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Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la malattia diverticolare del colon Possibilità di trattamento.

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Presentation on theme: "Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la malattia diverticolare del colon Possibilità di trattamento."— Presentation transcript:

1 Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la malattia diverticolare del colon Possibilità di trattamento chirurgico laparoscopico

2 Laparoscopic colonic resections for diverticular disease Results of a single center series of 105 pts. Surgical strategy and technique Laparoscopic colonic resections for diverticular disease Results of a single center series of 105 pts. Surgical strategy and technique Osp. Ital. Chir. 9: ; 2003

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4 Cases N°: m 61 f Mean age : 68.3 (min.30, max.81) Laparoscopic left colon resections for diverticulitis. Personal experience: 105 cases Left colectomies : 84 Segmental resections : 21

5 Laparoscopic left colon resections for diverticulitis. Personal experience: 105 cases ASA 148 (45,7%) ASA 250 (47,7%) ASA 3 7 (6,6%) ASA 4 0 (0%) Hinchey Classification I pericolic abscess II pelvic abscess III purulent peritonitis IV fecal peritonitis

6 Indications for surgery -2 or more diverticulitis episodes 56,2% - 2 or more diverticulitis episodes 56,2% - 1 severe diverticulitis episode in patients < 50 years 10,5% - Stenosis 5,7% - Fistula with urinary bladder 2,9% - Ileo-colic fistula 1,9% - Hinchey I Peridiverticular abscess 14,3% - Hinchey II Pelvic abscess 1,9% (percutaneous drainage and surgery) (percutaneous drainage and surgery) - Hinchey III Previous peritonitis 1,9% (laparoscopic lavage and resection after 6-8 weeks ) (laparoscopic lavage and resection after 6-8 weeks ) - Perforation 3,8% - Acute bleeding (embolization and surgery) 0,9% Patients affected by stercoral peritonitis (Hinchey IV) were excluded from present study. Recurrent diverticulitis or severe in young patients Urgency Stenosis Abscess and fistula

7 Surgical strategy - Primary identification of embryonary planes and ligation of the vessels with dissection from right to left and from up to bottom

8 Diffuse diverticular disease Standard left colectomy Diverticular disease localized in the sigmoid colon Sigmoid resection with preservation of the origin of IMA and left colic artery

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11 leaving the treatment of the fistula at the end Diverticular disease with fistula leaving the treatment of the fistula at the end - Ileo-colic fistula - Colo-vaginal or colo-vescical fistula

12 - Small pericolic abscess (Hinchey I) - Antibiotic therapy - TPN - Elective laparoscopic colectomy - Voluminous abscess (over 5 cm.) (Hinchey II) -Percutaneous drainage US or CT-guided - Percutaneous drainage US or CT-guided - Antibiotic therapy and TPN - Elective laparoscopic colectomy Diverticular disease with abscess

13 Diverticular disease with peritonitis Localized peritonitis Diffuse purulent peritonitis Fecal peritonitis

14 T 1 T 3 T 2 T 4 T 5 EMICOLECTOMIA SINISTRA

15 Surgical technique 1 - Preparation of the patient - Preparation of the operating field - Position of the surgeons - Exposure of the operating field - Identifying Gerotas fascia and sectioning the vessels

16 Surgical technique 2 - Lowering of the splenic flexure - Sectioning of the mesorectum and the rectum - Service minilaparotomy, extraction of the operative specimen and execution of the colo-rectal anastomosis

17 - Operating time163,3 min (range min) - Conversion rate 0,9% (1 case cirrhosis, severe diverticular disease) - I.op blood loss 66 ml (range ml) - Post-op blood loss 0,9% (1 case 2 units of blood) - Operating time163,3 min (range min) - Conversion rate 0,9% (1 case cirrhosis, severe diverticular disease) - I.op blood loss 66 ml (range ml) - Post-op blood loss 0,9% (1 case 2 units of blood) Results: 105 cases

18 - I.op. complications 0 - Average lenght of specimen25,05 cm. - Histological examination: Deaths - Deaths Results:Results: 2 (1,9%) adenocarcinomas 1 (0,9%) villous adenoma with severe displasia 1 (0,9%) pulmonary embolism on the 4th postoperative day

19 Results Post-operative complications12 pts11,4% - bleeding from anastomosis 1 0,9% - ileal perforation (reoperated) 1 0,9% - intraperitoneal bleeding 1 0,9% - wound infections 6 5,7% - abdominal fluid collection 3 2,8%

20 Results - Anastomotic leaks 0% - Restoring intestinal function 2,1 days - Oral liquid diet 2,4 days - Average hospital stay 9,2 days (range 7-18) Last 50 cases: average number of days effectively required for hospital treatment: 5,2 days (range 4-12)

21 Results: monocentric studies AuthorsyearPtsConversionsLeaksStenosis Operative times (min) Hospital stay (days) Bruce %4.0%0% Sher %5.0%0% Trebuchet %2.9%5.9% Berthou %1.0%4.0% Sala %2.8%0% Sartori %0%0.9% Schwandner %1.6%2.7%

22 Results: multicentric studies AuthorsyearPtsConversionsLeaksStenosis Operative times (min) Hospital stay (days) Franklin %0%1%-10.7 Kockerling %1.4%-164- Buillot %1.1%0.5%22313

23 Average operative time for colectomy for diverticulitis

24 Conversions: 17 (4,7%) %

25 TIPI DI CONVERSIONE Conversioni precoci Conversioni tardive

26 CAUSE DI CONVERSIONE Di principioLaparoscopia esplorativa Di necessitàPer impossibilità tecnica di proseguire in LAPS Per una complicanza intra-operatoria

27 Conversione di necessità tempi operatori tempi operatori morbilità morbilità costi costi

28 Cause di conversione Conversion rates in laparoscopic colorectal surgery A predicitive model with 1253 patients PP Tekkis, AJ Senagore, CP Delaney Departement of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation Surg. Endosc :47-54 %conversione Grado ASA 3-413,8 Obesità BMI >28,515,4 Tipo intervento: resezione bassa retto15,3 ascesso o fistola31,6 e 29,3 esperienza del chirurgo13,2 vs 8,7 % media di conversione su 1253 pazienti10.0%

29 Risk factors for conversion Le Moine, Br J Surg, 2003 Converted N = 24 Not converted N = 144 P Sigmoid stenosis* 10 (41.7) 28 (19.4) Pathological examination DiverticulosisDiverticulitisAbscess/perforationCancer 9 (37.5) 4 (16.7) 10 (41.7) 1 (4.2) 82 (56.9) 22 (15.3) 34 (23.6) Conversion rate/year (44.4) 15 (14.9) 1 (2) * Diagnosed at BE or colonoscopy

30 Laparoscopy: Diverticulitis Gonzalez et al, Surg Endosc 2004 Laparoscopy n = 95 Open n = 80 Demographics Age (years) Age (years) Sex (male:female) Sex (male:female) BMI (Kg/m 2 ) BMI (Kg/m 2 ) : : IndicationsDiverticulitis Perforated Perforated Fistula Fistula Stricture StrictureDiverticulosis

31 Laparoscopy: Diverticulitis Results Gonzalez et al, Surg Endosc 2004 Laparoscopy n = 95 Laparotomy n = 80 Operative time (min) Intraoperative complications 5 (5) 5 (6) Estimated blood loss (cc) * * Transfusions * 3 (4) 11 (14)* Time to first BM (h) * * Length of stay (d) * * Postoperative complications * 17 (19) 25 (31)* Mortality 1 (1) 3 (4) * (p< 0.05) - n (%)

32 Results-Open versus Laparoscopy Morbidity Hinchey IIA and IIB Hinchey IIA and IIB OverallLate experienceexperience * 13 * P<0.05 Morbidity (%) Sher et al, Surg Endosc, 1997

33 Results-Open versus Laparoscopy Hospital stay Days Sher et al, Surg Endosc, * 5 * * p<0.05 § P< § 9 5

34 Laparoscopy: Diverticular disease VariableLaparoscopicOpen Age (years)5952 Weight (pounds) ASA class Perforated75 Abscess1818 Operative time (minutes)* Blood loss (ml) Coogan et al, Surg Endosc 1997 (P<0.001)

35 VariableLaparoscopicOpen Oral intake (days)* Hospital stay (days)** OR cost ($)15,2007,200 Hospital cost ($)1,7006,800 Total cost ($)17,00015,800 *p<0.0001**p<0.001 Laparoscopy: Diverticular disease Coogan et al, Surg Endosc 1997

36 Author/yearnLap/Open OR ($) Hospital ($) Dwivedi/ Lap Open 9,566* 7,306 9,566* 7,306 13,953 14,863 Senagore/ Lap Open 1,694* 1,426 3,458* a 4,321* Lawrence/ Lap Open ,414 25,700 *p<0.05 a= Total direct cost/case Laparoscopy: Diverticular disease Costs

37 BMI No. of patients Age (yr: mean- range) Gender (M:F) Normal weight Group I (37-78) 16:13 Overweight Group (31-83) 14:13 Obese Group (33-86) 14:13 Morbidly Obese > Tuech et al. Surg Endosc 2001 Laparoscopy: Diverticulitis Obesity

38 Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Anastomotic leak (a) 101 Wound infection 223 Pulmonary infection 010 Postoperative ileus 100 Urinary infection 110 TOTAL (%) 5 (17.2) 4 (14.8) (b) 4 (19) (c) a.Anastomotic leak resolved with conservative drainage b.Group 1 vs. Group 2 – p=0.54 c.Group 1 vs. Group 3 – p=0.57 Tuech et al. Surg Endosc 2001 Laparoscopy: Diverticulitis Obesity

39 Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Mean hospital stay (d) (a) 9.8 (b) Inpatient rehabilitation 4/293/27 (c) 3/21 a.Hospital stay Group 1 vs. Group 2: p=0.31 b.Hospital stay Group 1 vs. Group 3: p=0.14 c.Inpatient rehabilitation Group 1 vs Group 2: p=0.54 d.Inpatient rehabilitation Group 1 vs Group 3: p=0.63 Tuech et al. Surg Endosc 2001 Laparoscopy: Diverticulitis Obesity

40 > 75 yrs < 75 yrs n= 22n = 63 Mean age (yrs)77.2 (75-82) 53.7 (38-74) Gender (M:F)10:1228:35 Operative time (min) IV analgesia(days) Morbidity (%)1814 Mortality 00 Conversion (%)96 Hospitalization (days)* Teuch et al. Hepatogast 2001 * p=0.003 Laparoscopy: Elderly

41 Laparoscopic Open p value n= 22 n = 24 Mean age (yrs)77.2 (75-82) (76-84) NS Gender (M:F)10:12 10:14 NS Operative time (min) NS IV analgesia(days) Morbidity (%) Mortality 0 0 NS Inpatient rehabilitation Hospitalization (days) Teuch et al. Surg Endosc 2000 Laparoscopy: Elderly

42 Laparoscopy: Diverticulitis Emergency 18 patients- acute perforation Laparoscopic lavage and suction + Omental patch closure 7.5 days in hospital 4-34 month follow-up Subsequent elective resection with primary anastomosis possible Franklin et al., Surg Endosc 1997

43 90% Success Elective resection- 4-5 days in hospital 5% Morbidity Better than Laparotomy Applicable in complex cases as well (Fistula, Abscess, Perforation) Franklin et al., Surg Endosc 1997 Laparoscopy: Diverticulitis Emergency

44 Conclusions - Surgical treatment of complicated diverticular disease carried out laparoscopically gives good results in terms of morbidity and mortality and confers many advantages over the traditional approach

45 Conclusions - Laparoscopy requires its own specific surgical strategy - The surgical team must be expert in laparoscopic surgery and in colo-rectal surgery - Emergency cases should be performed only by experienced laparoscopic surgeons

46 Conclusions - The technique must be standardized so that the incidence of complications, operating time and the rate of conversions to open surgery can be minimized


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