Preoperative diagnostic algorithm in colon diverticular disease

Preoperative diagnostic algorithm in colon diverticular disease
patrick ambrosetti XXIV congresso nazionale dell’associazione chirurghi ospedalieri italiani florence may 2005

Presentation of the exposure
1. Set up about diagnosing suspected acute diverticulitis: - bioclinical evaluation - CT compared to water-soluble contrast enema 2. In acute situation 3. After successful conservative management of the first episode of acute diverticulitis 4. Where do we end up with elective colectomy?

Acute diverticulitis: bioclinical diagnostic approach
1. History and clinical examination 2. Temperature, CRP, white blood count

Acute diverticulitis: diagnostic approach
Temperature, white blood count and repartition: total abscess (542) (69) temperature > % % leucocytes > % % left shift > % %

of 150 patients, prospectively evaluated, clinically suspected of having acute diverticulitis only 64 (43%) were proven so on CT. Rao et al. Am J Radiol 1998; 170: of 120 patients clinically suspected of presenting acute diverticulitis, only 67 (56%) had this diagnosis proven by spiral CT Werner et al. Eur Radiol 2003; 13: In fact CT scan will confirm the diagnosis of acute diverticulitis in only one of two patients bioclinically suspected

Compared performance of CT and GE. : 420 patients (
Compared performance of CT and GE*: 420 patients (*gastrografin enema) (p=0.0001) CT GE N patients 420 Not diagnostic 18 (5%) 53 (13%) Ambrosetti et al. Dis colon rectum 2000; 43:

Compared performance of CT and GE: sensitivity based on 136 operated patients (p=0.01)
True + 130 (96%) 121 (89%) False + 4 False - 2 11 Sensitivity 98% 92%

Performance of GE in case of CT associated abscess (69 patients (16%))
n patients Severe GE (29%)* * Contrast extravasation 18

Diagnosis of diverticular abscess
CT is now universally recognized as the 1st line morphological exam and has been proven to be largely superior to contrast enema study Ambrosetti, Eur Radiol 2002; 12: Ambrosetti, Dis Colon Rectum 2000; 43: Lawrimore, J Intensive Care Med 2004; 19: Buckley, Clin Radiol 2004; 59:

CT in emergency situation (42 patients)
Chances of medical treatment failure: CT severe diverticulitis % (wait and see) CT moderate diverticulitis % (wait and sit)

First episode of suspected acute diverticulitis
What are we looking for? 1. The confirmation of the diagnosis 2. The severity of the diverticulitis What is the only tool to answer these questions CT (with oral, rectal and iv contrast)

How do we grade the severity of the diverticulitis ?
Modified Hinchey Classification: Stage 0: mild clinical diverticulitis Stage Ia: confined pericolic inflammation-phlegmon Stage Ib: confined pericolic abscess Stage II: pelvic, distant intraabdominal or retroperitoneal abscess Stage III: generalized purulent peritonitis Stage IV: fecal peritonitis

Why the CT appreciation of severity?
A. To guide the therapeutic strategies: Mild diverticulitis: conservative ambulatory care (antibiotics?) Stage Ia: conservative care with oral antibiotics Stage Ib and II: hospitalization, iv antibiotics, eventual CT drainage, possible surgery Stage III and IV: surgery B. To evaluate the chances of secondary bad outcome after a first episode of acute diverticulitis susccessfully treated conservatively

So, where is the challenge ?
The existence of an associated abscess

Why ? 1. Frequent (between 15 to 20%) rao et al. am j radiol 1998
ambrosetti et al. eur radiol 2002 werner et al. eur radiol 2003 2. Difficult to diagnose bioclinically 3. Therapeutically challenging

Types of acute treatment
Should we drain ? « …small pericolic abscess may resolve with antibiotic therapy and bowel rest… » « …today the decision to drain remains to be individualized 1 » 1. The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43:

Secondary treatment 1. « Recently, some surgeons have suggested that surgical resection may not be mandatory in every case after successful percutaneous drainage: however, at present there are insufficient data to support universal endorsement of this concept » The Standard Task Force and the American Society of Colon and Rectum Surgeons, Dis Colon Rectum 2000; 43: 2. « …do a percutaneous drainage where possible, followed later by sigmoid resection in most cases… » European Association of Endoscopic Surgery, Surg Endosc 1999; 13: 430-6

Abscess associated to diverticulitis
Between october 1986 to october 1997: 465 patients had a CT evaluation 76 (16.3%) had an associated mesocolic or pelvic abscess 73 patients could be followed-up Median follow-up: 43 months (2 – 180) 26 women and 47 men with a mean age of 68 (30 – 94) Ambrosetti et al. Dis colon rectum, march 2005

Therapeutic principles: Percutaneous CT drainage of abscess were done only if no bioclinical improvement were noted after 48 hours of parenteral antibiotics Elective colectomy after successful conservative management of the abscess was not an absolute indication and was adapted for each patient

Associated abscess Location and CT percutaneous drainage
n drained not drained (%) (%) Mesocolic (24) (76) Pelvic (29) (71)

Surgical vs conservative treatment: no op. : conservative treatment op
Surgical vs conservative treatment: no op.: conservative treatment op. 1: surgery during 1st hospitalisation op. 2: surgery later on N No op. (%) Op. 1 Op. 2 mesocolic 45 22 (49) 7 (15) 16 (36) Pelvic 28 8 (29) 11 (39) 9 (32)

Long-term evolution 1. No patient needed an emergency surgical treatment 2. 15 patients (21%) died during the course of the follow-up. No one died from complications related to the diverticular disease

Essential findings 1. Initial CT is indispensable to confirm the diagnosis and precise the severity of the diverticulitis 2. Patients with a pelvic abscess should be immediately drained 3. Mesocolic abscess ≥ 5 cm should probably be drained immediately 4. Secondary colectomy after pelvic abscess seems highly reasonnable 5. Secondary colectomy after successful conservative treatment of mesocolic abscess is probably not mandatory for all patients

Acute left colonic diverticulitis
Prospective study October 1986 – October 1997 University Hospital Geneva

Acute diverticulitis: prospective study
542 patients 290 women and 252 men Mean age: 64 (23-97)

Acute diverticulitis: profile of the study
Patients included: 1. Clinical and history compatibility 2. Radiological confirmation (CT and water-soluble contrast enema=GE) 3. Histological diagnosis 4. 1st hospital admission Patients excluded: No radiological or histological confirmation

Acute diverticulitis: radiological criteria (CT and GE)
Moderate diverticulitis Severe diverticulitis CT: localized wall thickening (>=5mm) Inflammation of pericolic fat The same + at least one of the following: Abscess Extraluminal air/ contrast GE: segmental lumen narrowing Tethered mucosa +/- mass effect

Acute diverticulitis Long-term follow-up after a 1st acute episode of left colonic diverticulitis: is surgery mandatory ? R. Chautems, P. Ambrosetti, C. Soravia American Society of Colorectal Surgeons San Diego, June 2001 Dis Colon Rectum 2002; 45:

Acute diverticulitis: aims of the study
To evaluate on a long term (9.5 years) the outcome of 118 patients treated medically with success for a 1st episode of diverticulitis To determine risk factors of poor evolution To assess the place of surgery To propose a timing for surgery

Acute diverticulitis: Post hospitalisation evolution
No complications: 80 patients (68%) Evolutive complications: 38 patients (32%) 24 deaths (20%) 21 not related to diverticular disease No emergency operation

Severity of the inflammation on CT
Identification of initial parameters predictive of evolutive complications Age Severity of the inflammation on CT

Acute diverticulitis: indication for elective colectomy
EAES: after 2 episodes of symptomatic diverticular disease ASCRS: after 2 episodes of uncomplicated diverticular disease (phlegmon), but maybe recommended after a single attack of complicated diverticulitis ACGE: recurrent attacks, complicated disease (abscess or fistula). After 1 episode in young and immunocompromised patients

So, what is the medical evidence to sustain such a proposition ?
1. For the ASCRS (American Society of Colon and Rectal Surgeons) Dis Colon Rectum 2000; 43: page 293 « resection after recurrent attacks of diverticulitis »: « … with each recurrent episode the patient is less likely to to respond to medical therapy (70 percent chance of response to medical therapy after the 1st attack vs. 6 percent chance after the third) (ref. 65) »

Reference 65… Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. BMJ 1969; 4:

What is the profile of this study?
Retrospective study of 521 patients (455 treated as in-patients) Royal Victoria Hospital, Belfast 1951 – 1965

Results of conservative treatment (317 patients)
78 (25%) were readmitted for a 2nd attack (3.8%) for a 3rd one 5 (1.6%) for a 4th one 1st admission: 3.3% mortality (mostly post-surgical) 1st recurrence: 7.7% mortality Conclusion: « medical treatment of recurrent disease was less rewarding than treatment of the presenting attack… »

Critical reviewing The diagnostic accuracy is weak and considerably increase the probability of false positive 13 (17%) of the 78 patients with recurrent attacks were readmitted between 0 and 3 months after their discharge Post-surgical and post-medical mortality are not precised It seems that only one patient (8%) of the 12 patients who had more than one recurrence died, so the mortality after more than 2 attacks is not greater than after 2 attacks

Then, what would be the reasons to propose elective colectomy ?
I see 2 good reasons: 1. The evidence that after acute diverticulitis successfully treated medically the risk of spontaneous evolutive morbidity/ mortality is greater than the one related to elective surgery 2. The persistance of symptoms not responding to conservative means clearly related to diverticular disease

So…is nature better than surgeon ?
A presently asymptomatic patient is sent to you for sigmoidectomy because he (or she) had more than 2 episodes of CT-proven acute diverticulitis how should you advise the patient?

No scientifically demonstrated answer
No evidence to support the idea that elective surgery should follow two attacks of diverticulitis…! Medline search of english literature Janes et al. Br J Surg 2005; 92:

bioclinically suspected diverticulitis
Diagnostic algorithm bioclinically suspected diverticulitis clinical diffuse peritonitis localized signs emergency surgery CT Mild inflam. mesocolic abcess mesocolic abscess pelvic abscess (< 5cm) (> 5cm) Oral AB iv AB iv AB+drainage iv AB+drainage drain if failure surgery if failure after 48 h

Secondary treatment What are the scientific evidences to sustain such a proposition: none !

So, what is the medical evidence to sustain such a proposition ?
2. For the American College of Gastroenterology: same reference of Parks’study But mentioned that this recommandation of elective resection after 2 attacks has been questioned by Lorimer

Is prophylactic resection valid as an indication for elective surgery in diverticular disease? Lorimer Can J Surg 1997 Retrospective study of 154 patients with complicated DD (perforation, fistula and obstruction) 1987 – 1995 Only 10% of these 154 patients had been treated conservatively for acute diverticulitis and only 5% had been hospitalized for this reason Conclusions: interval prophylactic resection in patients after 1 or 2 episodes of diverticulitis is unlikely to prevent late major complications of DD

Acute diverticulitis: risk of error on bioclinical ground
Moreaux (br j surg 1990): on 72 patients with chronic symptoms: 25 (35%) had an associated abscess! on the contrary Morson (clin gastroenterol 1975): one third of the patients operated on for diverticulitis had no histological acute inflammation!

Acute diverticulitis: postcolectomy functional results
Breen (dis colon rectum 1986): 27% of 89 patients with a 37 months follow-up had postcolectomy persistant symptoms! Good results were related to: Histological signs of acute inflammation Male Symptoms < 1 year Pain in left lower quadrant Radiological confirmation

Consensus on diverticular disease
1. EAES European Association for Endoscopic Surgery, Rome, June 1998 surg endosc 1999; 13: 2. ASCRS the American Society of Colon and Rectal Surgeons dis colon rectum 2000; 43: 3. ACGE the American College of Gastroenterology am j gastroenterol 1999; 94:

Acute diverticulitis: initial evaluation
EAES: CT ASCRS: clinical ground or CT, water-soluble contrast enema or us depending on severity of the disease ACGE: clinical ground or CT

CT and diverticulitis 1. Generalities 2. Presentation of the study
3. Compared performance with water-soluble enema (GE) 4. Prognostic value in acute setting 5. Prognostic evolutive value after 1st episode of diverticulitis successfully treated conservatively 6. Conclusion

1. About diagnosis elective indications 3. Geneva Prospective Study: - presentation - long-term evolution after a 1st acute attack treated conservatively - evolution of mesocolic and pelvic associated abscesses 4. Conclusions

What is the nature of the commonly accepted surgical aggressiveness ?
Famous frightening doctors: Colcock (Lahey Clinic) N Engl J Med 1958; 259: 570-3 Keighley (Queen Elizabeth Hospital, Birmingham) Br J Surg 1994; 81: 733-5 Irvin (Royal Devon and Exeter Hospital, UK) Br J Surg 1997; 84: 535-9 Coelioscopic surgery

From where is coming the new wind of surgical moderation ?
From part of the literature that did not confirm the announced fate of secondary perforation after conservative treatment of the first acute attack: 1. Larson Gastroenterology 1976; 71: 2. Simonowitz Am J Gastroenterol 1977; 67: 69-72 3. Haglung Ann Chir Gyneacol 1979; 68: 41-46 4. Nylamo Ann Chir Gyneacol 1990; 79: 5. Vignati Dis Colon Rectum 1995; 38: and…

And… 4. Guzzo, Hyman Dis Colon Rectum 2004; 47: 1187-90:
259 patients < 50 y.o. with a median follow-up of 5.2 years Of 196 who were conservatively treated, only one (0.5%) presented at a later date with perforation

Indications for elective colectomy
American and European Consensus unanimously agree that elective colectomy is indicated after 2 attacks of acute diverticulitis 1. EAES European Association for Endoscopic Surgery, Rome, June 1998 Surg Endosc 1999; 13: 2. ASCRS the American Society of Colon and Rectal Surgeons Dis Colon Rectum 2000; 43: 3. ACGE the American College of Gastroenterology Am J Gastroenterol 1999; 94:

Recurrence after a 1st episode of acute diverticulitis treated conservatively Elements of reflection… Are there initial predictive factors ? How severe can the recurrence be ?

1. About diagnosis elective indications 3. Geneva Prospective Study: - presentation - long-term evolution after a 1st acute attack treated conservatively - evolution of mesocolic and pelvic associated abscesses 4. Conclusions

Abscess associated to diverticulitis P. Ambrosetti, R. Chautems, Cl
Abscess associated to diverticulitis P. Ambrosetti, R. Chautems, Cl. Soravia From October 1986 to October 1997: 465 patients had a CT evaluation 76 (16.3%) had an associated mesocolic or pelvic abscess Median follow-up of 43 months for 73 patients to july 2002 47 women and 26 men with a mean age of 68 (24 – 94)

Therapeutic principles: Percutaneous CT drainage of abscess were done only if no bioclinical improvement were noted after 48 hours of parenteral antibiotics Elective colectomy after successful conservative management of the abscess was not an absolute indication and was adapted for each patient

Surgical vs conservative treatment: no op. : conservative treatment op
Surgical vs conservative treatment: no op.: conservative treatment op. 1: surgery during 1st hospitalisation op. 2: surgery later on N No op. (%) Op. 1 Op. 2 mesocol 45 22 (49) 7 (15) 16 (36) pelvic 28 8 (29) 11 (39) 9 (32)

Essential findings 1. Initial CT is indispensable to precise the severity of the diverticulitis, and help the physician to choose the best immediate and late therapeutic options 2. After a first attack of diverticulitis succesfully treated conservatively, diverticular perforation with generalized peritonitis is an exceptional type of recurrence

Acute diverticulitis: conclusions 1
After a 1st episode of diverticulitis successfully treated conservatively: A. Elective colectomy could be proposed for: 1. Patients ≤ 50 year old with a CT severe inflammation 2. Patients with a pelvic abscess (which should always be drained first and operated later on)

Acute diverticulitis: conclusions 2
B. Mesocolic abscess ≥ 5 cm should probably be drained immediatly C. Secondary colectomy after successful conservative treatment of mesocolic abscess is probably not mandatory for all patients… D. A trial of high fiber diet for the other patients seems reasonable

Results after elective coelioscopic sigmoidectomy
Prospective series of 50 patients operated electively laparoscopically between 1998 and 2005 All diverticulitis were CT proven Indications to sigmoidectomy: after 1 CT severe attacks in young patients after 2 attacks Questionnaire sent in March 2005: 36 patients already answered Mean follow-up: 39.5 mois

Postoperative abdominal pain
Group 1 = No abdominal pain: 19 (53%) Group 2 = Abdominal pain not existing before the operation: 9 (25%)

Group 1 vs group 2: properative bowel function (BF)
No abd. Pain (19) Abd. Pain (9) Normal preop. BF 15 (79%) 6 (67%) Diarrhea Constipation 3 2 Alternation constipation-diarrhea 1

Group 1 vs group 2: length of resected sigmoid
No difference: 24.3 cm (15-45) vs 24.2 cm (16-50)

Group 1 vs group 2 vs bowel function
No abd. Pain (19) Abd. Pain (9) 1stool/2-3 days 2 1-2 stools/D 13 (68%) 4 (44%) >2stools/D 4 >5 stools/D 1 Normal stools 9 (47%) 2 (22%) Soft stools Hard stools Alternation hard-soft 8 (42%) 6 (67%) Metamucil 11 (58%) Laxatives

Would you do again the operation
How does abdominal pain impact on the general impression of the patient? BF=bowel function FR=final result No abd. Pain (19) Abd. Pain (9) Postop. BF better 13 (68%) 3 (33%) Postop BF idem 5 Postop BF worse 1 FR good to excellent 15 (79%) 1 (11%) FR satisfying 4 FR poor 2 FR very poor Would you do again the operation 19 (100%) 7 (78%) Would you not do it again

The last parutions in literature
1. The value of CT: Ambrosetti et al. Eur Radiol 2002; 12: 2. When and who to operate: Chautems, Ambrosetti, Soravia et al. Dis Colon Rectum 2002; 45: 3. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon. A prospective study of 73 cases Ambrosetti, Chautems, Soravia et al. Dis Colon Rectum, sous presse

Geneva prospective study: last informations…
1. When and who to operate: Chautems, Ambrosetti, Soravia et al. Dis Colon Rectum 2002; 45: 2. The value of CT: Ambrosetti et al. Eur Radiol 2002; 12: 3. Left colonic diverticulitis: long-term evolution of associated mesocolic and pelvic abscesses Ambrosetti, Chautems, Soravia et al. under study

Associated abscess Multivariate analysis under study: Location Size
Drainage or no drainage Sex age

Acute diverticulitis: important findings
On a long term follow-up after successful conservative treatment of a 1st episode of left colonic diverticulitis: no death from the disease no emergency surgery

Consensus on diverticular disease
1. EAES European Association for Endoscopic Surgery, Rome, June 1998 Surg Endosc 1999; 13: 2. ASCRS the American Society of Colon and Rectal Surgeons Dis Colon Rectum 2000; 43: 3. ACGE the American College of Gastroenterology Am J Gastroenterol 1999; 94:

Acute diverticulitis: initial evaluation
EAES: CT ASCRS: clinical ground or CT, water-soluble contrast enema or us depending on severity of the disease ACGE: clinical ground or CT

Associated abscess N Diameter (cm) Drained (%) Not drained Meso non op
22 4.3 (0.5-8) 5/ (23) 17/22 (77) Meso op 23 4.7 (2-13) 6/ (26) 17/23 (74) Pelvic non op 8 5.4 (2-9) 4/8 (50) 4/8 (50) Pelvic op 20 5.5 (2-9) 4/ (20) 16/20 (80)

Temperature, white blood count and repartition: total abscess (542) (69) temperature > % % leucocytes > % % left shift > % %

Acute diverticulitis: risk of error on bioclinical ground
Moreaux (Br J Surg 1990): on 72 patients with chronic symptoms: 25 (35%) had an associated unsuspected abscess! on the contrary Morson (Clin Gastroenterol 1975): one third of the patients operated on for diverticulitis had no histological acute inflammation!

Acute diverticulitis: postcolectomy functional results
Breen (Dis Colon Rectum 1986): 27% of 89 patients with a 37 months follow-up had postcolectomy persistant symptoms! Good results were related to: Histological signs of acute inflammation Male Symptoms < 1 year Pain in left lower quadrant Radiological confirmation

Acute diverticulitis: priority
During the 1st suspected episode of acute diverticulitis: immediate and later therapeutic strategies depend of the quality of the initial evaluation

Acute diverticulitis Radiological investigations: which ones?
Elective surgery: who? when?

Drainage related to size and location of the abscess
Mean size mesocol (cm) Mean size pelvic size≥5c Mesocol Pelvic Drained 6.8 (3.5-13) 6.6 (4-9) 8/11 (73%) 7/8 (88%) Not drained 3.8 (0.5-8) 5 (1-9.5) 12/34 (35%) P=0.03 10/20 (50%) P=0.07

Acute diverticulitis: bioclinical diagnostic approach
1. History and clinical examination 2. Temperature, CRP, white blood count

Age : p = 0.007 Age Nb No complic Complic ≤ 50 27 12 (44%) 15 (56%) > 50 91 68 (75%) 23 (25%)

CT severity: p = 0.003 Severity No complication Complication 30 severe
14 (47%) 16 (53%) 88 mild 66 (75%) 22 (25%)

Associated abscess: drainage
n drained not drained (%) (%) Mesocolic (24) (76) Pelvic (29) (71)

Reflection about natural evolution of diverticular disease after a 1st episode of acute diverticulitis In 2004 diagnosis and signs of severity of acute diverticulitis can only be precised on a CT scan The study of natural evolution of diverticular disease after a 1st episode of acute diverticulitis has to be based on the prognostic value of CT signs grading the severity of the inflammation Bias of the patients treated conservatively is related to the poorly defined indications for surgery

Acute diverticulitis: patients and methods
59 women and 59 men Median age: 63 (23-93) Median follow-up: 9.5 years ( ) Follow-up: Rehospitalisation (s) Questionnaires to patients and/ or physicians

Age and CT severity Age/severity Nb Complication No complication
≤ 50 moderate 14 6 (43%) 8 (57%) ≤ 50-severe 13 9 (69%) 4 (31%) >50 moderate 74 16 (22%) 58 (78%) > 50-severe 17 7 (51%) 10 (59%)

Introduction 1. Diverticular disease along the time:
1.1. rate of hospital admission in England 1.2. Incidence of perforated colonic diverticular disease 2.

1. Increase of annual age-standardized hospital admissions:
1.1. Hospital admissions in England between 1989/ 1990 and 1999/ 2000 kang et al. Aliment Pharmacol Ther 2003 1. Increase of annual age-standardized hospital admissions: 16% for males 12% for females 2. Increase of rates of operations at 1st admission: 16% fro males 14% for females 3. No change in population mortality

1.2. Incidence of perforated colonic diverticular disease (PCDD)
The incidence rate of PCDD seems to increase over these last years: 1.1. the annual prevalence in Northern Finland went from 2.4 per in 1986 to 3.8 per in 2000 dis colon rectum 2002 1.2. In Texas, San Antonio Hospital, it is reported a 75% increase in the rate of emergency operations for PCDD over a 15-year period arch surg 2000

2. Risk factors of PCDD 2.1. The strongest and most consistent evidence in case series and case-control studies is the NSAID use bmj 1985 / bmj 1987 / br j surg 1990 / br j surg 1991 / ann r coll surg engl 2002 2.2. Long-term or high steroid-dose am j surg 1971 / arch surg 1991 / ann thorac surg 1996 / j heart lung transplant 1997 2.3. Opiate analgesics br j surg 2003 2.4. Diet fiber deficiency gut 1985 / am j clin nutr 1994

3. Prevention of complications of colonic diverticulosis
3.1. high fiber diet 3.2. sequential oral antibiotics 3.3. calcium channel blockers

3.1. High fiber diet A high fiber diet, poor in total fat and red meat in association with regular physical training could play a role in preventing complications of diverticulosis 1. Hyland et al. Does a high fibre diet prevent the complications of diverticular disease? Br J Surg 1980; 67: Painter NS. Diverticular disease of the colon: the first of the Western diseases shown to be due to a deficiency of dietary fibers. S Afr Med J 1982; 61: 3. American Medical Association, Council on Scientific Affairs. Dietary fiber and health: Council report. JAMA 1989; 262: 542-6 4. Aldoori et al. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol 1995; 5: 221-8 5. Aldoori et al. A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr 1998; 128: 714-9 6. Aldoori, Ryan-Harshman. Preventing diverticular disease. Canadian Family Physician, octobre 2002, p. 1 à 8

3.2. Sequential oral antibiotics +/- 5-ASA
Beneficial effect of sequential oral rifaximin +/- associated with mesalazine on symptomatic or recurrent diverticular disease 1. Papi et al. Efficacy of rifaximin on symptoms of uncomplicated diverticular disease of the colon. A pilot multicenter open trial. Diverticular Disease Study Group. Ital J Gastroenterol 1992; 24: 452-6 2. Papi et al. Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon. A multicentre double-blind pacebo-controlled trial. Aliment Pharmacol Ther 1995; 9: 33-9 3. Trespi et al. Therapeutic and prophylactic role of mesalazine (5-ASA) in symptomatic diverticular disease of the large intestine: 4 year follow-up results. Minerva Gastroenterol Dietol 1999; 45: 4. Tursi et al. Long-term treatment with mesalazine and rifaximin vs rifaximin alone for patients with recurrent attcks of acute diverticulitis of colon. Digest Liver Dis 2002; 34:

3.3. Calcium channel blockers
A recent case-control study seems to show for the first time that a protective association exists between calcium channel blockers and PCDD morris et al. gut 2003

Results of elective colectomy
Recurrence Functional results

1. Recurrence Level of anastomosis (colosigmoid or colorectal) is the only recognized predictor of recurrence which varies from 4 to 8% 1. Benn et al. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151: 2. Bergamaschi et al. Anastomosis level and specimen length in surgery for uncomplicated diverticulitis of the sigmoid. Surg Endosc 1998; 12: 3. Thaler et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003; 46:

Its incidence varies from 20 to 27%
2. Persisting symptoms Its incidence varies from 20 to 27% 1. Breen et al. Are we really operating on diverticulitis? Dis Colon Rectum 1986; 29: 174-6 2. Munson et al. Diverticulitis: a comprehensive follow-up. Dis Colon Rectum 1996; 39: 3. Stevenson et al. Laparoscopic assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients. Ann Surg 1998; 227: 4. Thörn et al. Clinical and functional results after elective colonic resection in 75 consecutive patients with diverticular disease. Am J Surg 2002; 183: 7-11

2. Persisting symptoms: etiology
1. Limited sigmoid resection Munson et al. Diverticulitis: a comprehensive follow-up. Dis Colon Rectum 1996; 39: 2. No histological inflammation on the specimen Breen et al. Are we really operating on diverticulitis? Dis Colon Rectum 1986; 29: 174-6 3. Functional history of « irritable bowel syndrome » Stevenson et al. Laparoscopic assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients. Ann Surg 1998; 227: Thörn et al. Clinical and functional results after elective colonic resection in 75 consecutive patients with diverticular disease. Am J Surg 2002; 183: 7-11

1. Introduction 2. Bioclinic approach of acute diverticulitis 3. Elective colectomy: long-term results 4. Open vs laparoscopic sigmoidectomy: the same operation? 5. Geneva Prospective Study: - presentation - long-term evolution after a 1st acute attack treated conservatively - evolution of mesocolic and pelvic associated abscesses 6. Conclusions

3. Colectomie conventionnelle et coelioscopique: la même opération?
What do we know about the operative quality of laparoscopic colectomy compared to open one? Recurrence rates at minimum 5-year follow-up: laparoscopic vs open sigmoid resection for uncomplicated diverticulitis Klaus, Wexner et al. Surg Laparosc Percutan Tech 2003;

Klaus, Wexner et al. Retrospective study with prospective data Two institutions (France and US) 79 comparable patients in each group Conversion rate 6% No mortality No anastomotic leaks

Significant differences
Variable Laparoscopic N=79 (%) Open P Splenic angle down 19 (24) 41 (52) 0.001 Specimen length 16.1+/-5.5 18.3+/-4.1 0.043 Inflammed prox. Resection margin 21 (27) 4 (5) Taenia at distal resection margin 53 (70)

Does it influence recurrence rate?
NO ! 3 (4%) for laparoscopy vs 7 (10%) for open

1. Introduction 2. Bioclinic approach of acute diverticulitis 3. Elective colectomy: long-term results 4. Open vs laparoscopic sigmoidectomy: the same operation? 5. Geneva Prospective Study: - presentation - long-term evolution after a 1st acute attack treated conservatively - evolution of mesocolic and pelvic associated abscesses 6. Conclusions

Criteria of selection 1. Diagnosis of diverticular disease (DD) :
clinical features + one or both of the following: 1. Radiological evidence of diverticula or deformity consistent with DD 2. Confirmation of the presence of diverticula or of local inflammatory involvement of the colon consistent with DD at operation or necropsy 2. Diagnosis of diverticulitis: clinical findings of inflammation (tenderness, pyrexia, mass, leucocytosis) radiological changes consistent with inflammatory involvement histological confirmation of inflammation (operation or necropsy)

Characteristics of the cohort
patients had a final diagnosis of diverticulitis 95 (18%) had an inconclusive diagnosis have a barium enema: 230 had the diagnosis of diverticulosis 231 had the diagnosis of diverticulitis (performance of 59%) 3. Only 198 (38%) had a normal bowel habit before the diverticulitis (23%) had a frank bleeding

Results on the 455 in-patients
138 (30%) had surgical treatment during their 1st admission or shortly after Of the 317 patients treated conservatively: 78 (25%) were readmitted for a 2nd attack (3.8%) for a 3rd one 5 (1.6%) for a 4th one Mortality during 1st admission was 3.3% (15 of 455 patients, mostly post-surgical) Mortality of the 1st recurrence was 7.7% (6 of 78 patients) so twice that of the presenting attack Conclusion: « medical treatment of recurrent disease was less rewarding than treatment of the presenting attack… »

Types of acute treatment
Parenteral antibiotics alone Parenteral antibiotics + Drainage: 2.1. percutaneous CT-guided Neff, Radiology 1987; 163: 15-8 Mueller, Radiology 1987; 164: 321-5 Stabile, Am J Surg 1990; 159: Van Sonnenberg, World J Surg 2001; 25: 2.2. transrectal Finne, Dis Colon Rectum 1980; 23: 293-7 2.3. Transcolonic under EUS Baron, Gastrointest Endosc 1997; 45: 84-7 Attwell, Gastrointest Endosc 2003; 58: 2.4. Laparoscopically Franklin, Surg Endosc 1997; 11:

Drainage related to size and location of the abscess
Mean size mesocol (cm) Mean size pelvic size≥5cm Mesocol Pelvic Drained 6.8 (3.5-13) 6.6 (4-9) 8/11 (73%) 7/8 (88%) Not drained 3.8 (0.5-8) 5 (1-9.5) 12/34 (35%) P=0.03 10/20 (50%) P=0.07

Diagnostic value of CT for suspected diverticulitis
authors Sensitivity Specificity PPV NPV Accuracy Alternativ diagnosis seen (%) Cho 93 100 NA 69 Stefansson Pradel 91 77 81 88 84 50 Rao 97 98 58 Ambrosetti Na

Preoperative diagnostic algorithm in colon diverticular disease

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