1. Management of Colonic Diverticulitis
Joint Hospital Surgical Grand Round
24th Oct 2009

2. Diverticular Disease
The sigmoid colon is most commonly affected (> 90% of cases) 
Proximal colonic involvement in 40% of patients

3. Diverticular Disease
Prevalence
~40% of people by the age of 65 years
~60% of people by the age of 80 years.
~10% to 25% of patients with diverticulosis will develop diverticulitis

4. Diverticulitis
Inflammatory complications result from perforation of diverticula
Sympotms
Usually present within several hours to days
Pain localized to the left lower quadrant
Change in bowel habits
Bloating, nausea, vomiting and anorexia
Right sided diverticulitis is more common is Asian populations
Right sided diverticulitis often mimics other right sided inflammatory conditions

5. Diverticulitis History and Physical examination
Complete blood count (CBC), Urinalysis, and plain abdominal radiographs
CT scan of the abdomen and pelvis with intravenous contrast
Sigmoid diverticula
Peri-sigmoid inflammatory changes
Extraluminal gas or fluid
Pericolic abscess
Adjacent organ involvement
Alternative diagnoses include irritable
bowel syndrome, gastroenteritis, bowel obstruction,
inflammatory bowel disease, appendicitis, ischemic
colitis, colorectal cancer, urinary tract infection,
kidney stone, and gynecologic disorders.
Ddx:perforated malignancy, ischemia or inflammatory bowel disease

6. Classification Hinchey classification is most commonly described
Class I : localized pericolic inflammation
Class II : localized pericolic abscess
Class III : diffuse purulent peritonitis
Class IV : diffuse feculent peritonitis
Patients Hinchey class I-III inflammatory complications can often be managed non-operatively with or without percutaneous drainage of localized sepsis. Hinchey class IV patients often require urgent surgical therapy

7. Controversies Indication for surgery Operation Laparoscopic / open
Complicated
Hartmann's procedure
Primary resection + anastomosis
+/- diverting ileostomy
Uncomplicated
?Young age
?recurrence
Indication of interval OT After percutaneous drainage of abscess.
recent controversies revolve around the indications for surgery in cases of uncomplicated and complicated diverticulitis
a trend toward nonsurgical conservative management in many presentations of diverticular disease.

8. Trend toward nonsurgical conservative management in many presentations of diverticular disease

9. Uncomplicated Diverticulitis
Absence of complications
Abscess
Free perforation
Fistulization
Stenosis
a “response to empirical antibiotic therapy” does not constitute indirect evidence that diverticulitis was the original diagnosis.

10. Uncomplicated Diverticulitis
Abdominal pain, fever, and elevation of white blood cell (WBC) count
Diagnosis by clinical grounds
CT scan
Not mandatory
In severe clinical findings on presentation
Atypical symptoms
Re-evaluate patients
(CBC), urinalysis, and plain abdominal
radiographs

11. Management Bowel rest Antibiotic therapy
Common gram-negative and anaerobic pathogens
Little evidence on selection of specific regimens; no regimen has demonstrated superiority
Paucity of data regarding optimal duration
Byrnes et al. Antimicrobial therapy for acute colonic diverticulitis. [Review] Surgical Infections. 10(2):143-54, 2009 Apr.
The most frequent aerobic bacteria involved in diverticulitis are Escherichia coli, Proteus, Klebsiella, and Enterococcus; the most frequent anaerobic bacterium is Bacteroides fragilis..
Clinical improvement must be assessed by serial abdominal exams, serial WBC, and close monitoring of the patient's temperature.
Broad-spectrum antibiotics aerobic and anaerobic coverage (e.g., combination of ciprofloxacin and metronidazole)
~7-14 days

12. Uncomplicated Diverticulitis
Complete resolution without recurrence in at least 70% of cases
Colonoscopy to exclude underlying malignancy at a time interval for optimal resolution of the diverticular inflammation.
Those patients who fail conservative treatment within
the first week of hospitalization should be considered
for urgent surgery. This includes patients who have
signs of increasing sepsis or who develop sepsis after
admission.
(?4-6wk)

13. Uncomplicated Diverticulitis
Immunosuppressed /Immunocompromised patients are more likely to present with perforation or fail medical management
A lower threshold for urgent or elective surgery should apply
After 1st episode
Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

14. Uncomplicated Diverticulitis
Younger patients (<50) were previously thought to have more virulent disease
Previous studies have shown misclassification and selection bias
Diagnosis often delayed in younger patients resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated.
Review articles published between January 1965 and March 2008
27 studies >6000 patients
Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52:

15. Uncomplicated Diverticulitis
Lack of evidence for elective surgery after a single attack of diverticulitis
Should follow the guidelines for patients of any age
Higher cumulative risk for recurrent diverticulitis
Janes et al. The Place of Elective Surgery Following Acute Diverticulitis in Young Patients: When is Surgery Indicated? An Analysis of the Literature Dis Colon Rectum 2009; 52:

16. Uncomplicated Diverticulitis
Recurrence
Current practice guidelines recommend that surgery should be offered to patients after two documented episodes of uncomplicated diverticulitis
Factors influencing recommendation include:
Fitness for surgery
Number and severity of attacks
Rapidity and completeness of response to medical therapy
Persistence of residual symptoms after completion of treatment

17. Uncomplicated Diverticulitis
Large recent multicentric retrospective studies on outcome of patients whose first episode of acute diverticulitis treated conservatively confirmed that the risk of recurrent attacks was low
Broderick-Villa et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005;140:576–581.
In patients requiring urgent surgery, it is the initial attack in over 80% of cases
>3000 pt, 87% no recurrence

18. Somesakar and colleagues (2002) and Chapman and colleagues (2005)
Patients with perforated diverticulitis and the majority presenting with life-threatening diverticular disease had not had antecedent diverticular events
Salem and colleagues (2004)
Published a decision analysis showing that performing colectomy after the fourth (rather than the second) episode of diverticulitis resulted in fewer deaths, fewer colostomies, and significant cost savings, irrespective of patients’ age
The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2004; 199: 904–12.
therefore, a policy of elective colon resection after recovery from uncomplicated acute diverticulitis might not decrease the likelihood of later emergency surgery or overall mortality
A study by Richards et al.4(2002) found that performing
elective colectomy after the third attack of diverticulitis is
cost saving compared to resection performed for an earlier
attack

19. Uncomplicated Diverticulitis
Surgery should probably be reserved for patients with more recurrent episodes of uncomplicated diverticulitis
1/ A large retrospective cohort study of more than 3000 patients (mean follow-up 8 years) showed that only 13% of 2366 patients managed nonoperatively during their initial episode and who declined subsequent elective resection eventually had recurrence; all of the recurrences were safely managed nonoperatively (see Broderick-Villa and others 2005)
2/Salem and colleagues (2004) published a decision analysis showing that performing colectomy after the fourth rather than the second episode of diverticulitis resulted in fewer deaths, fewer colostomies, and significant cost savings, irrespective of patients’ age
3/Somesakar and colleagues (2002) and Chapman and colleagues (2005) looked at patients presenting with perforated diverticulitis and found that the majority presenting with life-threatening diverticular disease had not had antecedent diverticular events.

20. Complicated Diverticulitis
Contained Perforation: Pericolic and Pelvic Abscesses (Hinchey Stages I and II)
Intravenous antibiotics and close observation
Image-guided percutaneous catheter drainage

21. Complicated Diverticulitis
Small pericolic abscesses (<2 cm) and intra-mural abscesses may resolve without intervention
Conflicting data continue to fuel the controversy. Whereas data of Broderick-Villa and others (2005) support long-term nonoperative management even in patients with abscesses, several smaller case series suggest that patients with a history of abscess have a higher chance of recurrence
Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

22. Complicated Diverticulitis
Conflicting data
Broderick-Villa and others (2005) support long-term nonoperative management even in patients with abscesses
Several smaller case series suggest that patients with a history of abscess have a higher chance of recurrence

23. Complicated Diverticulitis
Free Perforation: Purulent and Fecal Peritonitis (Hinchey Stages III and IV)
Aggressive fluid resuscitation and intravenous broad-spectrum antibiotics
Early intensive care unit monitoring with the addition of a central venous catheter
Hemodynamic instability with shock, diffuse generalized peritonitis on examination, and free air on imaging studies

24. Complicated Diverticulitis
Acutely non-resolving symptoms Hinchey class I-III and patients with Hinchey class IV disease should be offered urgent surgery
Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

25. Complicated Diverticulitis
Urgent operative management
Primary resection / primary anastomosis and +/- diverting ileostomy
Hartmann's procedure
Safest option in patients with severe sepsis and generalized purulent or fecal peritonitis is
(1) overall patient stability
(2) degree and type of peritonitis (purulent or fecal peritonitis)
(3) the condition of the colon

26. Hartmann’s vs primary resection anastomosis
Review of eighteen studies between 1966 and December 2003 reported 884 patients with acute complicated diverticulitis
No significant differences were found between primary resection with anastomosis and Hartmann’s procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure
Studies and trials conducted between 1966 and December 2003
Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis (2007) 22: 351–357

27. Hartmann’s vs Primary Resection Anastomosis
Fifteen Comparative studies (between 1984 and 2004) 963 patients analyzed
Overall mortality was significantly reduced with primary resection and anastomosis
Retrospective nature of the included studies
Considerable degree of selection bias
Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review. Dis Colon Rectum 2006; 49: 966–981

28. Laparoscopic vs Open Resection
When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients
Level of Evidence: III; Grade of Recommendation: A
There is no increase in early or late complications
Cost and outcome are comparable
Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with complicated disease.
Practice Parameters for Sigmoid Diverticulitis. The American Society of Colon and Rectal Surgeons Guideline (2006)

29. Laparoscopic vs Open resection
Laparoscopy can be performed safely
benefits in terms of length of stay, less pain and quicker recovery. 
associated with longer operative times and more operative cost
Acceptable alternative to open surgery for an experienced laparoscopic surgeon with an adequate case volume
The benefits of laparoscopic colectomy however are not such that it should be used by lower volume surgeons or those not facile with advanced laparoscopic techniques.

30. Laparoscopic vs Open Resection
Laparoscopic sigmoid resection was associated with a 15.4% reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization at the cost of a longer operating time.
Anastomotic leakage* 3 5
Intra-abdominal bleeding† 0 2
Intra-abdominal abscess‡ 1 2
Evisceration* 0 1
Small bowel perforation* 0 1
Richter hernia* 1 0
Myocardial infarction 0 1
Pulmonary embolism
From 2002 to 2006, 104 patients were randomized in 5 centers. All
patients underwent the allocated intervention. Fifty-two LSR patients were
comparable to 52 OSR patients for gender, age, BMI, ASA grade, comorbid
conditions, previous abdominal surgery, and indication for surgery. LSR
took longer (P _ ) but caused less blood loss (P _ 0.033). Conversion
rate was 19.2%. Mortality rate was 1%. There were significantly more major
complications in OSR patients (9.6% vs. 25.0%; P _ 0.038). Minor complication
rates were similar (LSR 36.5% vs. OSR 38.5%; P _ 0.839). LSR
patients had less pain (Visual Analog Scale 1.6; P _ ), systemic
analgesia requirement (P _ 0.029), and returned home earlier (P _ 0.046).
The short form-36 questionnaire showed significantly better quality of life
for LSR.
Klarenbeek et al Laparoscopic Sigmoid Resection for Diverticulitis Decreases Major Morbidity Rates: A Randomized Control Trial Short-term Results of the Sigma Trial. Ann Surg Jan 2009;249: 39–44

31. Laparoscopic Lavage
Acute complicated diverticulitis managed by laparoscopic lavage and drainage with antibiotic
Majority of patients with Hinchey Grade 3 diverticulitis (diffuse purulent peritonitis) can effectively be managed by laparoscopic lavage in the acute setting. The overall conversion rate to laparotomy (including five treatment failures) was 3%, the mean length of stay was 9 days, 10% of the patients developed complications, and the overall mortality was 1.4%.
Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

32. Laparoscopic Lavage
Outcomes of laparoscopic lavage management in the published studies
Eight studies met the inclusion criteria and
reported 213 patients with acute complicated
diverticulitis managed by laparoscopic lavage
Conversion to laparotomy was made
in six (3%) patients and the mean hospital stay was nine
days. Ten percent of the patients had complications.
During the mean follow-up of 38 months, 38% of the
patients underwent elective sigmoid resection with
primary anastomosis.
Mean length of stay was 9 days
Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

33. Laparoscopic Lavage
Laparoscopic Lavage without sigmoid resection in the acute setting for patients with purulent peritonitis caused by complicated diverticulitis could be considered a valid alternative
Needs to be investigated more thoroughly
Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

34. Laparoscopic Lavage
Primary laparoscopic lavage for complicated diverticulitis may be a promising alternative to more radical surgery in selected patients
Larger studies have to be made before clinical recommendations can be given
Mahdi Alamili. Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Disease of colon rectum vol 52:7 (2009)

35. Summary Uncomplicated Diverticulitis
Surgery recommended after single attack for immunosuppressed /immunocompromised patients
Young patient should follow the guidelines for patients of any age
Reserved for patients with more recurrent episodes

36. Summary Complicated diverticulitis Urgent operation
Primary resection with anastomosis +/- diverting ileostomy
vs Hartmann’s procedure
? Elective operation after non operative management of acute episode

37. Summary Laparoscopic approach is appropriate in selected patients
Elective Sigmoid Resection
Laparoscopic approach is appropriate in selected patients
Laparoscopic Lavage
Could be considered a valid alternative in complicated diverticulitis with purulent peritonitis

38. Thank you