Role of Elective Surgery in Acute Divertiulitis

Role of elective surgery in acute divertiulitis

Diverticulosis: the presence of asymptomatic diverticula within the colon in the absence of associated inflammation

• Acute diverticulitis: clinically evident macroscopic inflammation of a diverticulum or diverticula

• 4% of patients with diverticulosis

• 15% of those patients will have complicated disease, )abscess, perforation, fistula, colonic obstruction or stricture(

• 15% to 30% will experience recurrence

• Emergency:

• laparoscopic lavage (with/without drain placement),

• defunctioning stoma • Hartmann’s procedure• sigmoid colectomy with primary anastomosis

either with/without covering loop stoma

• Elective:

• recurrent uncomplicted acute diverticulitis

• complicated acute divertiulitis

• In 2000 the American Society of Colon and Rectal Surgeons:

recommended elective surgery after two episodes of AD .

In 2006 the same group stated that elective colonic resection after AD

should be performed on a case-by-case basis

• Elective resection for a patient with a single episode of uncomplicated diverticulitis is not supported

• for a patient with recurrent (two or more) episodes of diverticulitis : a single blanket recommendation is not appropriate and the decision as to whether or not to offer surgery in this group of patients should be made on an individual patient basis

Association of Coloproctology of Great Britain and Ireland Commissioning guide: Colonic diverticular disease 2014

• the number of episodes of recurrent AD no longer an indication to elective resection• patient-related factors, not the number of

previous episode of AD, should lead to the elective surgical treatment

• Practice Parameters for the Treatment of Sigmoid Diverticulitis

Daniel Feingold, M.D. • Scott R. Steele, M.D. • Sang Lee, M.D. • Andreas Kaiser, M.D. Robin Boushey, M.D. • W. Donald Buie, M.D. • Janice Frederick Rafferty, M.D.

Prepared by the Clinical Practice Guideline Task Force of the American Society of Colon and Rectal Surgeons2014

• T he decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized.

Grade of Recommendation: Strong recommendation based on moderate-quality

evidence,1B.

• patient-related factors: Immunosuppressed patients and patients with chronic renal failure

or collagen-vasculardisease

effects on lifestyle(professional and personal) imposed by recurrent attacks

chronic or lingering symptoms that may constitute“smoldering” disease

severity of the attacks

the overall medical condition of the patient

• Elective colectomy should typically be considered after the patient recovers from an episode of complicated diverticulitis.

Grade of Recommendation: Strong recommendation based on moderate-quality

evidence, 1B.

• Neither phlegmon nor extraluminal gas alone seen on imaging is considered complicated disease

• mesocolic abscesses of ≥5 cm or pelvic abscess )elective colectomy should typically be advised(

• stricture or fistula formation elective or semielective resection is generally necessary to provide

symptomatic relief.

• Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications.

Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM –1Division of Colorectal Surgery, Department of Surgery, Keck

School of Medicine, University of Southern California, Los Angeles, California

Dis. Colon Rectum- March 1, 2016; 59 (3); 208-15

• retrospective review of all patients 210) patients(with diverticular abscess confirmed by CT from 2004 to 2014

• 185 patients successfully managed without surgery and discharged from the hospital

recurrent diverticulitis developed in 112 (60.5%)..... average time interval of 5.3 months.

47 patients (42%) experienced more than 1 episode. 51 patients (45.6%). Inreased modified Hinchey stage at time of recurrence Seventy one (63%) of 112 recurrences showed local disease complications (recurrent abscess, fistula, stricture, or peritonitis) Twenty nine (26%) of 112 recurrences required an urgent operation 13 (29.2%) of 45 patients with recurrence after successful CT-guided drainage

subsequently required an urgent operation.

• Diverticular abscesses represent complicated diverticulitis and are

• associated with a high risk of recurrences and disease complications.

• Recurrences (contrary to other series) were often more severe than the index presentation

• successful CT-guided drainage of a diverticular abscess does not appear to lower the risks of future recurrence or complication rates

• After initial successful nonoperative management, patients with diverticular abscess should be offered interval elective colectomy

patients’ perspective on the risk of recurrences and persistent bowel symptoms associated with surgical or conservative treatment

• systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.

data from 21 studies that comprised 1858 patients between January 1990 through May 2014

• patients had higher QOL scores after elective laparoscopic resection(73.4; 95% confidence interval [CI], 65.7–81.1) than conservative treatment (58.1; 95% CI,47.2–69.1).

• A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%–14%) than conservative treatment (36%; 95% CI, 27%–45%)

• Heterogeneity among the existing studies is substantial, impeding strong conclusions on best treatment

• Elective laparoscopic surgery might have benefits in terms of general QoL and gastrointestinal

symptoms compared with conservative treatment in patients with disabling chronic complaints or recurrent diverticulitis

• In the largest cohort of 500 laparoscopic resections for diverticulitis,

conversion rate was 2.8%, incidence of anastomotic leakage was 1.4%, and overall mortality was 0.2%.