Clinical Outcomes Of Complicated Diverticulitis Managed Nonoperatively

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  • 1. R. Scott Nelson D.O , B. Mark Ewing B.S., Timothy J. Wengert M.D. and Alan G. Thorson M.D. Clinical outcomes of complicated diverticulitis managed nonoperatively The Southwestern Surgical Congress December 2008 (Vol. 196, Issue 6, Pages 969-974)
  • 2.
    • The incidence of diverticulitis within the United States is increasing , This is based in part on technology that is able to provide a noninvasive diagnosis
    • Younger patients typically not thought of having this disease process are now more frequently being diagnosed
  • 3.
    • This technology, specifically computed tomography (CT) scans, is playing a more integral part in the diagnosis and management of the disease .
  • 4.
    • Frequently, a history of diverticulosis with the onset of typical symptomatology has been used to diagnosis a flare of diverticulitis without confirmatory study
    • CT scanning has redefined the diagnosis of diverticulitis by its ability to visualize and distinguish between the different variants of this disease process
  • 5.
    • Acute diverticulitis:
      • Uncomplicated :
        • evidence of colonic wall thickening
        • pericolonic inflammatory changes such as fat stranding
      • Complicated :
        • Abscess
        • Fistula
        • Obstruction
        • localized or free perforation
  • 6.
    • Radiographic findings, in conjunction with the patient's history, comorbidities, and physical examination are now frequently used to establish whether an operation or nonoperative management should be prescribed.
  • 7.
    • Historically, recommendations for resection of uncomplicated disease were based on
      • 2 previous episodes of diverticulitis or
      • 1 episode if the patient was less than 50 years of age
    • Newer data and recommendations have called for a revision of the practice of aggressive surgical resection in patients with uncomplicated disease, despite recurrence or age.
  • 8.
    • The basis of these arguments is that a majority of patients do not seem to progress from uncomplicated to complicated disease over time.
  • 9.
    • Complicated diverticulitis is considered an indication for elective operation.
    • Patients with an abscess or localized perforation in particular have been treated with antibiotics, and percutaneous drainage if indicated.
    • Following this course of action they are typically scheduled for elective resection.
  • 10.
    • However, our understanding of the natural history of diverticulitis is changing as our ability to visualize the disease has changed.
    • The aim of this study was to assess the outcomes of a group of individuals with complicated findings on CT scan that had been followed without an operation.
  • 11. Materials and Methods
    • Retrospective study
    • 14-year period (1993 - 2006)
    • complicated diverticulitis (CT scan)
      • Patient demographics (age and sex)
      • Operation performed
      • CT findings
      • Recurrence
    • Patients without CT scan evidence of complicated diverticular disease were not included in the study.
    • . P values ≤.05 were considered statistically significant.
  • 12. Results
    • 256 patients (142 males).
    • mean age of the population was 63 years (range 22–91)
    • 79% of the patients under the age of 70
    • 99 (38.6%) were initially managed nonoperatively
  • 13. Age distribution of population per decade Age yr 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91+ Operative group 2 24 38 19 38 24 9 3 Nonoperative group 3 8 11 27 33 12 5 0 Total group 5 32 49 46 71 36 14 3
  • 14. 256 Complicated Diverticulitis 99 Followed 157 Operated 46 Recurrence 82 Anterior Resection 75 Hartmann 20 Operation 1 Hartmann
  • 15.
    • Patients younger than age 50 were evaluated against those older than 50 years of age to determine if they were at risk of:
      • requiring an emergent operation, or
      • having more recurrent disease.
  • 16. 86 ( < 50 Y ) 22 ( non – operative ) 64 ( Operative ) 4 (18.2 %) Surgery 77 (> 50 Y ) Non-operative 16 (20.8 %) Surgery
  • 17. 157 Operated 82 Anterior Resection 75 Hartmann 27 (42% ) < 50 Y 48 ( 51.6 % ) > 50Y patients less than 50 years of age had fewer emergency operations
  • 18.
    • When followed without surgery, younger patients did not appear to be at higher risk for recurrent attacks compared with older patients.
    • 11 of the 22 patients (50%) younger than 50 years of age had at least 1 recurrence, whereas 31 of the 77 patients (40.3%) older than 50 had at least 1 recurrence ( P = .6453).
  • 19.
    • Thus, there was no difference between recurrence or need for emergency operation based on age .
  • 20. Reasons for nonoperative treatment patient response to medical management 32 no referral to a surgeon by the medical physicians 47 patient's refusal of an operation 9 patient being deemed too ill for an operation 11 total 99
  • 21. Initial CT scan findings for both groups SD = sample deficiency . CT scan findings Nonoperative group (n = 99) Operative group (n = 156) P value Abscess 56 55 .0011 Localized perforation 35 21 .0006 Free perforation 1 66 <.0001 † Fistula 2 13 .0713 Phlegmon 5 0 SD Obstruction 0 2 SD
  • 22. Non Operative Group 99 ( all recived Antibiotics ) 11 percutaneous drain placements 1 Hartmann procedure for obstruction 1 elective sigmoid resection
  • 23.
    • Mean follow-up of these 99 nonoperatively treated patients was 76.3 months.
    • 75 recurrent episodes requiring some form of treatment occurred in 46 patients (46.4%).
    • Of these recurrent episodes:
      • 62 were uncomplicated
      • 13 were complicated.
  • 24.
    • 20 of the 99 patients ultimately had an operation, greater than 6 months out from their first complicated attack, with 1 patient requiring the Hartmann procedure .
    • These 20 patients had significantly more recurrent episodes of diverticulitis
  • 25.
    • Of the patients undergoing an operation within 6 months of their complicated episode of diverticulitis:
      • 82 (52.2%) had a sigmoid resection
      • 75 (47.7%) underwent a Hartmann procedure
    • 19 CT-guided percutaneous drains were placed in this group
      • 17 were later treated with a sigmoid resection
      • 2 failed drainage, requiring a Hartmann
  • 26. Comments
    • While diverticular disease appears to be increasing in incidence, less than 1% of patients will need to be managed operatively
    • Different classification systems have been devised to better define the different presentations of diverticular disease.
  • 27.
    • Hinchey described his well-known 4 stages of complicated diverticulitis found at laparotomy
  • 28.
    • More recently, Ambrossetti et al have described a classification system for diverticulitis based on CT scan criteria .
    • 2 categories :
      • Complicated :
        • Abscess
        • extraluminal air
        • extraluminal contrast
      • Uncomplicated
  • 29.
    • The American Society of Colon and Rectal Surgeons (ASCRS) consensus statement includes obstruction and fistula
  • 30.
    • In a recent study by Chapman et al :
      • morbidity and mortality rates were not significantly different between patients who suffered multiple attacks (>3) versus those with only 1 or 2 attacks.
  • 31.
    • Haglund et al :
      • monitored 372 patients for 12 years and concluded that patients with complicated diverticulitis usually presented with perforation, on their first episode and not later on, even with multiple recurrences.
  • 32.
    • Anaya et al:
    • large population-based study of more than 20,000 patients admitted with nonoperatively managed diverticulitis, found that only 5.5% progressed to require an emergency colectomy or colostomy.
  • 33.
    • Our data similarly demonstrate that patients with complicated disease do not have a significant risk for returning on an emergency basis with perforation and need for colostomy.
  • 34.
    • Based on these findings, patients with diverticular disease who have had a complicated finding on CT scan should be informed that the risk of recurrence requiring fecal diversion is low.
  • 35.
    • However, the risk of recurrent disease is quite high and should be considered along with the patient's desires, lifestyle considerations, work requirements, and other comorbidities as a course of therapy is chosen.
  • 36. Conclusions
    • risk of perforation and need for colostomy after a medically treated complicated episode of diverticulitis were extremely low.
    • However, recurrence of disease within our mean follow-up period of 6 years was almost 50%.
    • The patient's comorbidities, response to treatment, age, and their desires, as well as type of operation available, should all play a role when designing the treatment algorithm for this disease.
  • 37. Thank You