updated management of colonic diverticulitis dr. tsang yi-po department of surgery pamela youde...

Updated Management of Colonic Diverticulitis

DR. TSANG YI-PO

DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL

JOINT HOSPITAL SURGICAL GRAND ROUND

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

Diverticulosis

Prevalence 30% by age 60 60% by age 80

Presentation Asymptomatic: 70% Diverticulitis: 10-25% Bleeding: 5-10%

Modified Hinchey ClassificationStage Description

0 Mild clinical inflammation

1a Confined pericolic inflammation

1b Confined pericolic abscess

2 Pelvic, distant intraabdominal or retroperitoneal abscess

3 Generalised purulent peritonitis (no open communication with bowel lumen)

4 Faecal peritonitis (free open perforation)

Fistula

Obstruction

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

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;57:284-2942. Salem et al. Dis Colon Rectum 2007;50:1-5

3. Wieghard et al. Ann Gastroenterol 2015;28:25-30

Complicated diverticulitis

Percutaneous drainage? Surgery

Peritoneal lavage? Stoma vs primary anastomosis? Laparoscopic?

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;186:680-6863. Ambrosetti et al. Dis Colon Rectum 2005;48:787-

791

Surgery

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

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

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

Peritoneal lavage

Systematic review 19 papers from 1996 to 2013 Total 871 patients

Cirocchi et al. Medicine (Baltimore) 2015;94:e334

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

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

Study No.

Design

Hinchey

Conversion (%)

Hospital stay (Day)

Amount of lavage (L)

Complication (%)

Readmission

Death (%)

Elective colectomy

I II IIIIV

Swank 2013

38Retro

0 533

0 3 10 4 32 3 5 0

Edeiken 2013

10 Pros 0 1 8 1 20 4 NR 40 4 0 2

Rogers 2012

427

Retro

0 0 427 NR 10 NR 14 NR 4 NR

Liang 2012

47Retro

0 0 47 2 6 NR 4 0 0 21

White 2010

35Retro

2 011

2 0 14 1 54 8 0 8

Lam 2009

9Retro

0 1 5 3 33 N/A NR N/A 3 0 3

Karoui 2009

35 Pros 0 035

0 0 8 15 28 1 0 25

Favuzza 2009

7Retro

0 1 6 0 0 7 NR NR 1 0 4

Mazza 2009

25 Pros 2 8 9 6 0 14 NR 12 NR 0 16

Lippi 2009

13 Pros 0 5 7 1 0 N/A NR N/A 3 2 0

Myers 2008

100

Pros 025

67

8 8 8 4 4 3 3 0

Bretagnol 2008

24 Pros 0 518

1 0 12 10 8 0 0 24

Franklin 2008

40Retro

0 532

3 0 8 15 20 0 0 24

Galleano 2007

4 Pros 0 2 2 0 0 10 10 0 0 0 4

Mutter 2006

10Retro

0 010

0 0 8 NR 0 1 0 6

Taylor 2006

14Retro

0 210

2 0 6 3 21 0 0 8

Da Rold 2004

7Retro

1 1 5 0 14 N/A NR 0 0 0 0

Faranda 2000

18 Pros 0 016

2 0 8 15 17 0 0 15

O’Sullivan 1996

8 Pros 0 0 8 0 0 10 NR 25 2 0 0

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

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;53:1537-15473. Rogers et al. Dis Colon Rectum 2012;55:932-938

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;57:284-2942. Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607

3. Abbas. Int J Colorectal Dis 2007;22:351-3574. Cirocchi et al. Int J Colorectal Dis 2013;28:447-457

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)

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

Laparoscopic

After complicated attacks…

Laparoscopic

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

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;57:284-2942. Klarenbeek et al. Ann Surg 2009;249:39-44

3. Gervaz et al. Ann Surg 2010;252:3-8

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;249:39-442. Klarenbeek et al. Surg Endosc 2011;25:1121-1126

3. Gervaz et al. Surg Endosc 2011;25:3373-33784. Feingold et al. Dis Colon Rectum 2014;57:284-294

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

End

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

Segmentation

Diverticulum

Contraction Contraction

Dietary fiber deficiency

Longer transit time Increases intraluminal pressure

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;57:284-2942. Hwang et al. Dis Colon Rectum 2010;53:1699-1707

3. Klarenbeek et al. Ann Surg 2010;251:670-674

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

Study No.

Design

Hinchey

Conversion (%)

Hospital stay (Day)

Amount of lavage (L)

Complication (%)

Readmission

Death (%)

Elective colectomy

I II IIIIV

Swank 2013

38Retro

0 533

0 3 10 4 32 3 5 0

Edeiken 2013

10 Pros 0 1 8 1 20 4 NR 40 4 0 2

Rogers 2012

427

Retro

0 0 427 NR 10 NR 14 NR 4 NR

Liang 2012

47Retro

0 0 47 2 6 NR 4 0 0 21

White 2010

35Retro

2 011

2 0 14 1 54 8 0 8

Lam 2009

9Retro

0 1 5 3 33 N/A NR N/A 3 0 3

Karoui 2009

35 Pros 0 035

0 0 8 15 28 1 0 25

Favuzza 2009

7Retro

0 1 6 0 0 7 NR NR 1 0 4

Mazza 2009

25 Pros 2 8 9 6 0 14 NR 12 NR 0 16

Lippi 2009

13 Pros 0 5 7 1 0 N/A NR N/A 3 2 0

Myers 2008

100

Pros 025

67

8 8 8 4 4 3 3 0

Bretagnol 2008

24 Pros 0 518

1 0 12 10 8 0 0 24

Franklin 2008

40Retro

0 532

3 0 8 15 20 0 0 24

Galleano 2007

4 Pros 0 2 2 0 0 10 10 0 0 0 4

Mutter 2006

10Retro

0 010

0 0 8 NR 0 1 0 6

Taylor 2006

14Retro

0 210

2 0 6 3 21 0 0 8

Da Rold 2004

7Retro

1 1 5 0 14 N/A NR 0 0 0 0

Faranda 2000

18 Pros 0 016

2 0 8 15 17 0 0 15

O’Sullivan 1996

8 Pros 0 0 8 0 0 10 NR 25 2 0 0

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

Laparoscopic surgery

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

Laparoscopic surgery

1. Gervaz et al. Ann Surg 2010;252:3-82. Klarenbeek et al. Ann Surg 2009;249:39-44

Laparoscopic surgery

Laparoscopic surgery

1. Gervaz et al. Ann Surg 2010;252:3-82. Klarenbeek et al. Ann Surg 2009;249:39-44

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

Conservative for Hinchey Ib / II

1. Lamb et al. Dis Colon Rectum 2014;57:1430-1440

Conservative for Hinchey Ib / II

1. Lamb et al. Dis Colon Rectum 2014;57:1430-1440

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;16:280-2842. 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

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