kiyanda baldwin mdkiyanda baldwin, md suny downstate m&m

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Perforated Diverticulitis Perforated Diverticulitis Kiyanda Baldwin MD Kiyanda Baldwin MD Kiyanda Baldwin, MD Kiyanda Baldwin, MD SUNY Downstate M&M SUNY Downstate M&M Lutheran Medical Center Lutheran Medical Center 4/15/2010 4/15/2010 downstatesurgery.org

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Page 1: 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

downstatesurgery.org

Page 2: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 3: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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

downstatesurgery.org

Page 4: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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

downstatesurgery.org

Page 5: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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

downstatesurgery.org

Page 6: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

downstatesurgery.org

Page 7: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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Page 8: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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 

downstatesurgery.org

Page 9: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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)

downstatesurgery.org

Page 10: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 11: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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 .

downstatesurgery.org

Page 12: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

COMMENTSCOMMENTS

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Page 13: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 14: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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Page 15: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

Diverticulitis

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

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

Sabiston

downstatesurgery.org

Page 16: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

Complicated Diverticulitis Abscess

Obstruction

Diffuse peritonitis (free air)

Fistulas between the colon and adjacent structures

Sabiston

downstatesurgery.org

Page 17: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 18: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 19: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 20: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 21: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 22: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 23: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 24: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 25: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 26: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 27: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 28: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 29: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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

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Page 30: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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

downstatesurgery.org

Page 31: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 32: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 33: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

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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Page 34: Kiyanda Baldwin MDKiyanda Baldwin, MD SUNY Downstate M&M

H ’Hartmann’s Procedure isProcedure is 

G ld S d d!Gold Standard!

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