Laparoscopia e peritonite

Malattia diverticolare Marco Azzola Guicciardi

&Andrea Favara

U.O. Chirurgia Generale e mininvasiva Ospedale Sant’ Antonio Abate Cantù (Co) A.O. Sant Anna Como

Diverticolosi -malattia diverticolare

Diverticolite

10 -20% pazienti con diverticolosi

CLASSIFICAZIONE HINCHEY (1978)

Stadio I Flemmone o ascesso pericolico

Stadio II a Ascesso pelvico

Stadio II b Ascesso pelvico complesso

Stadio III Peritonite purulenta

Stadio IV Peritonite stercoracea

* indicazioni alla resezione ridotte * resezione indicata dopo due episodi dogma superato* se resezione meglio laparoscopia

In elezione

L' indicazione al ricovero nelle diverticoliti non complicate da trattare con antibioticoterapia non è assoluta

Il ruolo stesso dell' antibioticoterapia è in discussione

Conclusions: Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis.Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis.

Ann Surg. 2014 Jan;259(1):38-44

Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial)

Biondo S et al.

Indicazioni in urgenza

Emorragia

stenosi\occlusione

PERFORAZIONE

•

Indicazioni

Hinchey 1 e 2a

Terapia medica ,drenaggio percutaneo o

laparoscopico

Diverticolite acuta

Terapia antibiotica

1) Ampicillina sulbactam

2) Cefalosporina 3 + metronidazolo

3) Chinolone + metronidazaolo

4) carbapenemi

Indicazioni

Hinchey 2b e 3

Lavaggio drenaggio laparoscopico

Indicazioni

Hinchey (3) e 4

Resezione colica con o senza anastomosi

laparoscopica o laparotomica

Hartmann

Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitisAuthorsE. Myers,M. Hurley,G. C. O'Sullivan,D. Kavanagh,I. Wilson,D. C. WinterFirst published: 12 December 2007

Conclusion:Laparoscopic management of perforated diverticulitis with generalized peritonitis is feasible, with a low recurrence risk in the short term

Methods:A prospective multi-institutional study of 100 patients was undertaken

Lavaggio laparoscopico

Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitisAuthorsF. Radé,F. Bretagnol,M. Auguste,C. Di Guisto,N. Huten,L. de Calan 9 September 2014Presented to the 114th French Congress of Surgery, Paris, France, October 2013 Abstract

BackgroundLaparoscopic peritoneal lavage has been proposed for generalized peritonitis from perforated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach.

ResultsFor patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more, American Society of Anesthesiologists grade III or above, and immunosuppression were associated with reintervention.

ConclusionElderly patients and those with immunosuppression or severe systemic co-morbidity are at risk of reintervention after laparoscopic lavage.

*QUATTRO studi randomizzati multicentrici *lavaggio laparoscopico vs resezione colica

- LAPLAND (Irlandese)

- LADIES (Olandese) - SCANDIV - DILALA (Scandinavo).

Treatment of acute diverticulitis laparoscopiclavage vs. resection (DILALA): study protocol fora randomised controlled trialAnders Thornell1*, Eva Angenete2, Elisabeth Gonzales2, Jane Heath2, Per Jess3, Zoltan Läckberg4, Henrik Ovesen3,Jacob Rosenberg5, Stefan Skullman6 and Eva Haglind2, for the Scandinavian Surgical Outcomes Research Group, SSORGAbstractBackground: Perforated diverticulitis is a condition associated with substantial morbidity. Recently publishedreports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomisedstudy has published any results.Methods: DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditionalHartmann’s Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpointsconsist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patientsare included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient isincluded and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally,placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months.A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40).Discussion: HP is associated with a high rate of complication. Not only does the primary operation entailcomplications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk oftreatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe,minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer reoperations,decreased morbidity, mortality, costs and increased quality of life.Trial registration: British registry (ISRCTN) for clinical trials ISRCTN82208287 http://www.controlled-trials.com/

Conclusion

Perforated acute diverticulitis is treated by surgical intervention. Worldwide, Hartmann’s procedure remains the gold standard and the primary choice for acute diverticulitis with fecal peritonitis. Peritoneal lavage is a more conservative and bowel-preserving approach compared to resection in purulent diverticulitis. Peritoneal lavage has currently been added to certain official treatment guidelines. The lack of level 1 evidence does, however, keep peritoneal lavage from being implemented as a routine treatment. Current ongoing randomized trials on surgical treatments for perforated diverticulitis are awaited to determine if peritoneal lavage can be recommended as a routine approach. When data from these are available, guidelines may be adjusted. In the meantime, treatment must be decided on an individual basis when treating acute perforated, colonic diverticulitis.

Esperienza personale12\2012 – 9\2014

• 93 pazienti ricoverati per diverticolite• 21 operati (13f 8m)• 16\21 pazienti eta’ superiore a 65 anni• Hinchey 2 7 casi• Hinchey 3 9 casi• Hinchey 4 5 casi

F 90 H3 laparoscopia laparotomia Hartmann

Infez ferita 27 gta dim

F74 H4 laparoscopia laparotomia Hartmann

Vers pleur, epa 41 gta dim

F65 H2 Laparoscopia drenaggio 7 gta dim

F73 H3 laparoscopia laparotomia Hartmann

Infez ferita 20 gta dim (5m ricanalizzata)

M33 H3 Laparoscopia drenaggio 10 gta dim

F76 H4 laparoscopia laparotomia Hartmann

Infez/ ematoma ferita 47 gta dim

M66 H3 Laparoscopia drenaggio Perforaz ileo reintervento I gta sutura

9 gta dim

M53 H2 Laparoscopia drenaggio Peggiore-tc-resez anast laparotomica 4 gta

11 gta dim

F81 H4 laparoscopia laparotomia Hartmann

Rein 4 gta raccolta Dim 27(ricanalizzato a un anno)

CASISTICA 12.2011~9.2014 21 PAZIENTI OPERATI

F 84 H4 laparoscopia laparotomia Hartmann polmonite dim 23 gta

F88 H3 laparotomia Hartmann - dim 28 gta

F66 H2 laparoscopia drenaggio - Dim 7gta resez anastomosi 2mesi dopo

F67 H2 laparoscopia drenaggio - 8 gta dim

M58 H2 laparoscopia drenaggio 6 gta dim 4 mesi dopo colon: k, attende resez

F66 H3 laparotomia Hartmann Infez ferita 17 gta dimessa ricanalizzata 5mesi dopo

M55 H2 Laparoscopia laparotomia drenaggio Infez ferita 11gta dimesso

M67 H2 Laparoscopia drenaggio - dim 9

F82 H4 Laparotomia Hartmann Infez ferita dim 26

F85 H3laparoscopia laparotomia resez anastomosi

fa – tvp (filtro cavale)

dim 40 gta

M34 H3 laparoscopia laparotomia Hartmann - dim 9 gta

F84 H4 laparoscopia drenaggio - Dim 6 gta

Intervento 4\2014

Colonscopia 8\2014

Interventi eseguiti

• 8 laparoscopia drenaggio• 1 laparoscopia conversione e

drenaggio• 9 laparoscopia conversione

Hartmann• 3 laparotomia ed Hartmann

Interventi in base allo stadio

Hinchey 2:

6 laparoscopia drenaggio (1 resez\anastomosi laparotomica in 4 gta ,

1 k colon alla colonscopia)

Interventi in base allo stadioHinchey 3 :

5 laparoscopia, conversione ed Hartmann

2 laparoscopia e drenaggio (1 reint 1 gta perforaz ileale)

2 laparotomia ed Hartmann

Interventi in base allo stadioHinchey 4:

4 laparoscopia conversione ed Hartmann

1 laparotomia ed Hartmann

1 laparoscopia e drenaggio

Casistica complessiva• Mortalita’ 0• Morbilita’ 80% Hartmann

• Infezione ferita

• Polmonite

• versamento pleurico

• Ep

• raccolta ascessuale

30% lavaggio

perforaz ileale

cancro non riconosciuto

Lavaggio drenaggio laparoscopicotecnica

• Verres in ipocondrio sinistro• Trocar ottico ombelicale• Due trocar da 5 mm accessori• Minima mobilizzazione dei visceri• Lavaggio con fisiologica e betadine• Sutura della perforazione se piccola e visibile• Due drenaggi , nel Douglas e nella doccia

parietocolica sinistra.

CONCLUSIONI I

• indicazioni in elezione ridotte e personalizzate

• terapia urgenza conservativa laparoscopica

• Età avanzata e comorbidità:Hartmann

CONCLUSIONI II La resezione laparoscopica con o senza anastomosi

in urgenza è un intervento complesso che richiede competenze non comuni a tutta l’ equipe, rendendo la conversione laparotomica frequente in questi casi

Surgeon, Not Disease Severity, often Determines the Operation for Acute Complicated DiverticulitisPresented at the New England Surgical Society 94th Annual Meeting, Hartford, CT, September 2013.Mohammad S. Jafferji, MD, Neil Hyman, MD, FACSemail

Grazie

Settembre in Valtellina