1. Current Management of Diverticulitis
Alexis Grucela, MD
Assistant Professor of Surgery
Controversies in Surgery
December 20, 2013
Hi my name is Alexis Grucela
Thank you for the opportunity to speak about this interesting and controversial topic of Diverticulitis
I am excited to give this talk as it really brings out the true nature of this conference which is Controversies in surgery

2. Overview Background Pathophysiology Clinical Classification
Presentation
Management: Controversies
Outcomes

3. Diverticula Small (0.5 - 1.0 cm) pouches protruding from bowel wall
Most pseudodiverticula:
mucosa and submucosa only- muscle layer not present
True diverticula: all layers of the bowel wall involved
Up to 60% of people living in industrialized countries will develop colonic diverticula
Floch MH, White JA. Management of diverticular disease is changing.
World J Gastroenterol. 2006; 12:

4. Most occur at sites of vascular penetration into the circular muscle layer between mesenteric and antimesenteric taenia

5. Pathophysioloy Diverticular Disease
Increased intraluminal pressure
Caused by low fiber, constipation
Sigmoid colon most commonly involved (95%)
Smallest diameter
Laplace’s law: generates highest pressure
Right sided disease tend to be younger
RLQ pain, fever, leukocytosis, suspect acute appendicitis
Incidence of diverticular disease increases with age:
30% at age 60
60-80% at age 80

6. Risk Factors
Low fiber Diet
Smoking
Constipation
Obesity
NSAIDS

7. Diverticulitis Diverticulum inflamed due to obstruction
Microperforation and inflammation of surrounding tissue results in phlegmon
Incidence 10% to 25% in patients with diverticula
75% Uncomplicated
25% complicated
Risk of diverticulitis increases
as pts. w/ diverticulosis age
10% after 5 years
35% after 20 years

8. Significance of Diverticulitis
Significant problem in Western Countries
One of the most common causes of acute surgical admission
152,000 yearly hospitalizations
1.5 million days of inpatient care per year
Annual costs of diverticular disease estimated at $2.7 billion per year
Sandler RS et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:

9. Clinical Classification
Uncomplicated vs. Complicated
Uncomplicated
Pericolic soft-tissue stranding, colonic wall thickening, phlegmon
Complicated: Acute diverticulitis +
Abscess
Obstruction
Perforation
Fistula

10. Complicated Diverticulitis: Hinchey Classification
Hinchey Stage I
Pericolic or Mesenteric abscess II
Retroperitoneal or Pelvic abscess
III
Purulent peritonitis IV
Fecal peritonitis

11. Presentation Symptoms LLQ Pain, Fever, Diarrhea or constipation
Urinary symptoms if inflammation adjacent to the bladder
Classic Triad
Fever, Leukocytosis, LLQ tenderness
Mass is occasionally felt
Complicated Diverticulitis:
Abscess: tender, +/- palpable mass on abdominal, rectal, or pelvic examination.
Obstruction: distention, tenderness
Free perforation: peritonitis, sepsis

12. Imaging: CT Scan CT scan is the most appropriate imaging modality
Accuracy is enhanced if oral, iV and rectal contrast used
Highly sensitive and specific w low false positive rate
Water-soluble contrast should be used as there is risk of extravasation.
Diverticula: appear as extraluminal air or fluid.
Findings in diverticulitis include bowel wall thickening, inflammation, fat stranding
Complications such as phlegmon, abscess, adjacent organ involvement, fistula and distant spetic complications can be identified.
However, Cancer cannot be excluded when there is thickening of the bowel wall
Severity staging by CT may allow the selection of pts most likely to respond to conserv therapy

13. Imaging Sensitivity: CT 98% vs. BE 92% Barium Enema
Avoid in acute setting
If scope not possible can aid in distinguishing CA vs. diverticulitis after acute attack
Consider CT Colonography
Sensitivity: CT 98% vs. BE 92%
Strictures in diverticulitis are usually longer and more regular then cancer

14. Colonoscopy Avoid with acute diverticulitis Risk of perforation
Perform 6 to 8 weeks after when
inflammation subsides
Confirms diagnosis and excludes malignancy
Current Accepted society and international guidelines recommend routine colonoscopic evaluation after 1 episode of acute diverticulitis

15. Is Colonoscopy Mandatory After Radiologically Confirmed Acute Diverticulitis?
N=319 had colonoscopy after episode
23 (2.1%) had cancer
Odds of Dx CRC
6.7 time in pts w abscess
4 times in local perforation
18 times in pts with fistula
Concluded: Recommend routine
colonoscopy in all cases
-Which brings us to our first controversial topic: Is Colonoscopy Mandatory After Radiologically Confirmed Acute Diverticulitis?
-Must consider: Significant resource burden, Small risk of M&M but greater in pts with diverticula, endoscopy maybe more technically difficult in these pts.
-No prospective RCT. 2 important studies
Australian Group in DCR
-1088 pts with diverticulitis but 319 had colonoscopy after episode. 23 or 2.1% found to have cancer.
-Negative Predictive value of diverticulitis dx by CT for CRC is 97.9%
-Odds of dx CRC 6.7 times in pts w abscess, 4 times in local perf, 18 times in pts with fistula
-Compared their cohort to their general population found although overall risk low- still higher risk than general population, especially in younger pts. And in complicated disease
-Concluded: Recommend routine colonoscopy in all cases

16. Proportion Estimated Risk of Malignancy:
Uncomplicated 0.7% vs. Complicated 10.8%
Conclusion: Risk of malignancy after radiographically proven episode of acute uncomplicated diverticulitis low
Routine colonoscopy may not be necessary in uncomplicated cases
Pts with complicated diverticulitis have significant risk & should have colonoscopy
2.Annals of surgery Meta Analysis: Limitations b/c Meta Analysis
-11 studies from 7 countries pooled population 1970 patients Showed cancer in 22.
-proportional est of malignancy in all pts 1.6%
-When stratifying pts by disease severity:
-In pts with uncomplicated diverticulitis – proportion est risk was low 0.7%
-In 79 pts with complicated disease the proportion est risk was high 10.8%
-Concluded- risk of malignancy after radiographically proven episode of acute uncomplicated diverticulitis low. Thus routine colonoscopy may not be necessary. However, pts with complicated diverticulitis have significant risk and should have subsequent colonoscopic evaluation

17. Management: Acute Uncomplicated Diverticulitis
Conservative Management
Nonoperative: Bowel rest, Antibiotics
PO or IV depending on severity
Anaerobic/GN coverage
Outpatient or Inpatient
Successful in % pts
Etzioni et al. 94% successful outpt mgmt of uncomplicated diverticulitis
6-8 weeks later
Scope to rule out cancer
Elective Resection??
Hospitalization if disease severity warrants (fever, vomiting, markedly tender) or fails outpt PO therapy
Recent study by Etzioni et al. from USC showed 94% successful outpt management of uncomplicated diverticulitis
Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum Jul;49(7):

18. DIVER Trial: Multicenter RCT, Ann Surg, Jan 2014
132 Patients, 5 Hospitals in Spain
Outpatient vs. Hospital Treatment of Uncomplicated Diverticulitis (CT Confirmed) + Abx
Same rate of treatment failure
Overall health care cost per episode was 3 times lower in outpatient group
No difference in QOL
Concluded: Outpatient treatment safe and effective selected patients with uncomplicated acute diverticulitis
Important costs saving without negative influence on QOL

19. AVOD Trial: Multicenter RCT, BJS 2012
10 surgical departments in Sweden & 1 Iceland
623 patients
Abx vs. No Abx in Uncomplicated Diverticulitis
Complication Rates same (1.9% vs. 1.0%)
LOS same (3 d)
Concluded: Antibiotics for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence
Should be reserved for the treatment of complicated diverticulitis

20. Elective Sigmoid Resection
Open, Lap, Robotic
Sigmoid Resection
Proximal Margin: compliant bowel
Include thickened, woody or grossly diseased bowel
Not all diverticula bearing colon must be removed
Distal: upper rectum
Ureteral stenting available

21. Elective Sigmoid Resection: Bowel Prep?
Concluded: bowel prep has no influence on anastomotic leak rates or other septic complications
Just as mechanical bowel prep has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery, this group from the Netherlands showed the same in a subgroup analysis of a Multicenter (13 hospitals) RCT of bowel prep vs. no prep in elective colorectal surgery
-Out of 190 undergoing sig rsxn for diverticulitis of the original 1350 pts
-Leak occurred in 7.8% prepped pts and 5.7% not prepped. Thus there were no sig differences between the groups w septic complications and mortality
-Concluded bowel prep has no influence on anast leak rates or other septic complications

22. Management of Acute Uncomplicated Diverticulitis: Elective Surgery
>20% will require surgical treatment
Management of acute diverticulitis has evolved over the past 2 decades
Shift toward higher threshold for elective resection in recurrent disease and in favor of primary anastomosis for patients with acute disease
-in 2000 ASCRS published practice parameters for sigmoid diverticulitis
-Goal is to prevent the sequence leading to perforated diverticulitis at recurrent episode
-Originally it included performing elective sig rsxn after the occurrence of 2 episodes of acute diverticulitis (Hinchey I/II), after single episode in young pts or when complication such as stenosis or fistulas occurred
-Based on original thinking that recurrence rates after every episode >33%, Each recurrence means higher risk perforation, and complicated diverticulitis a/w higher M&M
-Thus, elective sig rsxn would prevent mortality and colostomy
-But, newer data has challenged this and
Guidelines have been revised in 2006 to a more conservative and individualized approach
Shift toward higher threshold for elective resection in recurrent disease and in favor of primary anastomosis for patients with acute disease

23. Management of Acute Diverticulitis: Natural History of Disease
Most perforations and complications do not occur after recurrences, happen at first attack
Thus, a policy of elective resection after recovery from uncomplicated acute diverticulitis may not decrease likelihood of later emergent surgery or overall mortality
Conservative management of recurrent nonperforated diverticulitis associated with low rates of Morbidity & Mortality with mild course
-More Recently these recommendations have been challenged as
New data on natural history of diverticulitis have shown that most perforations do not occur after recurrences. – happen at first attack
-Thus, a policy of elective resection after recovery from uncomplicated acute diverticulitis may not decrease likelihood of later emergent surgery or overall mortality
-After 1 attack approx 1/3 pts will have second attack after second attacks further 1/3 will have yet another
-Also it has been shown that conserve mgmt of recurrent nonperforated diverticulitis is a/w low rates of M&M
-Thus the guidelines were revised in 2006 to a more conservative approach
Chapman J, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005;242:576–581.
Chapman JR, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg. 2006;243:876–880

24. “The decision to recommend elective sigmoid colectomy after recovery from acute diverticulitis should be made on a case-by-case basis”
Level of Evidence III; Grade B
Consider Age, comorbidities, frequency & severity of attacks, and if sx persistent after acute episode
Consider travel outside US and QOL
The decision to recommend elective sigmoid colectomy after recovery from acute diverticultitis should be made on a case-by-case basis
The decision to recommend surgery should be influenced by
Age, medical condition/comorbidities, frequency and severity of attacks, and if sx persistent after acute episode
Consider travel outside US and hospitalization/sick time interfering with QOL

25. What should be Indications for Elective Sigmoid Resection?
Study from Amsterdan Ann Surg 2010
Mortality rates in perforated diverticulitis 10% (Concur with Chapman series 12%)
High mortality rates stress importance of defining risk factors a/w perforation
This group Looked at multiple factors in cohort of pts from had been suggested by previously published studies including Age, CRF, DM, CVD, Steroid use, NSAIDS
In univariate and multivariate analysis significantly higher perforation rates were found in pts. Who use immunosuppression, have CRF, or CVD.
After successful conservative management of an episode of diverticulitis 48% had a recurrence. 7% risk perforation overall?????
In this sub group analysis one or more of the 3 RF increased perforation rate by 5-fold (36% vs. 7%)
The authors concluded that elective sigmoid rsxn should be restricted and only considered in complicated cases and for high risk patients (IS/CRF/CVD) following a conserv tx episode
Other studies have collaborated that Immunosuppressed or immunocompromised patients with acute diverticulitis are more likely to with perforation or fail medical management
Concluded elective sigmoid rsxn should be restricted and only considered in complicated cases and for high risk patients (IS/CRF/CVD) following a conservatively treated episode

26. Predicting Recurrence After Initial Attack
5-year Recurrence 36%
Complicated
Recurrence 3.9%
Concluded: although recurrence is common following an initial attack managed medically, complicated recurrence is uncommon
Can we predict recurrence After Initial Attack?
In 2011 Group from Lahey looked retrospectively at the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively
672 patients
Overall recurrence at 5 years was 36%
But Complicated recurrence (fistula, abscess, free perforation) occurred in only 3.9% of patients at 5 years by Kaplan-Meier estimate
Family history of diverticulitis, length of involved colon segment >5 cm, and retroperitoneal abscess were associated with diverticulitis recurrence
Right colon disease was associated with freedom from recurrence
So they concluded Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon.
Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease.
Patients who present with right-sided diverticulitis are at low risk for recurrent disease.
These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.
Approx 1/3 pts. Will have recurrence ??
Long term fiber supplementation may prevent recurrence

27. Diverticulitis in Young Patients
< Age 50
No clear consensus
More virulent course of disease untrue
Not at increased risk of complications or recurrent attacks
Longer lifespan – higher cumulative risk for recurrent attacks
Resection is no longer indicated at the time of the first attack in young pts.
Nelson et al. Management of Diverticulitis in Younger Patients. Dis Colon Rectum 2006; 49:
Guzzo J, Hyman N. Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum 2004;47:

28. Laparoscopic Resections
Sigma Trial: Multicenter double blind RCT
Lap vs. Open Elective Resection
Lap and Lap-assisted elective colon resections can be performed safely with low conversion and complication rates
Faster Recovery, Decreased LOS
Less postoperative pain, more cosmetic
Factors to Consider: body habitus, local tissue inflammation, complicated diverticulitis
More complicated disease may require conversion
Sigma Trial Multicenter double blind RCT
Significant reduction in morbidity
Ann Surg 2009
Published longer FU in Surg Endoscopy 2011
The late clinical outcomes did not differ between groups during the 30-day to 6-month follow-up period. Consideration of total postoperative morbidity shows a 27% reduction in major morbidity for patients undergoing laparoscopic surgery for diverticular disease.

29. Lap vs. Open
prospective, multicenter, double-blind, parallel-arm, RCT in 5 centers
Significantly more major complications in Open group 9.6% vs. 25.0% (P = 0.038)
Less pain, improved quality of life, and shorter LOS at the cost of a longer operating time
Minor complication rates were similar
Teeuwen PH, chouten MG, Bremers AJ, Bleichrodt RP Laparpscopic sigmoid resection for diverticulitis decreases major morbidity rates. Ann Surg Sep;250(3):500-1

30. Complicated Diverticulitis: Abscess
Hinchey Stages I (pericolic abscess) and II (retroperitoneal or pelvic abscess)
Approx 15% of patients with acute diverticulitis
Admission + IV Antibiotics
Abscesses <2 cm should resolve
Larger abscess amenable percuataneous drainage
Elective Resection?
Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum Jul;49(7):939-44

31. Management of Acute Diverticulitis with Abscess After Drainage
Elective resection typically advised after episode of complicated diverticulitis (ASCRS)
Association of Coloproctology of Great Britain and Ireland statement does not specifically address
After percutaneous drainage of abscess elective resection has been recommended as 41% will develop recurrence
This has been challenged
All small, retrospective, single-institution data sets with limited follow-up and lack of time-to-event analysis, and selection bias
What about complicated diverticulitis?
Elective resection typically advised after episode of complicated diverticulitis (based on ASCRS recs)
Association of Coloproctology of Great Britain and Ireland statement does not specifically address
After percutaneous drainage of abscess elective resection has been recommended as 41% will develop recurrence
This has been challenged by the U. Minnesota group
Gaertner et al describe their 5-year experience with 218 patients treated with percutaneous drainage for diverticular abscess.
Decent size of their initial cohort and high follow-up rate (88%)
We are not told how these patients were selected for percutaneous drainage
At 7.4 year fu, a majority of patients (85%) underwent colectomy: either emergently or electively
Suggests nearly universal compliance with the 2006 Practice Parameters.
in addition, the authors found that abscesses of >5cm were associated with emergency colectomies
32 patients were not offered colectomy over the study follow-up period. the majority of these patients had at least 1 severe medical comorbidity.
58% of this group did not have a recurrence of diverticulitis at 7.4 years
These findings are consistent with the findings of previous literature
But they are all small, retrospective, single-institution data sets with limited follow-up and lack of time-to-event analysis. all are replete with selection bias
Challenge going forward is to determine patient characteristics that suggest favorable outcomes in average risk patients who undergo nonoperative management.
it is unlikely that this question will be answered outside the confines of a prospective randomized trial

32. Complicated Diverticulitis: Obstruction
Can be partial or complete
Colonic obstruction from edema and/or inflammation.
Recurrent attacks can cause inflammation and fibrosis resulting in stricture
Must evaluate for cancer

33. Complicated Diverticulitis: Fistula
Abscess rupture
Incidence 5-33% reported
Types:
Colovesical fistula:
Most common fistula from diverticulitis
Diverticulitis most common cause of CVF
Less common in females due to uterus protection
Colovaginal fistula: Females after hysterectomy
Colocuteneous fistula
Less Common: Coloenteric, colouterine, Colosalpingeal

34. Complicated Diverticulitis: Fistula
Diagnosis is Clinical
Many wont be identified on imaging
Excess efforts should not be taken to demonstrate fistula
Primary aim is determine etiology (Ca, IBD, Diverticulitis) and manage appropriately
Treatment:
Treat acute attack
Elective resection, primary anastomosis

35. Complicated Diverticulitis: Free perforation
1% to 2% of cases
Mortality between 20% - 30%
Hinchey Stage III - Purulent peritonitis
Hinchey Stage IV - free perforation with fecal peritonitis
Emergent Operative Intervention
Management Options

36. Emergent Surgical Intervention
Controversial Management of Hinchey III & IV disease
According to current ASCRS guidelines, HP recommended
Sigmoid resection, end colostomy, closure of distal stump
Overall Morbidity up to 29%
Mortality 10-20%
Long LOS (20+ days)
Colostomy closure technically difficult
“Temporary” colostomies often never closed (30%-75%)
This has been challenged by European Association for Endoscopic Surgery recommendations + several studies
Alternative to HP include: PA +/-Diversion & Lap Lavage
Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum Jul;49(7):939-44

37. Emergent Surgical Intervention
RCT: HP vs. PA +DLI
N=62 Hinchey III/IV
Complication Rate (M&M) for resection and Stoma reversal comparable in each group
Primary Anastomosis Favored:
Stoma reversal rate significantly higher (90% vs. 57%)
Significantly reduced major complications, OR time, LOS, and cost
Primary Anastomosis (PA) performed since 1950’s
In this Swiss Multicenter RCT Annals of Surg 2012
Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis
-Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 centers were randomized to HP (n = 30) and to
-PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups
Complication Rate (M&M) for resection and Stoma reversal comparable in each group
Primary Anastomosis Favored:
Stoma reversal rate significantly higher (90% vs. 57%)
Significantly reduced major complications, OR time, LOS, and cost

38. Emergent Surgical Intervention
Salem and Flum et al. Meta-analysis
PA (569 cases 50 studies) v. HP
M&M greater in HP group
Concluded PA safe
Therefore PA +DLI in Left sided perforation
Higher Stoma reversal rate
Shown to be safe, with less complications, shorter LOS, and less cost
Future Question: Is diverting ileostomy is necessary?

39. Laparoscopic Lavage
Lap lavage for perforated diverticulitis is newer modality of treatment
First described by O’Sullivan et al. Ireland, 1996
2009 published 100 consecutive cases with 93% success
2012 published 427 cases 14% morbidity
Nonfeculent Perforated Diverticulitis (Hinchey 3)
Not actually new concept, now more realistic option
Increase in adoption of laparoscopy & advances in technical skill + Improvement in CT imaging
Treatment option now within skills set of most general surgeons
Mainly in Europe. Ireland. Australia
O’sullivan et al. Laparoscopic Management of generalized peritonitis due to perforated colonic diverticula. Am J surg 1996;171:

40. Laparoscopic Lavage
In institutions who use commonly: report refinements in technique and improvement in case selection have resulted in increased use
Generally Antibiotics +
Hinchey I-II Percutaneous Drainage
Hinchey III Lap Lavage
Hinchey IV Hartmann’s
Failures:
Fistula formation
Perforated cancer
Ongoing sepsis/inadequate washout/missed collection
Thought is Hinchey III is due to rupture/perforation of an abscess thus purulent peritonitis not a/w free colonic perforation
Lithotomy
10 cmra and 3 5 mm ports
Avg OR time 50 min
Approach medially
Mobilize sb omentum and pelvic oragns /take all attachments,/loculatons and minimal lavage-
some authors describe not disturbing attachments and using large volume lavage
Debride/sxn all abscess
Confrm stage
Hinchey I drain
Pelvic Hinchey II may have dense sb attachments
III easier suction all pus and irrigate about 1L
IV w macroperf generally resect do not repair
Drains placed lateral to sigmoid
Some will submerge and insufflate to ensure no free perf and make sure no tumor
White et al. A Ten-Year Audit of Perforated Sigmoid Diverticulitis: Highlighting the Outcomes of Laparoscopic Lavage. Dis Colon Rectum 2010; 53:

41. Laparoscopic Lavage Systematic Review Publications 1990 - 2008
8 studies met inclusion criteria
213 patients with acute complicated diverticulitis managed by laparoscopic lavage & Abx
Hinchey Grade 3 disease
Conversion to laparotomy in 6 (3%) patients
Mean LOS 9 days
10% had complications
Mean f/u 38 mos, 38% underwent elective sigmoid resection with primary anastomosis
Alternative to more radical surgery in selected patients
[read slide]
Small studies
Range Hinchey 2-4
Only 1 prospective
Interesting thing is how they managed them after
Postop –CT, colonoscopy, BE
3 styles of management
All elective resections (4 institutions)
Surgery to severe complicated diverticulitis + 3attacks mild
Conservative approach – resection only if readmitted requiring operation or of colonoscopy revealed a cancer (3 studies)
Alamili et al., Acute Complicated Diverticulitis Managed by Laparoscopic Lavage. Dis Colon Rectum. 2009; 52:

42. Concluded: Promising Therapeutic Option
Overall intervention rate same
Proportion of pts undergoing lap lavage increased 8% to 17%
Lap Lavage more likely in pts at extremes of age
Lap Lavage:
Lower mortality
Less complications 14.1% vs. 25% (P<0.001)
Shorter LOS
ICU admission rates significantly lower
Retrospective study in Ireland. Largest to date
28,500 admissions for diverticulitis
2,455 pts underwent surgery for diverticulitis (8.6% of admissions)
427 had Lap lavage
2028 Laparotomy/resection
Overall intervention rate stayed the same over time but proportion of pts undergoing lap lavage increased from 8% to 17%
Pts at extremes of age: <50 yo and >75 significantly more likely to undergo Lap Lavage (inherent selection bias)
Found that pts underwent lap lavage had significantly lower mortality (4 vs. 10.4%)
Less complications 14.1% vs. 25%
Shorter LOS 10 vs. 20 d
ICU admission rates significantly lower 3% vs. 11.6%
Pts older than 65 more likely to die as well as those interestingly with Connective tissue disease and chronic kidney disease
Selection bias
Concluded: Promising Therapeutic Option

43. Laparoscopic Lavage
Issues that have precluded this from being standard of care to replace HP
1. Patient selection (Hinchey 3)
2. Accuracy of Preop Determination
3. Lack Prospective RCT
Critiques:
Selection Bias
Inclusion Criteria Variable
Lack of Prospective Data
No Randomized Studies
It seems like a great option. Selection of suitable pts difficult
Issues that have precluded this from being standard of care to replace HP
1. Patient selection
Some would argue large portion may not need surg
Decision to operate difficult need good radiology and interventional radiology support is not always available
Most authors restrict the use of this technique to Hinchey 3 w/ purulent peritonitis w no perforation
2.Accuracy of preop determination of the correct Hinchey score has been questioned Frankin et al found preop CT to be inaccurate in 50% pts
But they did find the technique useful in the majority of their pts irrespective of Hinchey class
Also Dx Lapa offers a diagnostic approach to determine this pt group selection and Calss IV can convert to resection
[read slide]
The world is waiting for larger scale prospective results before adopting a new practice pattern
Without prospective RCT we cant know if the grade of disease/selection bias or the procedure itself leads to such good outcomes in M&M
Horgan, A. Laparoscopic Lavage for perforated diverticulitis: A Panacea? Another view. Dis Colon Rectum. 2013; 56:388.

44. Laparoscopic Lavage RCT in Progress
DILA-LA Scandinavia, Thornell et al.
The Ladies Trial Dutch Diverticular Disease (3D) Collaborative
LapLAND Hogan et al.
SCANDIV Scandinavia, Schultz et al.
Questions for future:
If we manage pts. successfully, what percent remain symptomatic?
Compare to HP and PA +/- DLI
Should elective resection be performed?
Current Data do not support the conclusion that Lap lavage is superior to resection, it shows that the technique is becoming more frequently used and the the postoperative outcomes are acceptable.
The results of upcoming RCT are eagerly awaited
started
DILA-LA Scandinavian Surgical Outcomes Research Group
The Ladies Trial Dutch Diverticular Disease (3D) Collaborative
LapLAND USA Hogan et al.
SCANDIV Scandinavian Diverticulitis Trial
[read slide]

45. Nationwide inpatient sample N=267,000 acute diverticulitis
33,500 operations
Admissions increased by 26%
Rates of admission increased
more rapidly for young pts (82% vs. 36%)
Elective operations rose 29%
No evid that PA becoming more widely used
Mortality decreased
So how has this affected us and what are the outcomes?
In looking at Diverticulitis in the US Nationwide inpt sample
Population adjusted rates of admissions increased by 26% from 120,500 to 151,900
Rates of admission increased more rapidly for young pts (age 18-44) 82% vs. older yo 36% (Black filled dot on the graph)
Min growth in US population growth
Elective operations rose 16,100 to 22,500 (29%)
More rapid increase in rates of surgery for pts age (likely based on old recs of operating after 1 attack)
Multivariate analysis found no evid that Primary anast becoming more widely used
Causes of increase in disease unknown
Outcomes improved with overall mortality decrease from 1.6% to 1.0%
Surgical mortality decreased from 5.7% to 4.3%
Operative Mortality rates for older pts (75+) significantly higher for both acute and elective operations

46. Outcomes
Despite a significant decline in surgical treatment for diverticulitis, there has been no change in the proportion of patients discharged for free diverticular perforation
Rationale for offering prophylactic surgery to prevent future free perforation is unsubstantiated
-Retrospective analysis of patients with diverticular disease in the Nationwide Inpatient Sample from 1991 through 2005.
-Ratio of diverticulitis discharges increased from 5.1 cases per 1,000 inpatients in 1991 to 7.6 cases per 1,000 inpatients in 2005
-The proportion of patients who underwent colectomy for uncomplicated diverticulitis significantly declined from 17.9% in 1991 to 13.7% in 2005
-During the same period, the proportion of free diverticular perforations as a fraction of all diverticulitis cases remained unchanged (1.5%)
-Significant Decrease in diverticular perforations and/or abscess treated with colectomy, 71.0% in 1991 to 55.5% in 2005
-Despite a significant decline in surgical treatment for diverticulitis, both in the complicated and uncomplicated setting, there has been no change in the proportion of patients w/ free diverticular perforation
-No significant change in the proportion of patients presenting with freely perforating disease, implying little to no consequence of the shift toward less surgical treatment
-Their data confirmed other previous data indicating that an algorithm of elective resection for recurring diverticulitis would have a minimal effect on preventing diverticular- free perforations or emergency colectomies
-Rationale for offering prophylactic surgery to prevent future free perforation is unsubstantiated
These results and those of others should lead to a reappraisal of the algorithm for surgery

47. Recurrence After Resection
Recurrent diverticulitis is rare after a colectomy for diverticulitis (3% to 13%)
As many as 3% will require repeat resection
Thaler et al. found level of anastomosis was the only predictor of recurrence
Important predictor is colosigmoid rather than colorectal anastomosis
Recurrence 4 times greater
To avoid recurrences, the rectum should be used for anastomosis
Where taeina coli splay out onto upper rectum
Thaler et al., Determinants of recurrence after sigmoid resection for uncomplicated
diverticulitis. Dis Colon Rectum Mar;46(3):385-8.

48. Take Home Message
Patients are often sent to a surgeon’s office to consider an elective colectomy to avoid urgent surgery and the possibility of a stoma
As few patients will actually require urgent surgery, should limit discussion regarding this uncommon complication
Instead should focus on discussion of risks and benefits of surgery, QOL implications, and the higher likelihood of similar episodes as the reason to, or not to, consider surgery
-Patients are often sent to a surgeon’s office to consider an elective colectomy to avoid urgent surgery and the possibility of a stoma. Yet, given that few patients will actually require urgent surgery following uncomplicated diverticulitis, the consulting surgeon should probably limit his or her discussion regarding this uncommon complication.
- Instead the consultation should focus on a more in-depth discussion of risks and benefits of surgery, quality-of-life implica- tions, and the higher likelihood of similar episodes of diverticulitis as the reason to, or not to, consider surgery
Ricciardi R et al. Is the Decline in Surgical Treatment for Diverticulitis Associated with an Increase in Complicated Diverticulitis? Dis Colon Rectum. 52(9): Sept 2009.

49. Conclusions
Colonoscopy in at least complicated if not all cases after an acute attack
Uncomplicated Diverticulitis: Admission and Antibiotics may not be necessary
Bowel Prep unnecessary
Elective sigmoid colectomy after recovery from acute diverticulitis should be made on a case-by-case basis
Guidelines should be revised
Recommendations continually evolving as we learn more about the Natural course of the disease

50. Conclusions
Emergent Resection: Primary Anastomosis Anastomosis + Diverting Loop Ilesotomy better outcomes than Hartmann Procedure
Laparoscopic Lavage is a promising new technique
Prospective RCT data needed
To avoid recurrence, ensure rectum

51. Thank You
Thank you for your attention