kiyanda baldwin mdkiyanda baldwin, md suny downstate m&m

Perforated DiverticulitisPerforated Diverticulitis

Kiyanda Baldwin MDKiyanda Baldwin MDKiyanda Baldwin, MDKiyanda Baldwin, MD

SUNY Downstate M&MSUNY Downstate M&M

Lutheran Medical CenterLutheran Medical Center

4/15/20104/15/2010

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C t tiCase presentation62 y/o F presented to LMC on 3/7/10 with left lower abdominal pain x 24 hr. 

“If I have surgery I’m going to die”

D i  h/   i i    di h Denies h/o constipation or diarrhea

Denies BPRDenies BPR

Denies change in appetite or weight loss

Denies having previous colonoscopy

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Case presentationCase presentation PMH – Morbid obesity, Hypotension (baseline SBP ~90‐100), CHF (EF 20%), A. Fib, ESRD on HD, DM, Asthma, CAD/MI 

PSH – B/L hip replacement, CABG 2000, stent 2008.

Meds:  coumadin, carvedilol, lantus, albuterol prn

All: NKDA All: NKDA

SH: lived at home with home attendant, on disability, denies tobacco, etoh, illicit drug use

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C t tiPE: 

Case presentation Vitals:  T 99.2, BP 107\66, HR 88, Sat 98, Weight 123 kg, 

Height 5`7”g 5 7

CVS:  S1S2 RRR

Chest :  CTA B/L

Abd:  soft, obese, moderate LLQ tenderness,  no R/G, 

+BS, no masses appreciated

Rectal:  good tone  no masses appreciated  guiaic ‐ Rectal:  good tone, no masses appreciated, guiaic ‐

Ext:  motor in tact x4, 2+ distal pulses x4

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C t tiLabs:

Case presentation CBC  11.9\11\35.5\136 Neu 84%

BMP  \ \ \ \ 8\ BMP  139\4.4\101\30\38\2.4

LFTs AST\ALT\AlP\Bil 19\17\52\0 8 LFTs AST\ALT\AlP\Bil ‐ 19\17\52\0.8

Coags 28\14\1.4g \ 4\ 4

Lac acid 0.9

ABG 7.43\92\38.9\98%\28.9\2

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Hospital courseHospital courseD L  C l  Di i li i  lik l   l d  f i Dx‐ Lt Colon Diverticulitis, likely sealed perforation

Admitted to POU with IV fluids + Zosyn / Flagyly gy

Day 2 – improved, WBC 11.98.57.9, afebrile

Day 3 – worse, tender abdomen, hypotensive

Free air on CXR

To OR for explorative laparotomy To OR for explorative laparotomy 

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Operative  Course Exp laparotomy – midline

Air evacuated  upon peritoneum openingAir evacuated  upon peritoneum opening

~ 100 cc purulent fluid, perforation distal left colon

L  h i l   i h  d  l  ( H   L. hemicolectomy with end colostomy ( Hartmann 

procedure)

During OR course patient required pressor support 

(vasopressin, levophed , & neosynephrine)

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Postop coursePostop courseI ICU i d i t b t d i d i l t In ICU: remained intubated, required maximal pressor support (3 drugs)

Profound septic shock complicated by cardiogenic shock later Profound septic shock complicated by cardiogenic shock later

Acidosis :

ABG 7 15\32\251\11\99%\-16 Transient improvement w/ IV ABG 7.15\32\251\11\99%\-16. Transient improvement w/ IV bicarb.

Swan Ganz placedS a Ga p aced

CO 5.3, CI 2.6, PAWP 17, CVP 17, SVR 497 (10am)

CO 3.2 ,CI 1.66, PAWP 11, CVP 12, SVR 219 ( 7pm), , , , ( p )

Troponin elevation to 2.5, LA 15

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Postop course (continued)

Despite maximal pressor support patient's hypotension progressively worsened

Postop day 1 (18 hours after surgery) patient coded x 2, second code was unsuccessful .

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COMMENTSCOMMENTS

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Colonic Diverticulae False diverticula  False diverticula 

mucosa and muscularis mucosa have herniated through the colonic wallg

Pulsion diverticula  resulting from high intraluminal pressure

b h l Occur between the taeniae coli points where the main blood vessels penetrate the colonic wall (presumably creating an area of colonic wall (presumably creating an area of relative weakness in the colonic muscle)

Sabiston/Maingot

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Diverticulitis

results from a perforation (either macroscopic or microscopic) of a diverticulum

leads to contamination  inflammation  and  leads to contamination, inflammation, and infection

Sabiston

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Complicated Diverticulitis Abscess

Obstruction

Diffuse peritonitis (free air)

Fistulas between the colon and adjacent structures

Sabiston

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Hinchey Classification Stage I: colonic inflammation with an associated pericolic abscessp

Stage II: colonic inflammation with a gretroperitoneal or pelvic abscess

Stage III: purulent peritonitis

Stage IV: fecal peritonitis

Sabiston/Maingot

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Treatment of Perforated Diverticulitis with Generalized Peritonitis: Past, Present, and FuturePeritonitis: Past, Present, and Future

What’s the surgical  “gold standard” for perforated diverticulitis?

Vermeulen & Lange, World J Surg 2010

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Three stage procedure Early 1900s – three stage procedure :

Diversion and drainage Resection ( in 3‐6 months ) Colostomy reversal

No antibiotics

Mortality >25%

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Two stage procedure

Mid 1900’s –two stage procedure: resection with diversion

d d h f d f l Understanding that perforated segment of colon remains as source of ongoing contamination

Using antibiotics

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H t dHartmann procedure Since mid‐1900’s standard practice changed to 

Hartmann procedurep

2000 American Society of Colon and Rectal 

Surgeons no longer recommended non 

resectional approach as standard

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Hartmann procedure

Second stage ( reversal of colostomy ) will never be performed in ~30% of patients

Could be technically challenging with significant morbidity and mortality

So is there another option? 

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O t dOne stage procedure Since 1960’s (Madden, Surg Gynecol Obstet 1961)

Resection of perforated sigmoid colon with primary anastomosis (PA)anastomosis (PA)

PA with or w/out diverting ileostomy not inferior to HP

Salem & Flum, Dis Colon Rectum 2004Constantinidas et al. Dis Colon Rectum 2006

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Why Not Single Stage ? Fear of anastomotic leakage defers many surgeons

Outcomes remain suboptimal: morbidity 25  50% mortality 10 20% for Hartmann’s and PRA respectivelymortality 10 20% for Hartmanns and PRA respectively

Didn’t really catch on as standard of care

So  what’s  next ?

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New !New !

New !New ! New !

Nonresectional laparoscopic lavage6 fi t  t   1996 first reports 

Patients without gross fecal peritonitis  P d  i l d Procedure includes:

laparoscopic peritoneal lavage,  inspection of the colon  inspection of the colon  pelvic‐abdominal drainage

Morbidity/mortality ~ 5%y/ y 5 Reduce length of stay on first admission Avoid ostomy and it’s complicationsy p Requires skilled laparoscopic surgeon … & guts

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From the Department of Digestive Surgery, Trousseau Hospital, Tours, France.

Am Coll Surg 2008;206:654–657. 

All ti t ith f t d di ti liti i i 2000 2004All patients with perforated diverticulitis requiring surgery 2000-2004

Indications: Diffuse peritonitis, septic shock, failure of conservative t t t ft 48h l i b ( Hi h 2 ) f ibl f IRtreatment after 48hr, pelvic abscess ( Hinchey 2 ) unfeasible for IR drainage

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Laparoscopic Technique

Laparoscopic full lavage, requiring at least 10 L

Pus drained and adhesions left untouched

P l i d i l ft i l Pelvic drain left in place

No ileostomy or colostomy y y

Postoperative bowel rest & 21 days of antibiotics

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Results 24 patients (mean 55 years), 23 were “first timers”

ASA I and II

3 on steroids, 10 had previous surgery

N t lit No mortality

Return of bowel function in 2-10 days (mean 3 days)

2 patients had abscesses that required IR drainage (Hinchey III)

Mean hospital stay 12 days Mean hospital stay 12 days

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B i i h J l  f S   8    British Journal of Surgery 2008; 95: 97–101

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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis

Prospectively collected database 2000 - 2007

1257 Pts admitted with diverticulitis

100 Pts recruited

Median age 62 5 ASAIII M:F 2:1 1 on steroids Median age 62.5, ASAIII, M:F 2:1, 1 on steroids

None had h/o diverticulitis

All had generalized peritonitis + perf on imaging

8 Pts with fecal peritonitis had Hartmann procedure

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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis

Irrigation of peritoneal cavity with 4L or more until drainage clearuntil drainage clear

Two non‐suctional Penrose drains

IV Abx 72Hr then PO 1 week7

Clears POD 1, solid according to clinical gprogression

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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis

Results:Results:

82 Pts (89%) recovered without morbidity82 Pts (89%) recovered without morbidity

4% morbidity (2 pelvic abscesses)

Mortality 3%  ( 2 ‐MOF, 1 ‐ PE)

resumed diet after 2 days and discharged after 8

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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis

Follow up:

88 pts underwent colonoscopy/Ba enema in 6 weeks6 weeks

M di  f/      Median f/u 3 years  2 pts were readmitted for acute diverticulitis and responded w/ Abx.p

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H ’Hartmann’s Procedure isProcedure is 

G ld S d d!Gold Standard!

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