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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