19. Anastomosis or not?  Effective alternative [1,2]  Primary anastomosis not worse than stoma in terms of mortality and morbidity [1-3]  Small-scale retrospective studies with selection bias [1,3,4] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294 2.Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607 3.Abbas. Int J Colorectal Dis 2007;22:351-357 4.Cirocchi et al. Int J Colorectal Dis 2013;28:447-457

20. Anastomosis or not? Cirocchi et al. Int J Colorectal Dis 2013;28:447-457  Lower mortality rate for anastomosis (P < 0.02)  Shorter hospital stay (P < 0.001)

21. Anastomosis or not?  Selection bias and heterogeneity  Age, sex, ASA scale, co-morbidity  Hinchey stage  Faecal diversion in anastomosis group  Critically ill patients in Hartmann’s group

22. Laparoscopic  After complicated attacks…

23. Laparoscopic Gaertner et al. World J Surg 2013;37:629-638

24. Laparoscopic  Short-term outcomes [1-3]  Less blood loss / postoperative ileus [1-3]  Less postoperative pain [1-3]  Similar complication rate [2,3]  Shorter hospital stay [1-3]  Improved quality of life [1-3] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294 2.Klarenbeek et al. Ann Surg 2009;249:39-44 3.Gervaz et al. Ann Surg 2010;252:3-8

25. Laparoscopic  Long-term outcomes  Comparable quality of life and morbidity [1-3]  Laparoscopic approach preferred when expertise available [4] 1.Klarenbeek et al. Ann Surg 2009;249:39-44 2.Klarenbeek et al. Surg Endosc 2011;25:1121-1126 3.Gervaz et al. Surg Endosc 2011;25:3373-3378 4.Feingold et al. Dis Colon Rectum 2014;57:284-294

26. Summary  Uncomplicated vs complicated  Percutaneous drainage – for large abscess  Peritoneal lavage?  Controversial (NOT for free perforation)  Expertise in laparoscopic surgery  Anastomosis?  Hartmann’s operation – gold standard  Primary anastomosis with proximal diversion in selected group  Laparoscopic?  Expertise in laparoscopic surgery

27. Factors for consideration Patient factors Surgeon factors Intraoperativ e conditions

28. End

29. Age-related changes  Increased elastin deposition in taenia coli  Increased type III collagen synthesis  Increased collagen crosslinking  Irreversible state of contracture and reduced resistance of colonic wall

30. Segmentation Diverticulum Contraction

31. Dietary fiber deficiency  Longer transit time  Increases intraluminal pressure

32. Uncomplicated diverticulitis  Low threshold of surgery for immunocompromised [1]  E.g. transplant, long-term steroid, renal failure  Medical treatment more likely to fail [2]  Higher mortality rate for medical treatment alone [2]  Higher risks of complicated attacks [3] 1.Feingold et al. Dis Colon Rectum 2014;57:284-294 2.Hwang et al. Dis Colon Rectum 2010;53:1699-1707 3.Klarenbeek et al. Ann Surg 2010;251:670-674

33. Percutaneous drainage  Potential benefit  Reducing pain, fever, leukocytosis [1]  Avoid emergency operation and stoma  Facilitate elective single-stage laparoscopic colectomy [2] 1.Beckham et al. Clin Colon Rectal Surg 2009;22:156-160 2.Dharmarajan et al. Dis Colon Rectum 2011;54:663-671

34. StudyNo. Desi gn Hinchey Conve rsion (%) Hospi tal stay (Day) Amou nt of lavage (L) Complic ation (%) Readm ission Death (%) Electi ve colect omy IIIIII IVIV Swank 2013 38 Retr o 053 0310432350 Edeiken 2013 10Pros0181204NR40402 Rogers 2012 42 7 Retr o 00427NR10NR14NR4 Liang 2012 47 Retr o 004726NR40021 White 2010 35 Retr o 201 2014154808 Lam 20099 Retr o 015333N/ANRN/A303 Karoui 2009 35Pros00 3535 00815281025 Favuzza 2009 7 Retr o 016007NR 104 Mazza 2009 25Pros2896014NR12NR016 Lippi 200913Pros05710N/ANRN/A320 Myers 2008 10 0 Pros0 2525 6767 88844330 Bretagnol 2008 24Pros05 1818 10121080024 Franklin 2008 40 Retr o 05 3232 30815200024 Galleano 2007 4Pros0220010 0004 Mutter 2006 10 Retr o 00 1010 008NR0106 Taylor 2006 14 Retr o 02 1010 206321008 Da Rold 2004 7 Retr o 115014N/ANR0000 Faranda 2000 18Pros00 1616 20815170015 O’Sullivan 1996 8Pros0080010NR25200

35. Heterogeneity for lavage  Hinchey stages  Amount of lavage  Indications for lavage  Failed conservative treatment with antibiotics  Failed percutaneous drainage  Treatment for failed lavage  Colectomy +/- anastomosis or stoma  Percutaneous drainage  Medical treatment  Primary repair for colonic perforation

36. Laparoscopic surgery Klarenbeek et al. Ann Surg 2009;249:39-44

37. Laparoscopic surgery 1.Gervaz et al. Ann Surg 2010;252:3-8 2.Klarenbeek et al. Ann Surg 2009;249:39-44 Laparoscopic surgery

38. 1.Gervaz et al. Ann Surg 2010;252:3-8 2.Klarenbeek et al. Ann Surg 2009;249:39-44

39. Laparoscopic surgery  Scarce data on emergency setting  Mainly retrospective reviews  Comparable in morbidity and mortality  Selection bias 1.Latarte et al. Am J Surg 2015;209:992-998

40. Conservative for Hinchey Ib / II 1.Lamb et al. Dis Colon Rectum 2014;57:1430-1440

41. Conservative for Hinchey Ib / II 1.Lamb et al. Dis Colon Rectum 2014;57:1430-1440

42. Right-sided diverticulitis  More common in Asian population  Often misdiagnosed as acute appendicitis  More indolent compared with left-sided disease with usually mild severity [1-4]  More long-term remission and disease control solely with medical treatment +/- drainage only [1,2]  Similar treatment algorithm as left-sided disease 1.Law et al. Int J Colorectal Dis 2001;16:280-284 2.Telem et al. Gastroenterol Res Pract 2009;359485 3.Kim et al. J Korean Soc Coloproctol 2010;26:402-406 4.Tan et al. Int J Colorectal Dis 2013;28:849-854

43. Right-sided diverticulitis  Diverticulitis found during surgery (esp during appendicectomy) without prior imaging  If obviously perforated with contamination  colectomy  If mild  no role for colectomy [1]; proceed to appendicectomy 1.Tan et al. Int J Colorectal Dis 2013;28:849-854