1. JH081705 Diverticular Dilemmas Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona Jacques Heppell, MD Mayo Clinic Scottsdale, Arizona JH081705

3. Diverticular Disease In the US, individual risk of 50% by age 60.In the US, individual risk of 50% by age 60. Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisationsDiverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisations 25% of patients with diverticulitis will present with a complication leading to surgery25% of patients with diverticulitis will present with a complication leading to surgery Diverticulitis is one of the five most costly GI disorder in the US populationDiverticulitis is one of the five most costly GI disorder in the US population In the US, individual risk of 50% by age 60.In the US, individual risk of 50% by age 60. Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisationsDiverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisations 25% of patients with diverticulitis will present with a complication leading to surgery25% of patients with diverticulitis will present with a complication leading to surgery Diverticulitis is one of the five most costly GI disorder in the US populationDiverticulitis is one of the five most costly GI disorder in the US population

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5. Patients are asking … If I have simple episodes of diverticulitis, when should I have an operation?If I have simple episodes of diverticulitis, when should I have an operation? How can you predict the severity of future episodes ?How can you predict the severity of future episodes ? What if I have a perforation or another complication ?What if I have a perforation or another complication ? The “fear factor” : the colostomy bag !The “fear factor” : the colostomy bag ! If I have simple episodes of diverticulitis, when should I have an operation?If I have simple episodes of diverticulitis, when should I have an operation? How can you predict the severity of future episodes ?How can you predict the severity of future episodes ? What if I have a perforation or another complication ?What if I have a perforation or another complication ? The “fear factor” : the colostomy bag !The “fear factor” : the colostomy bag !

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7. HistoryHistory

8. DiverticulitisDiverticulitis

9. DiverticulitisDiverticulitis 11 RCTs11 RCTs –3 examining lap vs. open for elective operation –3 examining abx therapy –2 examining probiotic therapy –1 examining timing of colonoscopy –2 examining type of surgery 11 RCTs11 RCTs –3 examining lap vs. open for elective operation –3 examining abx therapy –2 examining probiotic therapy –1 examining timing of colonoscopy –2 examining type of surgery

10. JH081705 Etzioni et al, Ann Surg 2006

11. JH081705 Domestic Admissions for Acute Diverticulitis, 1998 vs. 2005 19982005 %Δ%Δ%Δ%Δ Admissions Raw Raw120,541171,445+42% Age-Adjusted Age-Adjusted120,541151,878+26% Incidence Rates* Total Total0.600.77+30% 18-44 yo 18-44 yo0.150.26+82% 45-64 yo 45-64 yo0.660.90+37% 65-74 yo 65-74 yo1.411.63+16% 75+ yo 75+ yo2.532.55-- * per 1,000 population

12. JH081705 EpidemiologyEpidemiology Hjern et al, Aliment Pharmacol Ther, 2006

13. JH081705 Acutediverticulitis Resolution, spontaneous or with medical management Progression, with secondary complications: abscess, fistula, “smoldering”, peritonitis, obstruction

14. JH081705 “Uncomplicated diverticulitis may be managed as an outpatient (dietary modification and oral antibiotics) for those without appreciable fever, excessive vomiting, or marked peritonitis, as long as there is the opportunity for follow-up.” ASCRS Guidelines Rafferty J, DCR 2006

15. JH081705 What % of patients are treated outpatient? How successful is outpatient tx? Research Study: –Cohort: Kaiser ED eval for diverticulitis Kaiser member 5 yrs prev, no prior dx of tics CT scan  1 day of eval Not admitted Excluded: no antibiotic rx  1 day of eval –Outcome: Re-eval/ admission for within 60 days Results:Results: –n = 693, overall failure rate 5.6% What % of patients are treated outpatient? How successful is outpatient tx? Research Study: –Cohort: Kaiser ED eval for diverticulitis Kaiser member 5 yrs prev, no prior dx of tics CT scan  1 day of eval Not admitted Excluded: no antibiotic rx  1 day of eval –Outcome: Re-eval/ admission for within 60 days Results:Results: –n = 693, overall failure rate 5.6% Etzioni et al, DCR 2010

16. JH081705 “Uncomplicated diverticulitis”“Uncomplicated diverticulitis” –Conservative treatment NPO/IVF: Clears? IV Abx: Duration? 123 pts randomized to 4 vs. 7 days inpatient ertapenem No significant difference –Operate for failure to improve or deterioration What constitutes failure to improve? Within what time frame? –On discharge, oral abx? How long? “Uncomplicated diverticulitis”“Uncomplicated diverticulitis” –Conservative treatment NPO/IVF: Clears? IV Abx: Duration? 123 pts randomized to 4 vs. 7 days inpatient ertapenem No significant difference –Operate for failure to improve or deterioration What constitutes failure to improve? Within what time frame? –On discharge, oral abx? How long? Schug-Pass C, Int J Colorect Dis 2010

17. JH081705 Practice Parameters Elective resection after two documented attacks of diverticulitisElective resection after two documented attacks of diverticulitis Complicated diverticulitis: resection after the first attackComplicated diverticulitis: resection after the first attack Elective resection after two documented attacks of diverticulitisElective resection after two documented attacks of diverticulitis Complicated diverticulitis: resection after the first attackComplicated diverticulitis: resection after the first attack

18. JH081705 19951995 –“…elective resection should be considered after two well-documented attacks of diverticulitis…” 20002000 –“…after two attacks…resection is commonly recommended…” 20062006 –“…decision to recommend elective sigmoid colectomy …should be made on a case-by- case basis…” 19951995 –“…elective resection should be considered after two well-documented attacks of diverticulitis…” 20002000 –“…after two attacks…resection is commonly recommended…” 20062006 –“…decision to recommend elective sigmoid colectomy …should be made on a case-by- case basis…” Rafferty et al, DCR 2006 Roberts et al, DCR 1995 Wong et al, DCR 2000

19. JH081705 Long term follow-up after initial episode of diverticulitis Complicated recurrence is uncommon.Complicated recurrence is uncommon. Higher risk of recurrence if:Higher risk of recurrence if: Family history Family history Long segment involved Long segment involved Retroperitoneal abscess Retroperitoneal abscess Hall J et al DCR 54 (3), 2011 Complicated recurrence is uncommon.Complicated recurrence is uncommon. Higher risk of recurrence if:Higher risk of recurrence if: Family history Family history Long segment involved Long segment involved Retroperitoneal abscess Retroperitoneal abscess Hall J et al DCR 54 (3), 2011

20. JH081705 Acute Diverticulitis 15% progression of disease in remaining colon15% progression of disease in remaining colon 2-11% need for further surgery2-11% need for further surgery 27% pain in the same area (irritable bowel?)27% pain in the same area (irritable bowel?) 15% progression of disease in remaining colon15% progression of disease in remaining colon 2-11% need for further surgery2-11% need for further surgery 27% pain in the same area (irritable bowel?)27% pain in the same area (irritable bowel?) Evolution after Surgery

21. JH081705 ConsiderationsConsiderations Limited access to medical careLimited access to medical care General medical conditionGeneral medical condition Frequency and severity of attackFrequency and severity of attack Persistence of symptomsPersistence of symptoms Most severe attack is often the firstMost severe attack is often the first Colostomy is rarely required on second attackColostomy is rarely required on second attack Limited access to medical careLimited access to medical care General medical conditionGeneral medical condition Frequency and severity of attackFrequency and severity of attack Persistence of symptomsPersistence of symptoms Most severe attack is often the firstMost severe attack is often the first Colostomy is rarely required on second attackColostomy is rarely required on second attack

22. JH081705 Immuno-compromised patients Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2%Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2% Patient on steroids, chemotherapy, azathioprine, cyclosporine, diabetics, renal failurePatient on steroids, chemotherapy, azathioprine, cyclosporine, diabetics, renal failure Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2%Increased risk of perforation: 40% vs 15%, morbidity : 65% vs 25% and mortality : 40% vs 2% Patient on steroids, chemotherapy, azathioprine, cyclosporine, diabetics, renal failurePatient on steroids, chemotherapy, azathioprine, cyclosporine, diabetics, renal failure

23. JH081705 Immuno-compromised patient Operate earlier during the first episodeOperate earlier during the first episode Operate semi-electively after the first episodeOperate semi-electively after the first episode Cautious use of unprotected anastomosis in emergency situationCautious use of unprotected anastomosis in emergency situation Operate earlier during the first episodeOperate earlier during the first episode Operate semi-electively after the first episodeOperate semi-electively after the first episode Cautious use of unprotected anastomosis in emergency situationCautious use of unprotected anastomosis in emergency situation

24. JH081705 Patient < 50 years of Age Age: remain a controversial factor in the decision to operateAge: remain a controversial factor in the decision to operate Because of their longer life span, younger patients will have a higher cumulative risk for recurrence.Because of their longer life span, younger patients will have a higher cumulative risk for recurrence. Young patients should generally be treated using the same criteria as older patients.Young patients should generally be treated using the same criteria as older patients. No justification for surgery after a single attack of diverticulitisNo justification for surgery after a single attack of diverticulitis Age: remain a controversial factor in the decision to operateAge: remain a controversial factor in the decision to operate Because of their longer life span, younger patients will have a higher cumulative risk for recurrence.Because of their longer life span, younger patients will have a higher cumulative risk for recurrence. Young patients should generally be treated using the same criteria as older patients.Young patients should generally be treated using the same criteria as older patients. No justification for surgery after a single attack of diverticulitisNo justification for surgery after a single attack of diverticulitis

25. JH081705 Diverticular Disease  post-operative wound problems  post-operative wound problems  length of hospitalization  length of hospitalization  morbidity  morbidity 90% successful (148 of 164 patients)90% successful (148 of 164 patients)  post-operative wound problems  post-operative wound problems  length of hospitalization  length of hospitalization  morbidity  morbidity 90% successful (148 of 164 patients)90% successful (148 of 164 patients) Franklin ME, et al. Surg Endosc. 1997;11(10):1021. Laparoscopic Approach

26. JH081705 Laparoscopic approach Likely to become the standard surgical approach for uncomplicated diverticulitisLikely to become the standard surgical approach for uncomplicated diverticulitis “The Sigma-trial protocol”: a prospective double-blind multicentre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. Klarenbeek,BR et al BMC Surg 2007;7:16“The Sigma-trial protocol”: a prospective double-blind multicentre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. Klarenbeek,BR et al BMC Surg 2007;7:16 Likely to become the standard surgical approach for uncomplicated diverticulitisLikely to become the standard surgical approach for uncomplicated diverticulitis “The Sigma-trial protocol”: a prospective double-blind multicentre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. Klarenbeek,BR et al BMC Surg 2007;7:16“The Sigma-trial protocol”: a prospective double-blind multicentre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. Klarenbeek,BR et al BMC Surg 2007;7:16

27. JH081705 Complicated Diverticulitis Cases, Mortality No. (11%) Acute phlegmon1044 Pericolonic abscess3412 Purulent peritonitis4027 Large bowel obstruction316 Fecal peritonitis2348 Abscess with fistula283.5 Lower GI bleeding402.5 Cases, Mortality No. (11%) Acute phlegmon1044 Pericolonic abscess3412 Purulent peritonitis4027 Large bowel obstruction316 Fecal peritonitis2348 Abscess with fistula283.5 Lower GI bleeding402.5 Prospective National Study (Great Britain) 300 cases (1985-88) Prospective National Study (Great Britain) 300 cases (1985-88)

28. JH081705 Hinchey’s Classification Stage 0 Mild clinical diverticulitis Stage Ia Confined pericolic inflammation (no abscess) Stage Ib Confined pericolic abscess Stage II Pelvic, retroperitoneal, or distant intraperitoneal abscess (abscess/phlegmon, fever, systemic toxicity) Stage III Generalized purulent peritonitis, no communication with bowel lumen Stage IV Feculent peritonitis, open communication with bowel lumen Hinchey E, Adv Surg 1978

29. JH081705 Ambrosetti’s CT Staging of Diverticulitis MILD DIVERTICULITISMILD DIVERTICULITIS Localized sigmoid wall thickening Localized sigmoid wall thickening Inflammation of pericolonic fat Inflammation of pericolonic fat SEVERE DIVERTICULITISSEVERE DIVERTICULITIS Abscess Abscess Extraluminal air Extraluminal air Extraluminal contrast Extraluminal contrast MILD DIVERTICULITISMILD DIVERTICULITIS Localized sigmoid wall thickening Localized sigmoid wall thickening Inflammation of pericolonic fat Inflammation of pericolonic fat SEVERE DIVERTICULITISSEVERE DIVERTICULITIS Abscess Abscess Extraluminal air Extraluminal air Extraluminal contrast Extraluminal contrast

30. JH081705 Complicated Diverticulitis –Fistula = operate when medically fit –Obstruction = conservative treatment, then operate –Abscess = percutaneous drainage –Perforation = Operation but which one ? –Fistula = operate when medically fit –Obstruction = conservative treatment, then operate –Abscess = percutaneous drainage –Perforation = Operation but which one ?

31. JH081705

34. Percutaneous Abscess Drainage 75% successful75% successful Concomitant antibioticsConcomitant antibiotics Sinograms obtained at 7 days interval to monitor collapse of abscess cavitySinograms obtained at 7 days interval to monitor collapse of abscess cavity Surgery performed 10-14 days after disappearance of the abscess cavity because 41% of patients will develop severe recurrent sepsisSurgery performed 10-14 days after disappearance of the abscess cavity because 41% of patients will develop severe recurrent sepsis 75% successful75% successful Concomitant antibioticsConcomitant antibiotics Sinograms obtained at 7 days interval to monitor collapse of abscess cavitySinograms obtained at 7 days interval to monitor collapse of abscess cavity Surgery performed 10-14 days after disappearance of the abscess cavity because 41% of patients will develop severe recurrent sepsisSurgery performed 10-14 days after disappearance of the abscess cavity because 41% of patients will develop severe recurrent sepsis CT-GuidedCT-Guided

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37. CT Findings Pericolic lymph nodes: An aid in distinguishing diverticulitis from cancer of the colonPericolic lymph nodes: An aid in distinguishing diverticulitis from cancer of the colon

38. JH081705 ObstructionObstruction Resection, intra-operative colonic lavage with primary anastomosisResection, intra-operative colonic lavage with primary anastomosis Expendable metallic stent with resection and anastomosis within 7 daysExpendable metallic stent with resection and anastomosis within 7 days Hartmann's procedureHartmann's procedure Resection, intra-operative colonic lavage with primary anastomosisResection, intra-operative colonic lavage with primary anastomosis Expendable metallic stent with resection and anastomosis within 7 daysExpendable metallic stent with resection and anastomosis within 7 days Hartmann's procedureHartmann's procedure

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40. Perforated Diverticulitis ( Hinchey stages 3 and 4 ) Ideal operation ? 1-Primary resection with Hartmann pouch 2-Primary resection with anastomosis and temporary ileostomy 3-Primary resection with anastomosis and no temporary stoma 4-Simple laparoscopic washout with drainage Ideal operation ? 1-Primary resection with Hartmann pouch 2-Primary resection with anastomosis and temporary ileostomy 3-Primary resection with anastomosis and no temporary stoma 4-Simple laparoscopic washout with drainage

41. JH081705 Generalized Peritonitis Resect the perforated segmentResect the perforated segment Do not do more than you need to doDo not do more than you need to do Do not open further avenue for sepsis (splenic flexure, presacral space)Do not open further avenue for sepsis (splenic flexure, presacral space) Do not make a mucous fistulaDo not make a mucous fistula Examine the open specimen to rule out malignancyExamine the open specimen to rule out malignancy Resect the perforated segmentResect the perforated segment Do not do more than you need to doDo not do more than you need to do Do not open further avenue for sepsis (splenic flexure, presacral space)Do not open further avenue for sepsis (splenic flexure, presacral space) Do not make a mucous fistulaDo not make a mucous fistula Examine the open specimen to rule out malignancyExamine the open specimen to rule out malignancy Operative Guidelines Fazio VW, 1989

42. JH081705 Henri Hartmann (1860-1952) Two-staged....Two-staged....

43. JH081705 Hartmann Procedure in Complicated Diverticular Disease Retained Mortality,Morbidity,Colostomy, AuthorYear %% Krukowski & Matheson19841238NA Auguste et al 1985129520 Nagorney et al 198574125 Hackford et al 1985162329 Finlay and Carter 1987212616 Alanis et al 1989152346 Berry et al 1989286933 Peoples et al 19901927NA Arch Surg: Vol 131, June 1996

44. JH081705 The Hartmann’s Procedure First choice or last resort in diverticular disease?First choice or last resort in diverticular disease? U. of Minn., Arch Surg 1996

45. JH081705 Laparoscopic Peritoneal Lavage JH081705

46. Treatment Which Operation? Laparoscopic lavage First described 1996 in 8 patientsFirst described 1996 in 8 patients Two subsequent reportsTwo subsequent reports ComponentsComponents –Laparoscopy; look for exclusion criteria –Lavage with saline –Wide drainage –± repair (suture, glue, omentoplasty, etc) Laparoscopic lavage First described 1996 in 8 patientsFirst described 1996 in 8 patients Two subsequent reportsTwo subsequent reports ComponentsComponents –Laparoscopy; look for exclusion criteria –Lavage with saline –Wide drainage –± repair (suture, glue, omentoplasty, etc) O’Sullivan et al, Am JSurg1996Faranda et al, SLEPT 2000Taylor et al, ANZ J Surg 2006

47. JH081705 Laparoscopic peritoneal lavage (LPL) for generalized peritonitis due to perforated diverticulitis PROSPECTIVE MULTI-INSTUTIONAL STUDYPROSPECTIVE MULTI-INSTUTIONAL STUDY 100 patients : 8 with fecal peritonitis (Hartmann), 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 36 months (median follow-up).100 patients : 8 with fecal peritonitis (Hartmann), 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 36 months (median follow-up). Myers et al. Br J Surg 2008;95:97Myers et al. Br J Surg 2008;95:97 PROSPECTIVE MULTI-INSTUTIONAL STUDYPROSPECTIVE MULTI-INSTUTIONAL STUDY 100 patients : 8 with fecal peritonitis (Hartmann), 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 36 months (median follow-up).100 patients : 8 with fecal peritonitis (Hartmann), 92 LPL with morbidity and mortality of 4 and 3 % respectively, 2 pts had intervention for pelvic abscess and only 2 patients re-presented with diverticulitis at 36 months (median follow-up). Myers et al. Br J Surg 2008;95:97Myers et al. Br J Surg 2008;95:97

48. JH081705 Laparoscopic Lavage Myers E, Br J Surg 2008

49. JH081705 Treatment Which Operation? Issues with laparoscopic lavage:Issues with laparoscopic lavage: –Lots of patients who we think need surgery get better without an operation... –...so what is the threshold for operation? –Is there a role for interval sigmoidectomy? Issues with laparoscopic lavage:Issues with laparoscopic lavage: –Lots of patients who we think need surgery get better without an operation... –...so what is the threshold for operation? –Is there a role for interval sigmoidectomy?

50. JH081705 Treatment Which Operation? Toorenvliet et al, Colorectal Dis 2009

51. JH081705 Laparoscopic Peritoneal Lavage Too good to be true !!Too good to be true !! Need for a randomized clinical trial ??Need for a randomized clinical trial ?? Too good to be true !!Too good to be true !! Need for a randomized clinical trial ??Need for a randomized clinical trial ??

52. JH081705 Treatment Which Operation? Pending trial: Ladies trialPending trial: Ladies trial – –Laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis Pending trial: Ladies trialPending trial: Ladies trial – –Laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis

53. JH081705 One stage....One stage....

54. JH081705 Treatment Which Operation? 1.5 stage....1.5 stage.... Resection plus loop ileostomyResection plus loop ileostomy 1.5 stage....1.5 stage.... Resection plus loop ileostomyResection plus loop ileostomy

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56. ConclusionsConclusions The management of patients with sigmoid diverticulitis is still evolving.The management of patients with sigmoid diverticulitis is still evolving. Big problem that is becoming bigger !Big problem that is becoming bigger ! Paucity of data on when to operate and what operation to performPaucity of data on when to operate and what operation to perform Need larger Randomized Clinical Trials to guide TherapyNeed larger Randomized Clinical Trials to guide Therapy We must tailor our treatment to the specific situation for each individual patientWe must tailor our treatment to the specific situation for each individual patient The management of patients with sigmoid diverticulitis is still evolving.The management of patients with sigmoid diverticulitis is still evolving. Big problem that is becoming bigger !Big problem that is becoming bigger ! Paucity of data on when to operate and what operation to performPaucity of data on when to operate and what operation to perform Need larger Randomized Clinical Trials to guide TherapyNeed larger Randomized Clinical Trials to guide Therapy We must tailor our treatment to the specific situation for each individual patientWe must tailor our treatment to the specific situation for each individual patient