John Marks MD Chief: Section of Colorectal Surgery Main Line Health System

1. When to operate for diverticulitis: Acute vs Chronic John Marks MD Chief: Section of Colorectal Surgery Main Line Health System Professor: Lankenau Institute of Medical Research Director: Fellowship in Minimally Invasive Colorectal Surgery and Rectal Cancer Management

2. Incidence of Diverticulosis • 50% > 60 years • 80% > 80 years • 10% of those with diverticulosis may go on to develop diverticulitis • 75% of cases are simple • Very small subset require surgery

3. Diverticulitis: A Spectrum • Simple • Complicated • Abscess • Fistula • Stenosis • Perforation

4. Studying Diverticulitis • Study selection bias • Few prospective randomized trials • Patrick Ambrosetti MD • Overall Studies are of poor quality overall

5. When to Operate • Acute • Free perforation • Peritonitis • Acute abdomen

6. When to Operate: Standard Teaching • Chronic • Complicated diverticulitis • Abscess • Fistula • Stenosis • Medically refractory • 2 or more hospitalizations • 1 hospitalization < 50 yrs • Immunocompromised

7. Hinchey Classification • Stage I: Pericolic abscess or phlegmon • Stage II: Pelvic, intra-abdominal or retroperitoneal abscess • Stage III: Generalized purulent peritonitis • Stage IV: Generalized fecal peritonitis

8. Simple Diverticulitis • Classic indications called into question • Minority of patients develop subsequent attacks • Are we justified in telling people that they will avoid life threatening situations with elective resection? • What is the effect on QOL?

9. Complicated Diverticulitis Options • Percutaneous drainage of abscess • Hartmann’s • Laparoscopic vs. Open • Resection with primary anastomosis • proximal diverting stoma • on table lavage • Laparoscopic lavage

10. Overall Diverticulitis Recurrences N = 502 Timing of first recurrent attack of acute diverticulitis for all patients. Eglinton et al. Br J Surg 2010

11. Simple Diverticulitis N = 320/502 Timing of first recurrent attack of acute diverticulitis for patients with an uncomplicated first attack. Eglinton et al. Br J Surg 2010

12. Complicated Diverticulitis N = 165 Timing of first recurrent attack of acute diverticulitis for patients with a complicated first attack. Eglinton et al. Br J Surg 2010

13. Timing of Elective Colectomy in Diverticulitis • “The timing of elective colectomy in diverticulitis: A decision analysis.” Salem et al. J AmerCollSurg 2004 • Markov model of clinical pathways • Simulation based on statewide hospital discharge database • Colectomy after 4th episode • lower mortality • Fewer colostomy • Decreased cost

14. Management Strategies Salem et al. J Amer Coll Surg 2004

15. Timing of Elective Colectomy in Diverticulitis • “Timing of prophylactic surgery in prevention of diverticulitis recurrence: A cost-effectiveness analysis.” Richards et al. Dig Dis Sci 2002. • Markov model as well • Probabilities based on published data • Compared surgery after 1, 2 and 3 episodes • Surgery after 3rd attack = decreased cost

16. Timing of Elective Colectomy in Diverticulitis Richards et al. Dig Dis Sci 2002.

17. Trends in Management 2002 – 2007 • Urgent admissions: big increase • Urgent surgery: very small increase • Improvement in antibiotics • Interventional procedures • Elective surgery: increasing • Laparoscopy

18. Diverticulitis Admissions (2002) 179k 210k (2007) Nationwide Inpatient Sample (NIS) database Masoomi et al. Arch Surg 2010

19. Elective & Urgent Surgeries Masoomi et al. Arch Surg 2010

20. Role of Laparoscopic Resection Masoomi et al. Arch Surg 2010

21. Complicated Diverticulitis Options • Percutaneous drainage of abscess • Hartmann’s • Laparoscopic vs. Open • Resection with primary anastomosis • proximal diverting ileostomy • on table lavage • Laparoscopic lavage

22. Hartmann’s Procedure • Gold standard for Hinchey III & IV • Significant complications • Wound infection 30% • Stoma complications 10% • Leak rate 30% with reversal • Overall mortality 15-30% • Primary resection & anastomosis for Hinchey I & II • Resection & anastomosis w/ protective stoma for Hinchey III

23. Hartmann’s vs. Primary Anastomosis • Alternative for Hinchey I and II • Diverting proximal stoma for Hinchey III • Reduced post-operative mortality • Avoidance of stoma • Lower SSI • Studies flawed with selection bias • No large randomized trials

24. Hartmann’s vs. Primary Anastomosis Bauer VP, Clinics in Colorectal Surgery 2009

25. Laparoscopic Lavage Methods • Franklin et al. World J Surg, 2008 • N = 40 • All pts with peritonitis • 33% with free air on CXR • Hinchey 2b, 3 and 4 (intraop finding) • No readmissions for complicated disease • Average f/u 96 months (range 1 – 120 months) • 24 patients underwent subsequent elective surgery

26. Laparoscopic Lavage Methods • Described for Hinchey class II, III, & IV • Culture of purulent material • 4 – 12 L of warm saline reported • Drain placement near colonic lesion • Adhesions to the colon left untouched • Visible perforations closed w/ suture, omental patch, fibrin glue • IV antibiotics x 7 days minimum

27. Laparoscopic Lavage Methods • Karoui et al. Dis Colon & Rectum 2009 • N = 59 • 35 lavage • 24 resection with anastomosis and diverting ostomy • Case matched study • Hinchey 3

28. N = 59 Laparoscopic Lavage Karoui et al. Dis Colon & Rectum 2009

29. N = 59 Lavage vs. Resection w/ Ileostomy Karoui et al. Dis Colon & Rectum 2009

30. Accuracy of CT Hinchey Class

31. Laparoscopic Lavage Alamili et al. Dis Colon & Rectum 2009

32. N = 47 Smoldering Diverticulitis • Diverticulitis vs IBS • Evidence of diverticula only on CT • No fever or leukocytosis • 88% pain-free at 12 months • Histologic evidence of inflammation in 76% Horgan et al. Dis Colon & Rectum 2001

33. Quality of Life after Lap Colectomy Forgioneet al. Annals of Surgery, 2009 • N = 46 • Patients evaluated had CT documented attack of diverticulitis • Multiple validated questionnaires used preop, 3, 6 and 12 months post-op • Evaluation of GI, urologic and sexual function • GIQLI • IPSS (international prostate symptom score) - men • EIIF-5 (international index of erectile function) • UDI (urinary distress inventory) - women

34. Quality of Life N = 46 *denotes significant difference (P < 0.05). Forgioneet al. Annals of Surgery, 2009

35. Functional Results • Functional results following elective laparoscopic sigmoidectomy after CT-proven diverticulitis. • Ambrosetti et al, J GastrointestSurg 2007 • N = 43 • Mean follow up 40 months (3-76) • Post operative questionnaire • Recurrent disease • Bowel function • New abdominal pain • Overall satisfaction • Overall satisfaction rate 95%

36. N = 43 Postoperative Results • Ambrosetti et al, J GastrointestSurg 2007

37. Why the CT appreciation of severity? A. To guide the therapeuticstrategies: • Milddiverticulitis: conservative ambulatory care (antibiotics?) • Stage Ia: conservative care with oral antibiotics • Stage Ib and II:hospitalization, iv antibiotics, eventual CT drainage, possible surgery • Stage III and IV:surgery B. To evaluate the chances of secondarybadoutcomeafter a first episode of acute diverticulitissusccessfullytreatedconservatively

38. So, whereis the challenge ? The existence of an associatedabscess

39. Why ? 1. Frequent(between 15 to 20%) rao et al. am j radiol 1998 ambrosetti et al. eurradiol 2002 werner et al. eurradiol 2003 2. Difficult to diagnose bioclinically 3. Therapeuticallychallenging

40. Types of acute treatment Shouldwe drain ? « …smallpericolicabscessmayresolvewithantibiotictherapy and bowelrest… » « …today the decision to drain remains to beindividualized1 » 1. The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: 289-97

41. Secondarytreatment 1. « Recently, some surgeons have suggestedthatsurgicalresectionmay not bemandatory in every case aftersuccessfulpercutaneous drainage: however, atpresentthere are insufficient data to support universalendorsement of this concept » The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: 289-97 2. « …do a percutaneous drainage where possible, followedlater by sigmoidresection in most cases… » European Association of EndoscopicSurgery, SurgEndosc 1999; 13: 430-6

42. Abscessassociated to diverticulitis • Betweenoctober 1986 to october 1997: • 465 patients had a CT evaluation • 76 (16.3%)had an associatedmesocolic or pelvicabscess • 73 patients couldbefollowed-up • Medianfollow-up: 43 months(2 – 180) • 26 women and 47 men with a meanage of 68 (30 – 94) Ambrosetti et al. Dis colon rectum, march 2005

43. Abscessassociated to diverticulitis • Therapeuticprinciples: • Percutaneous CT drainage of abscessweredoneonly if no bioclinicalimprovementwerenotedafter 48 hours of parenteralantibiotics • Elective colectomyaftersuccessful conservative management of the abscesswas not an absolute indication and wasadapted for each patient

44. Associatedabscess Location and CT percutaneous drainage n drainednot drained (%) (%) Mesocolic45 11 (24) 34 (76) Pelvic 28 8 (29) 20 (71)

45. Surgicalvs conservative treatment:no op.: conservative treatmentop. 1: surgeryduring 1st hospitalisationop. 2: surgerylater on

46. Long-termevolution 1.No patient needed an emergency surgicaltreatment 2. 15 patients (21%)diedduring the course of the follow-up. No one diedfrom complications related to the diverticulardisease

47. Essential findings 1. Initial CT is indispensable to confirm the diagnosis and precise the severity of the diverticulitis 2. Patients with a pelvicabscessshouldbeimmediatelydrained 3. Mesocolicabscess≥ 5 cm shouldprobablybedrainedimmediately 4. Secondarycolectomyafterpelvicabscessseemshighlyreasonnable 5. Secondarycolectomyaftersuccessful conservative treatment of mesocolicabscessisprobably not mandatory for all patients

48. Acute leftcolonicdiverticulitis Prospective study October 1986 – October 1997 UniversityHospital Geneva

49. Acute diverticulitis: prospective study 542 patients 290 women and 252 men Meanage: 64 (23-97)

50. Acute diverticulitis: profile of the study Patients included: 1. Clinical and history compatibility 2. Radiological confirmation (CT and water-soluble contrastenema=GE) 3. Histologicaldiagnosis 4. 1st hospital admission Patients excluded: No radiological or histological confirmation