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Acute Complicated Diverticulitis Managed by
Mahdi Alamili, M.S. • Ismail Go¨genur, M.D. • Jacob Rosenberg, M.D., D.Sc.
Department of Surgery D, Herlev Hospital, Herlev, Denmark PURPOSE: The classic surgical treatment of acute
patients underwent elective sigmoid resection with complicated sigmoid diverticulitis with peritonitis is often a two-stage operation with colon resection and a CONCLUSION: Primary laparoscopic lavage for
temporary stoma. This approach is associated with high complicated diverticulitis may be a promising alternative mortality and morbidity and the reversal of the stoma is to more radical surgery in selected patients. Larger in many cases not performed because of concurrent studies have to be made before clinical recommendations diseases and age. Recently, several studies have experimented with laparoscopic lavage as a treatment ofacute complicated diverticulitis. The aim of this reviewwas to give an overview of the literature for this new KEY WORDS: Acute/perforated diverticulitis;
approach and to determine the safety compared with Hartmann’s procedure for patients with acutecomplicated sigmoid diverticulitis.
METHODS: A PubMed search was performed for
Theprevalenceofdiverticulardiseaseofthesigmoid colon has increased over the past century.1 One- publications between 1990 and May 2008. The terms third of the Western population older than 50 years acute, perforated, diverticulitis, lavage, drainage, and and more than 60% of the population older than 70 years laparoscopy were used in combination. The EMBASE are affected.2 Approximately 20% of patients with divertic- and Cochrane databases were also searched.
The management of diverticulitis depends on the ex- RESULTS: Eight studies met the inclusion criteria and
tent of the disease (Table 1).4 For patients with compli- reported 213 patients with acute complicated cated diverticulitis with localized abscess (Hinchey Grade diverticulitis managed by laparoscopic lavage. None of 2) percutaneous drainage seems to be an effective initial these studies were randomized. The patients’ mean age therapeutic approach.5–8 The emergency surgical man- was 59 years and most patients had Hinchey Grade 3 agement has changed in the past 20 years for patients with disease. All patients were treated with antibiotics and generalized peritonitis (Hinchey Grades 3 and 4), but the laparoscopic lavage. Conversion to laparotomy was made ideal treatment remains controversial. The standard for in six (3%) patients and the mean hospital stay was nine these patients may be a one-stage, two-stage, or three-stage days. Ten percent of the patients had complications.
procedure. The procedure most often used in Denmark is a During the mean follow-up of 38 months, 38% of the Hartmann’s procedure (HP) where the diseased sigmoidcolon is resected and the oral colon is placed as a temporaryor permanent stoma. However, this procedure involves amajor laparotomy with significant morbidity and mortal- Address of correspondence: Mahdi Alamili, M.S., Department of Sur-gery D, Herlev Hospital, 2730 Herlev, Denmark. E-mail: mahdi_ ity and, most of the patients never undergo colostomy re- versal. The controversial management, primary resectionand anastomosis, emerged as an alternative to HP, but the outcomes remain suboptimal with an overall morbidity DOI: 10.1007/DCR.0b013e3181a0da34The ASCRS 2009 rate of 29%9 and mortality rates of 10 to 20%.10 DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009) ALAMILI ET AL: COMPLICATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE review relevant to this subject was found. Thus, the total TABLE 1. The Hinchey classification4
number of studies found was eight. None of the studies were controlled or randomized. Only one study was pro- Diverticulitis with a phlegmonous or a pericolic abscess spective16 and the other seven were retrospective.11–15,18 Diverticulitis with a pelvic abscess or a retroperitoneal Data concerning the number of patients in the studies, the mean age of the patients, the Hinchey classification based Diverticulitis with diffuse/generalized purulent peritonitis on the operative findings, the preoperative American So- ciety of Anesthesiologists’ (ASA) grade, the mean length ofhospital stay, the number of patients converted to laparot- In recent years published studies have shown that pa- omy (during the primary operation and in the immediate tients with acute complicated diverticulitis with peritonitis postoperative period caused by failure of laparoscopic la- may be successfully managed by laparoscopic lavage with- vage), the rates and the number of patients treated with out sigmoid resection in the acute setting. In this system- resection after the primary laparoscopic lavage, the mor- atic review we present the current literature where laparo- bidity, and the mortality can be seen in Tables 2 and 3.
scopic treatment for acute complicated diverticulitis with The inclusion period for the studies was 3 years in one study,18 4 years in two studies,11,14 5 years in two stud-ies,12,17 7 years in two studies,13,16 and 15 years in one METHODS
study.15 The total number of patients was 213 with a meanage of 59 years; most of the patients were in ASA Class 3.
A systematic literature search was performed to identify all The inclusion criterion was surgically confirmed acute English-language publications where laparoscopic treat- complicated diverticulitis with localized or generalized ment for acute complicated diverticulitis with peritonitis peritonitis. The diagnosis was based on clinical signs indi- had been reported. The search was made in the following cating perforated diverticulitis with supplementary com- databases: MEDLINE, EMBASE, and The Cochrane Li- puted tomography (CT) or ultrasound (US). Patients brary. The search period was 1990 to May 2008. The search without peritonitis were excluded. Patients with acute di- consisted of the following key word combinations: acute/ verticulitis that responded to conservative treatment or ra- perforated diverticulitis AND lavage/drainage AND lapa- diologic drainage were excluded in all studies. Two studies roscopy. Studies where laparoscopic lavage as treatment excluded patients with fecal peritonitis,13,16 one study ex- for complicated diverticulitis, including purulent or fecal cluded patients with spontaneously visible perforation and peritonitis, were used. Studies with less than five patients patients with extensive generalized peritonitis13, and one were not included in the review. Reference lists from the study excluded a patient with rheumatoid arthritis, who included articles were manually checked and additional studies were included when appropriate.
All patients in the eight studies were classified accord- ing to the Hinchey classification based on the opera- RESULTS
tive findings. The majority of the patients were HincheyGrade 3.
The database search gave seven studies where laparoscopiclavage had been used in the treatment for complicated di- Emergency Surgery
verticulitis.11–17 An additional study was found in the The surgical treatment in the emergency surgical setting manual search of the reference lists.18 No related Cochrane consisted of laparoscopic peritoneal lavage, and drains TABLE 2. Patient demographics
ASA ϭ American Society of Anesthesiologists’ risk classification.
aUnspecified classification of the 10 patients in this study.
DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009) TABLE 3. The outcomes of laparoscopic lavage management in the published studies
LOS ϭ length of hospital stay.
aFive of the patients had reoperations within weeks after the primary treatment because of failure of the original procedure, and the treatment of one patient was convertedto laparotomy during the original procedure.
bResection rate ϭ secondary elective sigmoideum resection rate.
were placed near the affected colon. No resection of the (3.3%) died after laparoscopic drainage.16 No deaths oc- colon was made in the acute setting and colostomy was curred in the other studies. The overall mortality is 1.4% never performed (Table 3). Intravenous antibiotics and liquids were administered in the perioperative period andthe choice of antibiotics differed between the studies.
Conversion to laparotomy was necessary in four of the The patients were monitored after the laparoscopic drain- eight studies and was performed in six patients, resulting in age with a mean follow-up period of 38 (range, 2–96) an overall conversion rate of 3%. Intestinal obstruction months. The interventions in this period consisted of ab- making insufflation impossible was the reason for conver- dominal CT, double-contrast barium enema, and colonos- sion in one patient.12 Reoperations with laparotomy were copy to rule out colorectal carcinomas and to plan elective performed in five patients. One patient had peritonitis resection of the diseased colon. There were three strategies: three weeks after primary laparoscopic lavage and, because 1) Surgery to all patients: four institutions performed sec- of the presence of local adhesions, the procedure had to be ondary elective surgery in 53 of 62 patients (the rest of the done open.13 One patient with Hinchey Grade 2 disease patients refused, were rejected by the anesthetist, or be- had a laparotomy and HP after a failure in the laparoscopic cause of other reasons).11,13,14,17 2) Surgery to the compli- intervention because of a pelvic abscess that did not resolve cated patients: This policy was supported by the study with after percutaneous drainage.16 In one study three patients the longest mean follow-up period.15 Inclusion criteria had a laparotomy: an 86-year-old and a 78-year-old pa- were defined by age, presence of severe diverticulitis, com- tient, both with fecal peritonitis (Hinchey Grade 4), under- plicated diverticulitis, and the presence of three episodes of went Hartmann’s procedure on the fifth and on the second mild diverticulitis.15 In this study 24 of 40 patients under- postoperative day, respectively, and a 39-year-old patient went elective laparoscopic resection. 3) Conservative ap- with obesity who had Hinchey Grade 3 disease required proach: In the three remaining studies (a total of 105 who open resection with primary anastomosis because of fever underwent a successful laparoscopic lavage), resection and tenderness.14 Thus, overall, the operation was con- were only performed if a readmission required a resection verted to laparotomy during the initial laparoscopic inter- or if the colonoscopy revealed a colorectal carcinoma. As a vention in one patient, and five patients underwent lapa- result, in two of these three studies, no patients had resec- rotomy days to weeks after the initial laparoscopy because tions, whereas in the third study one patient had a colonic resection because of a carcinoma of the descending colon Morbidity after laparoscopic drainage consisted of during the follow-up period.12,16,18 During the follow-up cardiopulmonary complications (myocardial infarction, period four patients from two of these three studies were respiratory infection, pulmonary embolus, and atelecta- readmitted with acute diverticulitis and responded to con- sis), gastrointestinal complications (paralytic ileus and an- servative management.16,18 No readmissions occurred in tibiotic-related diarrhea), and other (lymphangitis). In the rest of the six studies. The total number of patients that one study two patients developed pelvic abscess and were had an elective colon resection was 78 (38%).
managed by radiologic drainage.17 The total number ofpatients with postoperative complications was 22 corre- DISCUSSION
sponding to an overall complication rate of 10%. In theonly prospective study with the largest number of patients, The basic finding of the present study was that the majority three patients, where two were immunoincompetent, of 92 of patients with Hinchey Grade 3 diverticulitis (diffuse pu- ALAMILI ET AL: COMPLICATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE rulent peritonitis) can effectively be managed by laparo- Thus, the number of Hinchey Grade 4 patients in the eight scopic lavage in the acute setting. The overall conversion rate studies was low, although the clinical gain may be largest in to laparotomy (including five treatment failures) was 3%, the this group of patients. Larger studies have to be made be- mean length of stay was 9 days, 10% of the patients devel- fore clinical recommendations can be given regarding this oped complications, and the overall mortality was 1.4%.
The standard procedure for patients with acute com- The follow-up period lasted for a mean period of 38 plicated diverticulitis with peritonitis in many hospitals months where 38% of the patients underwent an elective is an acute HP. The advantages and disadvantages of HP resection of the sigmoid colon. Elective resection is meant have been thoroughly investigated.19–24 HP has decreased to prevent complications and readmission of diverticular mortality and morbidity compared with the previous disease and is based on the assumption that, without sur- three-stage surgical intervention that dominated until the gical management, complications and readmission are 1980s and consisted of a first stage with establishment more likely to occur. The criteria for resection were differ- of a colostomy and drainage, a second stage with colonic ent in the studies. In four studies (n ϭ 62), where all pa- resection, and a third stage with the reversal of the sto- tients were offered laparoscopic resection, 85% of the pa- ma.9,19 The disadvantages of HP are high mortality (10 – tients underwent resection. In the study with the longest 28%), high risk of surgical site infection (25%), reanasto- mean follow-up period, where elective resection was per- mosis that is often not performed (30 –75%), risk of fistula formed in patients with complicated disease, 60% of the (7–16%), and a high risk for cardiovascular complications patients underwent elective resection. In three other stud- (25%) because of comorbidities the result of the typically ies (n ϭ 105) where laparoscopic resection was performed high age for patients with diverticulitis.13,21,23–25 Patients selectively only, 1% of the patients underwent resection.
undergoing HP have a typical length of hospital stay (LOS) Readmission was only seen in four patients, all from stud- of 20 to 38 days,21 but the patients who undergo laparo- ies that performed laparoscopic resection if needed, which scopic lavage have an average LOS of 9 days during their corresponds to 4%. An important issue is whether the pa- tients without resections will be readmitted if they are The laparoscopic approach with lavage, drainage, and monitored for a longer period. A recent review highlighted no resection seems to have a low mortality and morbidity that there is no evidence to support the idea that elective rate despite patient comorbidity and disease severity. Co- surgery should follow two attacks of diverticulitis.26 Fur- lostomy and the occurrence of wound infection are thermore, there is no association between recurrent epi- avoided, and subsequent development of incisional hernia sodes of diverticulitis and increased risk of complicated is not seen. Subsequent elective resection, laparoscopic or diverticulitis, and there is no association between multiple open, may be unnecessary in many patients, and readmis- attacks of diverticulitis and a less favorable outcome or an sion is unusual. The studies included in this article, how- increased mortality risk if complications develop.27–30 ever, may reflect the experience from specialist centers The outcomes from the eight studies show that the with a high level of expertise in this field, and inclusion new intervention with laparoscopic lavage combined with criteria for laparoscopic lavage was not always clear. The intravenous antibiotics apparently had a low morbidity mean age of the patients included in the studies were also in rate, low mortality, and short LOS, and it can be performed the lower range. The present data may therefore be biased, without placing a colostomy. Other advantages compared and future studies should clarify which patient groups can with acute HP are shorter operation time and lower eco- benefit from this minimally invasive approach for treat- nomic costs. Thus, laparoscopic lavage without sigmoid ment of peritonitis caused by complicated diverticulitis.
resection in the acute setting for patients with purulent The eight studies included in this review are compara- peritonitis caused by complicated diverticulitis could be ble with respect to the reported outcome parameters.
considered a valid alternative to more radical procedures, However, the number of included patients has generally including the Hartmann’s procedure. However, this needs been low and no randomized controlled trials have yet to be investigated more thoroughly: preoperative and in- been performed. The inclusion criteria were not the same traoperative indications should be specified, whether elec- in the studies. Patients with Hinchey Grade 2 and 3 disease tive colonic resection should be performed for all patients were included in all studies, but patients with Hinchey or for a selected group in the follow-up period, and finally Grade 4 disease were only included in four stud- randomized clinical trials are needed before clinical refer- ies.11,14,15,17 Only two of the eight patients with fecal diver- ticulitis who underwent a laparoscopic lavage were con-verted to HP (conversion rate, 25%). This is very lowconsidering that these patients have a higher ASA grade REFERENCES
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