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Dr. Carlo Augusto Sartori

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

2 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 Laparoscopic left colon resections for diverticulitis
Laparoscopic left colon resections for diverticulitis. Personal experience: 105 cases 44 m Cases N°: 105 61 f Mean age : 68.3 (min.30, max.81) Left colectomies: 84 Segmental resections : 21

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

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

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

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

14 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 Gerota’s 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 Results: 105 cases - Operating time 163,3 min (range 80-300 min)
- Conversion rate 0,9% (1 case cirrhosis, severe diverticular disease) - I.op blood loss ml (range ml) - Post-op blood loss 0,9% (1 case 2 units of blood)

18 Results: - I.op. complications 0
- Average lenght of specimen 25,05 cm. - Histological examination: - Deaths 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 complications 12 pts 11,4%
- bleeding from anastomosis ,9% - ileal perforation (reoperated) ,9% - intraperitoneal bleeding ,9% - wound infections ,7% - abdominal fluid collection ,8%

20 Results - Anastomotic leaks 0%
- Restoring intestinal function 2,1 days - Oral liquid diet ,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
Authors year Pts Conversions Leaks Stenosis Operative times (min) Hospital stay (days) Bruce 1996 25 12.0% 4.0% 0% 397 4.2 Sher 1997 18 39.0% 5.0% 215 5.0 Trebuchet 1999 170 2.9% 5.9% 141 8.5 Berthou 110 8.0% 1.0% 166 8.0 Sala 2000 45 7.4% 2.8% 162 7.9 Sartori 2003 105 0.9% 163 9.2 Schwandner 2004 396 6.8% 1.6% 2.7% 193 11.8

22 Results: multicentric studies
Authors year Pts Conversions Leaks Stenosis Operative times (min) Hospital stay (days) Franklin 1997 54 27.% 0% 1% - 10.7 Kockerling 1999 304 7.2% 1.4% 164 Buillot 2002 179 13.9% 1.1% 0.5% 223 13

23 Average operative time for colectomy for diverticulitis

24 Conversions: 17 (4,7%) %

25 Conversioni “precoci”
TIPI DI CONVERSIONE Conversioni “precoci” Conversioni “tardive”

26 CAUSE DI CONVERSIONE Di principio Laparoscopia esplorativa
Di necessità Per impossibilità tecnica di proseguire in LAPS Per una complicanza intra-operatoria

27 Conversione di necessità
tempi operatori morbilità 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 3-4 13,8 Obesità BMI >28,5 15,4 Tipo intervento: resezione bassa retto 15,3 ascesso o fistola 31,6 e 29,3 esperienza del chirurgo 13,2 vs 8,7 % media di conversione su 1253 pazienti 10.0%

29 Risk factors for conversion
Converted N = 24 Not converted N = 144 P Sigmoid stenosis* 10 (41.7) 28 (19.4) 0.025 Pathological examination Diverticulosis Diverticulitis Abscess/perforation Cancer 9 (37.5) 4 (16.7) 1 (4.2) 82 (56.9) 22 (15.3) 34 (23.6) 0.035 Conversion rate/year 1994 8 (44.4) 15 (14.9) 1 (2) 10 86 48 0.002 * Diagnosed at BE or colonoscopy Le Moine, Br J Surg, 2003

30 Laparoscopy: Diverticulitis
Laparoscopy n = 95 Open n = 80 Demographics Age (years) Sex (male:female) BMI (Kg/m2) 47:48 31 + 6 32:48 28 + 2 Indications Diverticulitis Perforated Fistula Stricture Diverticulosis 78 12 7 1 17 58 13 9 22 Gonzalez et al, Surg Endosc 2004

31 Laparoscopy: Diverticulitis Results
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) * 67 + 7 88 + 5* Length of stay (d) * 7 + 1 12 + 2* Postoperative complications * 17 (19) 25 (31)* Mortality 1 (1) * (p< 0.05) - n (%) Gonzalez et al, Surg Endosc 2004

32 Results-Open versus Laparoscopy Morbidity
43 29* 29 13 Hinchey IIA and IIB Overall Late experience experience * P<0.05 Sher et al, Surg Endosc, 1997

33 Results-Open versus Laparoscopy Hospital stay
7* 5 * * p<0.05 § P<0.01 10§ 9 Days Sher et al, Surg Endosc, 1997

34 Laparoscopy: Diverticular disease
Variable Laparoscopic Open Age (years) Weight (pounds) ASA class Perforated Abscess Operative time (minutes)* Blood loss (ml) (P<0.001) Coogan et al, Surg Endosc 1997

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

36 Laparoscopy: Diverticular disease
Costs Author/year n Lap/Open OR ($) Hospital ($) Dwivedi/02 Lap Open 9,566* ,306 13, ,863 Senagore/02 1,694* ,426 3,458* a 4,321* Lawrence/03 Lap Open --- 17, ,700 *p<0.05 a= Total direct cost/case

37 Laparoscopy: Diverticulitis Obesity
BMI No. of patients Age (yr: mean-range) Gender (M:F) Normal weight Group I 29 58.4 (37-78) 16:13 Overweight Group 2 27 55.2 (31-83) 14:13 Obese Group 3 21 54.1 (33-86) Morbidly Obese >40 --- Tuech et al. Surg Endosc 2001

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

39 Laparoscopy: Diverticulitis Obesity
Group 1 (n=29) Group 2 (n=27) Group 3 (n=21) Mean hospital stay (d) 8.2 8.5 (a) 9.8 (b) Inpatient rehabilitation 4/29 3/27 (c) 3/21 Hospital stay Group 1 vs. Group 2: p=0.31 Hospital stay Group 1 vs. Group 3: p=0.14 Inpatient rehabilitation Group 1 vs Group 2: p=0.54 Inpatient rehabilitation Group 1 vs Group 3: p=0.63 Tuech et al. Surg Endosc 2001

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

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

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 Laparoscopy: Diverticulitis Emergency
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

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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