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Diverticular DilemmasDiverticular DilemmasDiverticular DilemmasDiverticular Dilemmas

Jacques Heppell, MDJacques Heppell, MDMayo Clinic Mayo Clinic

Scottsdale, ArizonaScottsdale, Arizona

Jacques Heppell, MDJacques Heppell, MDMayo Clinic Mayo Clinic

Scottsdale, ArizonaScottsdale, Arizona

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Diverticular DiseaseDiverticular DiseaseDiverticular DiseaseDiverticular Disease

• In the US, individual risk of 50% by age 60.In the US, individual risk of 50% by age 60.

• Diverticulitis occur in 20 to 30% of patient and is one of Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisationsthe most common GI related hospitalisations

• 25% of patients with diverticulitis will present with a 25% of patients with diverticulitis will present with a complication leading to surgerycomplication leading to surgery

• Diverticulitis is one of the five most costly GI disorder in Diverticulitis is one of the five most costly GI disorder in the US populationthe US population

• In the US, individual risk of 50% by age 60.In the US, individual risk of 50% by age 60.

• Diverticulitis occur in 20 to 30% of patient and is one of Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisationsthe most common GI related hospitalisations

• 25% of patients with diverticulitis will present with a 25% of patients with diverticulitis will present with a complication leading to surgerycomplication leading to surgery

• Diverticulitis is one of the five most costly GI disorder in Diverticulitis is one of the five most costly GI disorder in the US populationthe US population

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Patients are asking …Patients are asking …Patients are asking …Patients are asking …

• If I have simple episodes of If I have simple episodes of diverticulitis , when should I have an diverticulitis , when should I have an operation?operation?

• How can you predict the severity of How can you predict the severity of future episodes ?future episodes ?

• What if I have a perforation or another What if I have a perforation or another complication ?complication ?

• The “fear factor” : the colostomy bag !The “fear factor” : the colostomy bag !

• If I have simple episodes of If I have simple episodes of diverticulitis , when should I have an diverticulitis , when should I have an operation?operation?

• How can you predict the severity of How can you predict the severity of future episodes ?future episodes ?

• What if I have a perforation or another What if I have a perforation or another complication ?complication ?

• The “fear factor” : the colostomy bag !The “fear factor” : the colostomy bag !

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HistoryHistoryHistoryHistory

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DiverticulitisDiverticulitisDiverticulitisDiverticulitis

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DiverticulitisDiverticulitisDiverticulitisDiverticulitis

• 11 RCTs11 RCTs– 3 examining lap vs. open for elective 3 examining lap vs. open for elective

operationoperation– 3 examining abx therapy3 examining abx therapy– 2 examining probiotic therapy2 examining probiotic therapy– 1 examining timing of colonoscopy1 examining timing of colonoscopy– 2 examining type of surgery2 examining type of surgery

• 11 RCTs11 RCTs– 3 examining lap vs. open for elective 3 examining lap vs. open for elective

operationoperation– 3 examining abx therapy3 examining abx therapy– 2 examining probiotic therapy2 examining probiotic therapy– 1 examining timing of colonoscopy1 examining timing of colonoscopy– 2 examining type of surgery2 examining type of surgery

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Etzioni et al, Ann Surg 2006

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Domestic Admissions for Acute Diverticulitis, 1998 vs. Domestic Admissions for Acute Diverticulitis, 1998 vs. 20052005

19981998 20052005 %%ΔΔ

AdmissionsAdmissions

RawRaw 120,541120,541 171,445171,445 +42%+42%

Age-AdjustedAge-Adjusted 120,541120,541 151,878151,878 +26%+26%

Incidence Rates*Incidence Rates*

TotalTotal 0.600.60 0.770.77 +30%+30%

18-44 yo18-44 yo 0.150.15 0.260.26 +82%+82%

45-64 yo 45-64 yo 0.660.66 0.900.90 +37%+37%

65-74 yo65-74 yo 1.411.41 1.631.63 +16%+16%

75+ yo75+ yo 2.532.53 2.552.55 ----

* per 1,000 population

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EpidemiologyEpidemiologyEpidemiologyEpidemiology

Hjern et al, Aliment Pharmacol Ther, 2006

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AcuteAcutediverticulitisdiverticulitis

AcuteAcutediverticulitisdiverticulitis

Resolution, spontaneous or Resolution, spontaneous or with medical managementwith medical managementResolution, spontaneous or Resolution, spontaneous or with medical managementwith medical management

Progression, with Progression, with secondary complications: secondary complications: abscess, fistula, abscess, fistula, “smoldering”, peritonitis, “smoldering”, peritonitis, obstructionobstruction

Progression, with Progression, with secondary complications: secondary complications: abscess, fistula, abscess, fistula, “smoldering”, peritonitis, “smoldering”, peritonitis, obstructionobstruction

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• “Uncomplicated diverticulitis may be managed as an outpatient (dietary modification and oral antibiotics) for those without appreciable fever, excessive vomiting, or marked peritonitis, as long as there is the opportunity for follow-up.”

• “Uncomplicated diverticulitis may be managed as an outpatient (dietary modification and oral antibiotics) for those without appreciable fever, excessive vomiting, or marked peritonitis, as long as there is the opportunity for follow-up.”

ASCRS GuidelinesASCRS GuidelinesASCRS GuidelinesASCRS Guidelines

Rafferty J, DCR 2006

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What % of patients are treated outpatient?

How successful is outpatient tx?• Research Study:

– Cohort:Cohort:

Kaiser ED eval for diverticulitisKaiser ED eval for diverticulitis

Kaiser member 5 yrs prev, no prior dx of Kaiser member 5 yrs prev, no prior dx of ticstics

CT scan CT scan 1 day of eval 1 day of eval

NotNot admitted admitted

Excluded: no antibiotic rx Excluded: no antibiotic rx 1 day of eval 1 day of eval– Outcome: Re-eval/ admission for within 60 daysOutcome: Re-eval/ admission for within 60 days

• Results:Results:– n = 693, overall failure rate 5.6%n = 693, overall failure rate 5.6%

What % of patients are treated outpatient?

How successful is outpatient tx?• Research Study:

– Cohort:Cohort:

Kaiser ED eval for diverticulitisKaiser ED eval for diverticulitis

Kaiser member 5 yrs prev, no prior dx of Kaiser member 5 yrs prev, no prior dx of ticstics

CT scan CT scan 1 day of eval 1 day of eval

NotNot admitted admitted

Excluded: no antibiotic rx Excluded: no antibiotic rx 1 day of eval 1 day of eval– Outcome: Re-eval/ admission for within 60 daysOutcome: Re-eval/ admission for within 60 days

• Results:Results:– n = 693, overall failure rate 5.6%n = 693, overall failure rate 5.6%

Etzioni et al, DCR 2010

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• ““Uncomplicated diverticulitis”Uncomplicated diverticulitis”

– Conservative treatmentConservative treatment

NPO/IVF: Clears? NPO/IVF: Clears?

IV Abx: Duration?IV Abx: Duration?

123 pts randomized to 4 vs. 7 123 pts randomized to 4 vs. 7 days inpatient ertapenemdays inpatient ertapenem

No significant differenceNo significant difference

– Operate for failure to improve or deteriorationOperate for failure to improve or deterioration

What constitutes failure to improve?What constitutes failure to improve?

Within what time frame?Within what time frame?

– On discharge, oral abx? How long?On discharge, oral abx? How long?

• ““Uncomplicated diverticulitis”Uncomplicated diverticulitis”

– Conservative treatmentConservative treatment

NPO/IVF: Clears? NPO/IVF: Clears?

IV Abx: Duration?IV Abx: Duration?

123 pts randomized to 4 vs. 7 123 pts randomized to 4 vs. 7 days inpatient ertapenemdays inpatient ertapenem

No significant differenceNo significant difference

– Operate for failure to improve or deteriorationOperate for failure to improve or deterioration

What constitutes failure to improve?What constitutes failure to improve?

Within what time frame?Within what time frame?

– On discharge, oral abx? How long?On discharge, oral abx? How long?Schug-Pass C, Int J Colorect Dis 2010

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Practice ParametersPractice ParametersPractice ParametersPractice Parameters

• Elective resection after two Elective resection after two documented attacks of diverticulitisdocumented attacks of diverticulitis

• Complicated diverticulitis: resection Complicated diverticulitis: resection after the first attackafter the first attack

• Elective resection after two Elective resection after two documented attacks of diverticulitisdocumented attacks of diverticulitis

• Complicated diverticulitis: resection Complicated diverticulitis: resection after the first attackafter the first attack

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• 19951995

– “…“…elective resection should be considered elective resection should be considered after two well-documented attacks of after two well-documented attacks of diverticulitis…”diverticulitis…”

• 20002000

– “…“…after two attacks…resection is after two attacks…resection is commonly recommended…”commonly recommended…”

• 20062006

– “…“…decision to recommend elective sigmoid decision to recommend elective sigmoid colectomy …should be made on a case-colectomy …should be made on a case-by-case basis…”by-case basis…”

• 19951995

– “…“…elective resection should be considered elective resection should be considered after two well-documented attacks of after two well-documented attacks of diverticulitis…”diverticulitis…”

• 20002000

– “…“…after two attacks…resection is after two attacks…resection is commonly recommended…”commonly recommended…”

• 20062006

– “…“…decision to recommend elective sigmoid decision to recommend elective sigmoid colectomy …should be made on a case-colectomy …should be made on a case-by-case basis…”by-case basis…”

Rafferty et al, DCR 2006

Roberts et al, DCR 1995Wong et al, DCR 2000

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Long term follow-up after initial episode Long term follow-up after initial episode of diverticulitisof diverticulitis

Long term follow-up after initial episode Long term follow-up after initial episode of diverticulitisof diverticulitis

• Complicated recurrence is uncommon.Complicated recurrence is uncommon.• Higher risk of recurrence if:Higher risk of recurrence if:

Family historyFamily history

Long segment involvedLong segment involved

Retroperitoneal abscessRetroperitoneal abscess

Hall J et al DCR 54 (3) , 2011Hall J et al DCR 54 (3) , 2011

• Complicated recurrence is uncommon.Complicated recurrence is uncommon.• Higher risk of recurrence if:Higher risk of recurrence if:

Family historyFamily history

Long segment involvedLong segment involved

Retroperitoneal abscessRetroperitoneal abscess

Hall J et al DCR 54 (3) , 2011Hall J et al DCR 54 (3) , 2011

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Acute DiverticulitisAcute DiverticulitisAcute DiverticulitisAcute Diverticulitis

• 15% progression of disease in 15% progression of disease in remaining colonremaining colon

• 2-11% need for further surgery2-11% need for further surgery

• 27% pain in the same area 27% pain in the same area (irritable bowel?)(irritable bowel?)

• 15% progression of disease in 15% progression of disease in remaining colonremaining colon

• 2-11% need for further surgery2-11% need for further surgery

• 27% pain in the same area 27% pain in the same area (irritable bowel?)(irritable bowel?)

Evolution after SurgeryEvolution after SurgeryEvolution after SurgeryEvolution after Surgery

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ConsiderationsConsiderationsConsiderationsConsiderations

• Limited access to medical careLimited access to medical care• General medical conditionGeneral medical condition• Frequency and severity of attackFrequency and severity of attack• Persistence of symptomsPersistence of symptoms• Most severe attack is often the firstMost severe attack is often the first• Colostomy is rarely required on Colostomy is rarely required on

second attacksecond attack

• Limited access to medical careLimited access to medical care• General medical conditionGeneral medical condition• Frequency and severity of attackFrequency and severity of attack• Persistence of symptomsPersistence of symptoms• Most severe attack is often the firstMost severe attack is often the first• Colostomy is rarely required on Colostomy is rarely required on

second attacksecond attack

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Immuno-compromised patientsImmuno-compromised patientsImmuno-compromised patientsImmuno-compromised patients

• Increased risk of perforation: Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2%25% and mortality : 40% vs 2%

• Patient on steroids, Patient on steroids, chemotherapy, azathioprine, chemotherapy, azathioprine, cyclosporine, diabetics, cyclosporine, diabetics, renal failurerenal failure

• Increased risk of perforation: Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2%25% and mortality : 40% vs 2%

• Patient on steroids, Patient on steroids, chemotherapy, azathioprine, chemotherapy, azathioprine, cyclosporine, diabetics, cyclosporine, diabetics, renal failurerenal failure

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Immuno-compromised patientImmuno-compromised patientImmuno-compromised patientImmuno-compromised patient

• Operate earlier during the first episodeOperate earlier during the first episode

• Operate semi-electively after the first Operate semi-electively after the first episodeepisode

• Cautious use of unprotected Cautious use of unprotected anastomosis in emergency situationanastomosis in emergency situation

• Operate earlier during the first episodeOperate earlier during the first episode

• Operate semi-electively after the first Operate semi-electively after the first episodeepisode

• Cautious use of unprotected Cautious use of unprotected anastomosis in emergency situationanastomosis in emergency situation

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Patient < 50 years of AgePatient < 50 years of AgePatient < 50 years of AgePatient < 50 years of Age

• Age: remain a controversial factor in the decision to Age: remain a controversial factor in the decision to operateoperate

• Because of their longer life span, younger patients Because of their longer life span, younger patients will have a higher cumulative risk for recurrence.will have a higher cumulative risk for recurrence.

• Young patients should generally be treated using Young patients should generally be treated using the same criteria as older patients .the same criteria as older patients .

• No justification for surgery after a single attack of No justification for surgery after a single attack of diverticulitisdiverticulitis

• Age: remain a controversial factor in the decision to Age: remain a controversial factor in the decision to operateoperate

• Because of their longer life span, younger patients Because of their longer life span, younger patients will have a higher cumulative risk for recurrence.will have a higher cumulative risk for recurrence.

• Young patients should generally be treated using Young patients should generally be treated using the same criteria as older patients .the same criteria as older patients .

• No justification for surgery after a single attack of No justification for surgery after a single attack of diverticulitisdiverticulitis

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Diverticular DiseaseDiverticular DiseaseDiverticular DiseaseDiverticular Disease

post-operative wound problemspost-operative wound problems

length of hospitalizationlength of hospitalization

morbiditymorbidity

• 90% successful (148 of 164 patients)90% successful (148 of 164 patients)

post-operative wound problemspost-operative wound problems

length of hospitalizationlength of hospitalization

morbiditymorbidity

• 90% successful (148 of 164 patients)90% successful (148 of 164 patients)

Franklin ME, et al. Surg Endosc. 1997;11(10):1021.Franklin ME, et al. Surg Endosc. 1997;11(10):1021.

Laparoscopic ApproachLaparoscopic ApproachLaparoscopic ApproachLaparoscopic Approach

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Laparoscopic approach Laparoscopic approach Laparoscopic approach Laparoscopic approach

• Likely to become the standard surgical Likely to become the standard surgical approach for uncomplicated diverticulitisapproach for uncomplicated diverticulitis

• ““The Sigma-trial protocol”: a prospective The Sigma-trial protocol”: a prospective double-blind multicentre comparison of double-blind multicentre comparison of laparoscopic versus open elective sigmoid laparoscopic versus open elective sigmoid resection in patients with symptomatic resection in patients with symptomatic diverticulitis . Klarenbeek ,BR et al BMC diverticulitis . Klarenbeek ,BR et al BMC Surg 2007;7:16Surg 2007;7:16

• Likely to become the standard surgical Likely to become the standard surgical approach for uncomplicated diverticulitisapproach for uncomplicated diverticulitis

• ““The Sigma-trial protocol”: a prospective The Sigma-trial protocol”: a prospective double-blind multicentre comparison of double-blind multicentre comparison of laparoscopic versus open elective sigmoid laparoscopic versus open elective sigmoid resection in patients with symptomatic resection in patients with symptomatic diverticulitis . Klarenbeek ,BR et al BMC diverticulitis . Klarenbeek ,BR et al BMC Surg 2007;7:16Surg 2007;7:16

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Complicated DiverticulitisComplicated DiverticulitisComplicated DiverticulitisComplicated Diverticulitis

Cases, Cases, MortalityMortality

No. No. (11%)(11%)

Acute phlegmonAcute phlegmon 104104 44

Pericolonic abscessPericolonic abscess 3434 1212

Purulent peritonitisPurulent peritonitis 4040 2727

Large bowel obstructionLarge bowel obstruction 3131 66

Fecal peritonitisFecal peritonitis 2323 4848

Abscess with fistulaAbscess with fistula 2828 3.53.5

Lower GI bleedingLower GI bleeding 4040 2.52.5

Cases, Cases, MortalityMortality

No. No. (11%)(11%)

Acute phlegmonAcute phlegmon 104104 44

Pericolonic abscessPericolonic abscess 3434 1212

Purulent peritonitisPurulent peritonitis 4040 2727

Large bowel obstructionLarge bowel obstruction 3131 66

Fecal peritonitisFecal peritonitis 2323 4848

Abscess with fistulaAbscess with fistula 2828 3.53.5

Lower GI bleedingLower GI bleeding 4040 2.52.5

Prospective National Study (Great Britain)Prospective National Study (Great Britain)300 cases (1985-88)300 cases (1985-88)

Prospective National Study (Great Britain)Prospective National Study (Great Britain)300 cases (1985-88)300 cases (1985-88)

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Hinchey’s Hinchey’s ClassificationClassification

Hinchey’s Hinchey’s ClassificationClassification

Stage 0Stage 0 Mild clinical diverticulitisMild clinical diverticulitis

Stage IaStage Ia Confined pericolic inflammation (no abscess)Confined pericolic inflammation (no abscess)

Stage IbStage Ib Confined pericolic abscessConfined pericolic abscess

Stage IIStage II Pelvic, retroperitoneal, or distant intraperitoneal abscess Pelvic, retroperitoneal, or distant intraperitoneal abscess (abscess/phlegmon, fever, systemic toxicity) (abscess/phlegmon, fever, systemic toxicity)

Stage IIIStage III Generalized purulent peritonitis, no communication with Generalized purulent peritonitis, no communication with bowel lumenbowel lumen

Stage IVStage IV Feculent peritonitis, open communication with bowel lumenFeculent peritonitis, open communication with bowel lumenHinchey E, Adv Surg 1978

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Ambrosetti’s CT Staging of DiverticulitisAmbrosetti’s CT Staging of DiverticulitisAmbrosetti’s CT Staging of DiverticulitisAmbrosetti’s CT Staging of Diverticulitis

• MILD DIVERTICULITISMILD DIVERTICULITIS• Localized sigmoid wall thickeningLocalized sigmoid wall thickening• Inflammation of pericolonic fatInflammation of pericolonic fat• SEVERE DIVERTICULITISSEVERE DIVERTICULITIS• AbscessAbscess• Extraluminal airExtraluminal air• Extraluminal contrast Extraluminal contrast

• MILD DIVERTICULITISMILD DIVERTICULITIS• Localized sigmoid wall thickeningLocalized sigmoid wall thickening• Inflammation of pericolonic fatInflammation of pericolonic fat• SEVERE DIVERTICULITISSEVERE DIVERTICULITIS• AbscessAbscess• Extraluminal airExtraluminal air• Extraluminal contrast Extraluminal contrast

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Complicated DiverticulitisComplicated DiverticulitisComplicated DiverticulitisComplicated Diverticulitis

– Fistula = operate when medically fitFistula = operate when medically fit

– Obstruction = conservative treatment, Obstruction = conservative treatment, then operatethen operate

– Abscess = percutaneous drainageAbscess = percutaneous drainage

– Perforation = Operation but which Perforation = Operation but which one ?one ?

– Fistula = operate when medically fitFistula = operate when medically fit

– Obstruction = conservative treatment, Obstruction = conservative treatment, then operatethen operate

– Abscess = percutaneous drainageAbscess = percutaneous drainage

– Perforation = Operation but which Perforation = Operation but which one ?one ?

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Percutaneous Abscess DrainagePercutaneous Abscess DrainagePercutaneous Abscess DrainagePercutaneous Abscess Drainage

• 75% successful75% successful• Concomitant antibioticsConcomitant antibiotics• Sinograms obtained at 7 days interval Sinograms obtained at 7 days interval

to monitor collapse of abscess cavityto monitor collapse of abscess cavity• Surgery performed 10-14 days after Surgery performed 10-14 days after

disappearance of the abscess cavity disappearance of the abscess cavity because 41% of patients will develop because 41% of patients will develop severe recurrent sepsissevere recurrent sepsis

• 75% successful75% successful• Concomitant antibioticsConcomitant antibiotics• Sinograms obtained at 7 days interval Sinograms obtained at 7 days interval

to monitor collapse of abscess cavityto monitor collapse of abscess cavity• Surgery performed 10-14 days after Surgery performed 10-14 days after

disappearance of the abscess cavity disappearance of the abscess cavity because 41% of patients will develop because 41% of patients will develop severe recurrent sepsissevere recurrent sepsis

CT-GuidedCT-GuidedCT-GuidedCT-Guided

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CT FindingsCT FindingsCT FindingsCT Findings

• Pericolic lymph nodes: An aid in Pericolic lymph nodes: An aid in distinguishing diverticulitis from distinguishing diverticulitis from cancer of the coloncancer of the colon

• Pericolic lymph nodes: An aid in Pericolic lymph nodes: An aid in distinguishing diverticulitis from distinguishing diverticulitis from cancer of the coloncancer of the colon

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Obstruction Obstruction Obstruction Obstruction

• Resection, intra-operative colonic Resection, intra-operative colonic lavage with primary anastomosislavage with primary anastomosis

• Expendable metallic stent with Expendable metallic stent with resection and anastomosis within 7 resection and anastomosis within 7 daysdays

• Hartmann's procedure Hartmann's procedure

• Resection, intra-operative colonic Resection, intra-operative colonic lavage with primary anastomosislavage with primary anastomosis

• Expendable metallic stent with Expendable metallic stent with resection and anastomosis within 7 resection and anastomosis within 7 daysdays

• Hartmann's procedure Hartmann's procedure

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Perforated Diverticulitis Perforated Diverticulitis ( Hinchey stages 3 and 4 )( Hinchey stages 3 and 4 )Perforated Diverticulitis Perforated Diverticulitis

( Hinchey stages 3 and 4 )( Hinchey stages 3 and 4 )

Ideal operation ?Ideal operation ?

1-Primary resection with Hartmann pouch1-Primary resection with Hartmann pouch

2-Primary resection with anastomosis and temporary 2-Primary resection with anastomosis and temporary ileostomyileostomy

3-Primary resection with anastomosis and no 3-Primary resection with anastomosis and no temporary stomatemporary stoma

4-Simple laparoscopic washout with drainage4-Simple laparoscopic washout with drainage

Ideal operation ?Ideal operation ?

1-Primary resection with Hartmann pouch1-Primary resection with Hartmann pouch

2-Primary resection with anastomosis and temporary 2-Primary resection with anastomosis and temporary ileostomyileostomy

3-Primary resection with anastomosis and no 3-Primary resection with anastomosis and no temporary stomatemporary stoma

4-Simple laparoscopic washout with drainage4-Simple laparoscopic washout with drainage

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Generalized PeritonitisGeneralized PeritonitisGeneralized PeritonitisGeneralized Peritonitis

• Resect the perforated segmentResect the perforated segment• Do not do more than you need to doDo not do more than you need to do• Do not open further avenue for sepsis Do not open further avenue for sepsis

(splenic flexure, presacral space)(splenic flexure, presacral space)• Do not make a mucous fistulaDo not make a mucous fistula• Examine the open specimen to Examine the open specimen to

rule out malignancyrule out malignancy

• Resect the perforated segmentResect the perforated segment• Do not do more than you need to doDo not do more than you need to do• Do not open further avenue for sepsis Do not open further avenue for sepsis

(splenic flexure, presacral space)(splenic flexure, presacral space)• Do not make a mucous fistulaDo not make a mucous fistula• Examine the open specimen to Examine the open specimen to

rule out malignancyrule out malignancy

Operative GuidelinesOperative GuidelinesOperative GuidelinesOperative Guidelines

Fazio VW, 1989Fazio VW, 1989

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Henri Hartmann (1860-1952)Henri Hartmann (1860-1952)Henri Hartmann (1860-1952)Henri Hartmann (1860-1952)

• Two-staged....Two-staged....• Two-staged....Two-staged....

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Hartmann Procedure in Hartmann Procedure in Complicated Diverticular DiseaseComplicated Diverticular Disease

Hartmann Procedure in Hartmann Procedure in Complicated Diverticular DiseaseComplicated Diverticular Disease

RetainedRetainedMortality,Mortality, Morbidity,Morbidity, Colostomy,Colostomy,

Author Author Year Year %% %% %%

Krukowski & MathesonKrukowski & Matheson 19841984 1212 3838 NANA

Auguste et al Auguste et al 19851985 1212 9595 2020

Nagorney et al Nagorney et al 19851985 77 4141 2525

Hackford et al Hackford et al 19851985 1616 2323 2929

Finlay and Carter Finlay and Carter 19871987 2121 2626 1616

Alanis et al Alanis et al 19891989 1515 2323 4646

Berry et al Berry et al 19891989 2828 6969 3333

Peoples et al Peoples et al 19901990 1919 2727 NANA

RetainedRetainedMortality,Mortality, Morbidity,Morbidity, Colostomy,Colostomy,

Author Author Year Year %% %% %%

Krukowski & MathesonKrukowski & Matheson 19841984 1212 3838 NANA

Auguste et al Auguste et al 19851985 1212 9595 2020

Nagorney et al Nagorney et al 19851985 77 4141 2525

Hackford et al Hackford et al 19851985 1616 2323 2929

Finlay and Carter Finlay and Carter 19871987 2121 2626 1616

Alanis et al Alanis et al 19891989 1515 2323 4646

Berry et al Berry et al 19891989 2828 6969 3333

Peoples et al Peoples et al 19901990 1919 2727 NANA

Arch Surg: Vol 131, June 1996Arch Surg: Vol 131, June 1996

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The Hartmann’s ProcedureThe Hartmann’s ProcedureThe Hartmann’s ProcedureThe Hartmann’s Procedure

• First choice or last resort First choice or last resort in diverticular disease?in diverticular disease?

• First choice or last resort First choice or last resort in diverticular disease?in diverticular disease?

U. of Minn., Arch Surg 1996U. of Minn., Arch Surg 1996

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Laparoscopic Peritoneal LavageLaparoscopic Peritoneal LavageLaparoscopic Peritoneal LavageLaparoscopic Peritoneal Lavage

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TreatmentTreatmentWhich Operation?Which Operation?TreatmentTreatment

Which Operation?Which Operation?

Laparoscopic lavageLaparoscopic lavage

• First described 1996 in 8 patientsFirst described 1996 in 8 patients

• Two subsequent reports Two subsequent reports

• ComponentsComponents

– Laparoscopy; look for exclusion criteriaLaparoscopy; look for exclusion criteria

– Lavage with salineLavage with saline

– Wide drainageWide drainage

– ± repair (suture, glue, omentoplasty, etc)± repair (suture, glue, omentoplasty, etc)

Laparoscopic lavageLaparoscopic lavage

• First described 1996 in 8 patientsFirst described 1996 in 8 patients

• Two subsequent reports Two subsequent reports

• ComponentsComponents

– Laparoscopy; look for exclusion criteriaLaparoscopy; look for exclusion criteria

– Lavage with salineLavage with saline

– Wide drainageWide drainage

– ± repair (suture, glue, omentoplasty, etc)± repair (suture, glue, omentoplasty, etc)

O’Sullivan et al, Am JSurg1996 Faranda et al, SLEPT 2000Taylor et al, ANZ J Surg 2006

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Laparoscopic peritoneal lavage (LPL) for Laparoscopic peritoneal lavage (LPL) for generalized peritonitis due to perforated generalized peritonitis due to perforated

diverticulitis diverticulitis

Laparoscopic peritoneal lavage (LPL) for Laparoscopic peritoneal lavage (LPL) for generalized peritonitis due to perforated generalized peritonitis due to perforated

diverticulitis diverticulitis

• PROSPECTIVE MULTI-INSTUTIONAL PROSPECTIVE MULTI-INSTUTIONAL

STUDYSTUDY• 100 patients : 8 with fecal peritonitis 100 patients : 8 with fecal peritonitis

(Hartmann) , 92 LPL with morbidity and (Hartmann) , 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 2 patients re-presented with diverticulitis at 36 months (median follow-up).36 months (median follow-up).

• Myers et al. Br J Surg 2008;95:97Myers et al. Br J Surg 2008;95:97

• PROSPECTIVE MULTI-INSTUTIONAL PROSPECTIVE MULTI-INSTUTIONAL STUDYSTUDY

• 100 patients : 8 with fecal peritonitis 100 patients : 8 with fecal peritonitis (Hartmann) , 92 LPL with morbidity and (Hartmann) , 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 2 patients re-presented with diverticulitis at 36 months (median follow-up).36 months (median follow-up).

• Myers et al. Br J Surg 2008;95:97Myers et al. Br J Surg 2008;95:97

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Laparoscopic LavageLaparoscopic LavageLaparoscopic LavageLaparoscopic Lavage

Myers E, Br J Surg 2008

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TreatmentTreatmentWhich Operation?Which Operation?TreatmentTreatment

Which Operation?Which Operation?

• Issues with laparoscopic lavage:Issues with laparoscopic lavage:– Lots of patients who we think need Lots of patients who we think need

surgery get better without an surgery get better without an operation...operation...

– ...so what is the threshold for ...so what is the threshold for operation?operation?

– Is there a role for interval Is there a role for interval sigmoidectomy?sigmoidectomy?

• Issues with laparoscopic lavage:Issues with laparoscopic lavage:– Lots of patients who we think need Lots of patients who we think need

surgery get better without an surgery get better without an operation...operation...

– ...so what is the threshold for ...so what is the threshold for operation?operation?

– Is there a role for interval Is there a role for interval sigmoidectomy?sigmoidectomy?

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TreatmentTreatmentWhich Operation?Which Operation?TreatmentTreatment

Which Operation?Which Operation?

Toorenvliet et al, Colorectal Dis 2009

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Laparoscopic Peritoneal LavageLaparoscopic Peritoneal LavageLaparoscopic Peritoneal LavageLaparoscopic Peritoneal Lavage

• Too good to be true !! Too good to be true !!

• Need for a randomized clinical trial ??Need for a randomized clinical trial ??

• Too good to be true !! Too good to be true !!

• Need for a randomized clinical trial ??Need for a randomized clinical trial ??

JH081705

TreatmentTreatmentWhich Operation?Which Operation?TreatmentTreatment

Which Operation?Which Operation?

• Pending trial: Ladies trialPending trial: Ladies trial– Laparoscopic peritoneal lavage or resection

for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis

• Pending trial: Ladies trialPending trial: Ladies trial– Laparoscopic peritoneal lavage or resection

for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis

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• One stage....One stage....• One stage....One stage....

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TreatmentTreatmentWhich Operation?Which Operation?TreatmentTreatment

Which Operation?Which Operation?

• 1.5 stage....1.5 stage....• Resection plus Resection plus

loop ileostomyloop ileostomy

• 1.5 stage....1.5 stage....• Resection plus Resection plus

loop ileostomyloop ileostomy

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ConclusionsConclusionsConclusionsConclusions

• The management of patients with sigmoid diverticulitis is The management of patients with sigmoid diverticulitis is still evolving.still evolving.

• Big problem that is becoming bigger !Big problem that is becoming bigger !

• Paucity of data on when to operate and what operation to Paucity of data on when to operate and what operation to performperform

• Need larger Randomized Clinical Trials to guide Therapy Need larger Randomized Clinical Trials to guide Therapy

• We must tailor our treatment to the specific situation for We must tailor our treatment to the specific situation for each individual patienteach individual patient

• The management of patients with sigmoid diverticulitis is The management of patients with sigmoid diverticulitis is still evolving.still evolving.

• Big problem that is becoming bigger !Big problem that is becoming bigger !

• Paucity of data on when to operate and what operation to Paucity of data on when to operate and what operation to performperform

• Need larger Randomized Clinical Trials to guide Therapy Need larger Randomized Clinical Trials to guide Therapy

• We must tailor our treatment to the specific situation for We must tailor our treatment to the specific situation for each individual patienteach individual patient