1. Update on management of colonic diverticulitis Dr. Nerissa Mak Oi Sze Department of Surgery North District Hospital/ Alice Ho Miu Ling Nethersole Hospital Joint Hospital Surgical Ground Round 11 th February 2012

2. Colonic Diverticulitis A common disease 90% involving sigmoid colon Classification –Asymptomatic (diverticulosis) –Diverticulitis Uncomplicated diverticulitis Complicated diverticulitis –Perforation –Abscess –Fistula –Obstruction –hemorrhage Chapman et al. Ann Surg 2005

3. Acute management of diverticulitis Hinchey’s classification of diverticulitis & management

4. Evolution of management of perforated diverticulitis 3 stage procedure –Mortality approaching 25% Classen et al. Ann Surg 1976 198020002010

5. Evolution of management of perforated diverticulitis Favor resectional surgery –Lower mortality compared with non-resectional surgery Hartmann’s operation –Mortality drop by half compared with 3 stage procedure Krukowski et al. Br J Surg 1984 198020002010

6. Evolution of management of perforated diverticulitis Primary Resection and Anastomosis (PRA) –Comparable mortality rate with Hartmann’s operation –An effective alternative to Hartmann’s procedure Constantinidas et al. Dis Colon Rectum 2006 198020002010

7. Is PRA good enough? Mortality rate 10-20% Morbidity rate 29% –Leakage rate 14% Salem et al. Dis Colon Rectum 2004 Any better alternatives?

8. Evolution of management of perforated diverticulitis Non-resectional approach: Laparoscopic Lavage –Lower morbidity & mortality –Stoma avoidance Mahdi Alamili et al. Dis Colon Rectum 2009 198020002010

9. Evolution of management of perforated diverticulitis Non-operative approach –Avoid emergent operation in >90% cases Sekhar Dharmarajan et al. Dis Colon Rectum 2011 Costi et al. Surg Endosc 2012 198020002010

10. Today’s focus: For perforated diverticulitis: Operative or non-operative approach? Resection or non resection?

11. Joint Hospital Surgical Ground Round 11 th February 2012 Update on management of colonic diverticulitis Management of Perforated Diverticulitis Operative Vs Non-operative

12. Costi et al. Surg Endosc 2012 Sekhar Dharmarajan et al. Dis Colon Rectum 2011 Retrospective review CT diagnosed perforated acute diverticulitis

13. Conservative management in perforated diverticulitis Sekhar Dharmarajan et alCosti et al Year20112012 Cases13639 Successful conservative management 91.2% (n=124) 92.3% (n=36) Reasons for emergent operation Free gas with non-loculated free fluid on CT Haemodynamically unstable Generalized peritonitis Symptoms failed to resolve in 4-5 days Clinical deterioration Symptoms failed to resolve up to 7 days *Clinical signs of peritonitis is not an indication for EOT *Active rectal contrast extravasation on CT or unstable patients were excluded Overall mortality3%0%

14. Contraindications of conservative management Sekhar Dharmarajan et al. Dis Colon Rectum 2011 Costi et al. Surg Endosc 2012 Hemodynamically unstable CT features suggestive of perforated communicating peritonitis Failed rapid response to conservative management

15. Conservative management in perforated diverticulitis Sekhar Dharmarajan et al. Dis Colon Rectum 2011 Costi et al. Surg Endosc 2012 Pneumoperitoneum is not an indication for emergency operation Can be attempted in case of –Hemodynamically stable –CT features not suggestive of perforated communicating peritonitis Await comparative study or multicentre prospective trials

16. Joint Hospital Surgical Ground Round 11 th February 2012 Update on management of colonic diverticulitis Management of Perforated Diverticulitis Resection Vs Non-Resection

17. Drawback of resectional approach McGillicuddy et al. Arch Surg 2009 Maggard et al. Am Surg 2004 Vermeulen et al. Colorectal Dis 2009 High mortality rate –Up to 35% after emergency operation for diverticulitis Morbidity secondary to stoma –Up to 35-55% of patients never have the stoma reversed –Reversal of stoma also have significant morbidities

19. Mahdi Alamili et al. Dis Colon Rectum 2009

21. Laparoscopic Lavage in perforated diverticulitis Low morbidity of 10% Low mortality of 1.4% Overall conversion rate of 3% Shorter length of stay (median 9 days; compared with 20-38 days after Hartmann’s operation Avoidance of colostomy Majority of patients with Hinchey Grade 3 diverticulitis can effectively be managed by laparoscopic lavage in the acute setting Mahdi Alamili et al. Dis Colon Rectum 2009

22. Laparoscopic Lavage The new standard of care? The inclusion criteria was not clear –Some depends on clinical signs of peritonitis, some required surgical diagnosis of perforated diverticulitis Relatively young age Generally small number of patients Lack of RCT Further evidence required to become the recommended treatment

23. For Hinchey Grade 4… Only 4 studies include cases of Hinchey Grade 4 2 out of 8 patients failed laparoscopic treatment and required Hartmann’s procedure Larger studies are also required

24. In summary For perforated diverticulitis: Non-operative management may be attempted in selected group of patients Resection is still the standard treatment Laparoscopic lavage is a possible alternatives