1. Acute Diverticulitis: Lap , open or
conservative?
Savvas Papagrigoriadis MD MSc FRCS
Consultant Surgeon
King’s College Hospital, London

3. King’s research in diverticular
 Epidemiology
disease
– National UK study on
hospital admissions
– Economical analysis
 Pathogenesis
– Neurotransmitters:
serotonin
– Role of smoking in
complications
 Treatment
– RCT Mesalazine for
prevention in diverticulitis
– RCT Probiotics
 Quality of life
 Diverticular Disease
Clinic

4.  Int J Colorectal Dis. 2012 Dec;27(12):1597-605. doi: 10.1007/s00384-012-1515-
6.Epub 2012 Jun 29.A clinicopathological study of serotonin of sigmoid colon
mucosa in associationwith chronic symptoms in uncomplicated
diverticulosis.Jeyarajah S, Akbar N, Moorhead J, Haji A, Banerjee S,
Papagrigoriadis S.
 Dig Dis. 2012;30(1):114-7. doi: 10.1159/000335916. Epub 2012 May 3.Differences in
early outcomes after open or laparoscopic surgery: what is theevidence?
Papagrigoriadis S.
 Aliment Pharmacol Ther. 2011 Apr;33(7):789-800. doi:10.1111/j.1365-
2036.2011.04586.x. Epub 2011 Feb 9.Review article: the pathogenesis of
diverticular disease--current perspectives onmotility and
neurotransmitters.Jeyarajah S, Papagrigoriadis S.
 Aliment Pharmacol Ther. 2009 Dec 1;30(11-12):1171-82. doi:10.1111/j.1365-
2036.2009.04098.x. Epub 2009 Jul 20.Diverticular disease hospital admissions are
increasing, with poor outcomes inthe elderly and emergency admissions.Jeyarajah
S, Faiz O, Bottle A, Aylin P, Bjarnason I, Tekkis PP, Papagrigoriadis S.
 Aliment Pharmacol Ther. 2009 Sep 15;30(6):532-46. doi:10.1111/j.1365-
2036.2009.04072.x. Epub 2009 Jun 22.Review article: the current and evolving
treatment of colonic diverticulardisease.Tursi A, Papagrigoriadis S.
 Int J Colorectal Dis. 2008 Jun;23(6):619-27. doi: 10.1007/s00384-008-0446-8.
Epub2008 Feb 15.Diverticular disease increases and effects younger ages: an
epidemiological studyof 10-year trends.Jeyarajah S, Papagrigoriadis S.
 Int J Colorectal Dis. 2007 Jun;22(6):643-9. Epub 2006 Nov 4.Increased presence of
serotonin-producing cells in colons with diverticulardisease may indicate
involvement in the pathophysiology of the condition.Banerjee S, Akbar N, Moorhead
J, Rennie JA, Leather AJ, Cooper D, Papagrigoriadis S.
 Colorectal Dis. 2004 Mar;6(2):81-4.Impact of diverticular disease on hospital
costs and activity.Papagrigoriadis S, Debrah S, Koreli A, Husain A.
 Colorectal Dis. 2003 Jul;5(4):320-3.Diverticular disease has an impact on quality
of life -- results of a preliminarystudy.Bolster LT, Papagrigoriadis S.
 Br J Surg. 1999 Jul;86(7):923-6.Smoking may be associated with complications in
diverticular disease.Papagrigoriadis S, Macey L, Bourantas N, Rennie JA.

5. Clinical Scenarios
 The Patient with
– First time acute diverticulitis
– previous diverticulitis and recurrent symptoms
– after recent emergency hospitalisation for DD
• With surgery
• With medical management
• Admission for bleeding
– atypical abdominal pain and diverticulosis on colonoscopy/
radiology

6. Complications:
Free perforation
 Generalized peritonitis -
septicaemia
 Free gas in the abdomen
 Pneumoperitoneum -
abdominal distention
 Treatment: Urgent
laparotomy
 High mortality

7. Complications:
Phlegmon or Abscess
 Most common
complication
 Localized peritonitis of
left iliac fossa
 Initial conservative
treatment
 Percutaneous aspiration
of abscess under CT
guidance
 Laparotomy if no
improvement

8. Complications:
Colovesical fistula
 Pneumaturia
 Fecaluria, haematuria,
frequency
 25% fever and abdominal
pain
 Sepsis
 Gastrografin enema
 IVP (useful to detect ureter
involvement)
 Laparotomy (1 or 2 stage)

9. Complications:
Colovaginal fistula
 Itrarely occurs if the uterus is present
 Vaginal discharge of feces, blood, gas
 Colposcopy and sigmoidoscopy put the
diagnosis
 One stage resection of the fistula

10. Complications:
Thigh abscess
 Not uncommon
 Suspected if enteric
organisms are isolated
 Retroperitoneal
perforation
 Neurovascular bundles
that penetrate the
abdominal wall
 Inguinal rings
 Through the pelvic floor

11. Complications:
Bleeding
 Common
 acute massive/ not
chronic
 ? overdiagnosed
QuickTim e™ and a
decom pressor
Urgent colonoscopy
are needed to see this picture.

or Angiogram
 Subtotal colectomy

12. The “appendicitis model”
 When acute  Problems:
pathology presents  Emergency treatment of
treat with DD complications has
high morbidity.
emergency surgery.
 Without surgery high
 Surgical treatment recurrence rate.
has minimal  After surgery some
morbidity. relapse of symptoms.
 The disease does
not relapse.

13. The “peptic ulcer model”
 1980s: numerous  Problem:
emergency admissions  By performing elective
for peptic ulcer sigmoid colectomy on DD
complications patients for prevention of
 Numerous elective complications….
 …do we have evidence we
operations aimed to
decrease emergency are achieving it?
 …or are we operating on a
complications…
different population of
 …then H. Pylori was patients?
discovered.

14. Elective surgery is justified only if it decreases
emergency surgery
 Etzioni Ann Surg 2009
 USA national data on
admissions for 160000
diverticulitis 1998 -2005 140000
120000
 Emergency admissions 100000
80000 Emergency Admissions
rose by 26% 60000
Elective Surgery
40000
 Elective Surgery rose 20000
by 29%
0

15. The patient with acute diverticulitis
 Treatment with:
– Antibiotics (IV or oral)
– IV fluids / ressuscitation
– 5-ASAs
– early CT scan
– Some form of colonic imaging at a second stage
when acute inflammation settles
– Evidence for all of the above?

16. The patient with acute diverticulitis:
which antibiotics?
 Broad spectrum  Byrnes MC, Surg Infect 2009
 Review of literature for
 Gram negative evidence and guidance on
-anaerobes choice of antibiotics in
Diverticulitis
 Non absorbable?  No evidence on what is
– Best scheme
– Optimal duration of
treatment

17. The patient with acute diverticulitis: outpatient
treatment
 Martin Gil, Gastronterol Hepatol  Mizuki A, Aliment Pharmacol
2009 Ther 2005
 Ambulatory treatment of  Ambulatory treatment of
Hinchey 1 & 2 diverticulitis diverticulitis and abscesses up
 Ciprofloxacin + metronidazole to 2 cms large (US diagnosis)
8.8 days  Oral antibiotics 10 days
 70/74 patients treated without  68/70 patients treated without
admission admission
 13 patients had subsequent  16 recurrences (median fup 30
elective surgery months)

18. We may not need IV antibiotics
 Ridgway P, Colorectal  48 hour rule?
Dis 2008  Evans J, J Gastrointest Surg
2008
 RCT 79 inpatients with  198 inpatients retrospective
diverticulitis  Drop of WCC & Temperature
within 48 hours predicted
 Oral v. IV ciprofloxacin discharge with oral
& metronidazole antibiotics by day 4
 All cases resolved  Lack of 48 hour response
went on to prolonged stay or
without conversion of surgery
oral to IV regime

19. Or even… no antibiotics?
 Hjern F, Scand J  30 months fup
Gastroenterol 2007  Same recurrence rate
between 2 groups -29%
 Retrospective 311  Multivariance analysis did
inpatients not show antibiotics ro
 118 patients received reduce risk of recurrence
antibiotics  Mild DD does not require
antibiotics?
 193 patients
 Comment: may indicate that
observation and there are many
restriction of oral intake unrecognized episodes of
diverticulitis ?

20. Hinchey II: Do we need drainage?
 Brandt D, Dis Colon Rectum 2006
 Case control study 66 patients Hinchey
II abscess
 CT drainage v. antibiotics
 Outcome identical
 Questioning whether CT drainage is
necessary

21. Laparotomy v. Laparoscopy

22. Is Laparoscopy safer and cheaper?
 USA national database study
 Elective surgery only 2002-2007
 Total 124,734 patients
– Open 110,172
– Laparoscopic 14,562
 Lower intra-operative complications in laparoscopic
group 0.63% v. 1.15% (p 0.001)
 All post-op complications higher for open
 Laparoscopic had shorter mean stay 5 v. 6.6 days
 Laparoscopic was cheaper $36k v $39k
 Masoomi et al World J Surg 2011

23. Is Laparoscopy safer and cheaper?
 USA national database study
 Elective surgery only 2002-2007
 Total 124,734 patients
– Open 110,172
– Laparoscopic 14,562
 Lower intra-operative complications in laparoscopic
group 0.63% v. 1.15% (p 0.001)
 All post-op complications higher for open
 Laparoscopic had shorter mean stay 5 v. 6.6 days
 Laparoscopic was cheaper $36k v $39k
 Masoomi et al World J Surg 2011

24. Cochrane Meta-analysis – Schwenk 2005
 25 RCTs comparing open (OS) with laparoscopic colorectal surgery
(LS)
 LS longer operative time but less blood loss
 LS less post op pain
 LS better pulmonary function
 Morbidity less in LS
 Mortality same after OS & LS
 Post op hospital stay less in LS
 QoL better with LS
 Conclusion: clear advantages of LS in most areas

25.  Cochrane systematic review
 Meta-analysis 11 non randomised, 1
RCT
 Elective laparoscopic resection safe
 Laparoscopic: lower overall morbidity
and minor complications
 Cirrochi 2011

26. Lap surgery for diverticulitis
 Hinchey I, II, III/ chornic diverticulitis, bleeding,
stricture
 260 operations
 5% conversions
 Average stay 10 -+3 days
 11% complications
 5 anastomotic leaks
 2 deaths
 El Zarrok Elgazwi et al JSLS 2010

27.  52 patients diverticulitis Hinchey I-II
– 36 Lap
– 16 Open
 Only 1 conversion
 Complications
– Lap 16%
– Open 43%
 Wound infections
– Lap 11%
– Open 37%
 Katsuno 2011

28. Lap or Hand-Assisted?
 361 patients
 136 with complicated diverticulitis
 Lap 36%
 Hand - assisted Lap 64%
 Conversion 14% + 11%
 No difference in complications, hospital stay between Lap and
Hand- assisted Lap
Pendlimari 2011

29. Risk factors of lap surgery for
diverticulitis
 526 patients with recurrent diverticulitis - lap sigmoid
colectomy
 Risk factors for complications
– Anaemia
– Myocardial infarction
– Heart failure
– Surgeon’s experience
– Male gender
– Age > 75
– Kirchoff 2011

30. Randomised CT
 104 patients either Lap or Open for sigmoid resection
for diverticular disease
 Conversion 19%
 Complications
– Lap 9%
– Open 23%
 QoL better for Lap at 6 weeks (SF36)
 At 6 months no differences in outcomes
 Similar financial costs between Lap & Open
 Klarenbeek 2011

31. Meta-analysis
 Elective open v Lap sigmoi colectomy for div disease
 1991-2009
 22 studies, 10,898 patients
– 1538 Lap
– 9360 Open
 Same mortality
 Shorter hospital stay in Lap
 Morbidity higher in open RR = 0.56
 Siddiqui 2010

32. We cannot randomize anymore…
 149 recruited patients in multicentre RCT
between open and lap surgery for diverticular
disease
 294 randomized patients
 Most patients refused randomization
 Recruitment aborted
 Patients have formed opinions from internet/
media
 Raue 2011

33. Hybrid techniques
 15 patients
 4 port laparoscopic surgery
 Operating rectoscope used to extract specimen
trans-anally and do anastomosis
 No abdominal incision
 3/15 patients needed opiates
 No complications
 Saad 2011

34. Single Port Laparoscopic Surgery
 Aim to minimize
trauma and improve
cosmetics
 Right and left
hemicolectomy
 No significant data
yet on outcomes &
benefits

35. SILS for DD
 SILS to offer fewer wounds-less pain
 10 patients for recurrent diverticulitis
 2.5 umbilical incision
 9/10 completed
 Median time 120 minutes
 Hospital stay 7 days]no complications
 Vestweber 2010

36. Robotic Surgery
 Rectal cancer
 Enough data
 Safety and outcomes similar
to laparoscopic
 No advantage to
laparoscopy
 Bypasses training need for
laparoscopy?
 Large costs -will have to
show convincing advantages

37. Robotic surgery for DD
 24 patients with recurrent diverticulitis (9
complicated)
 Primary anastomosis without stoma
 No conversion
 Complications 12.5%
 No anastomotic leak
 324 mins average time (half docking and
console time)
 Ragupathi 2011

38. Emergency Surgery: Options of operations

39. Surgical treatment:
Results
 Reversal of colostomy may be
complicated by anastomotic leak or
other complications
 One third of the patients with Hartman’s
never have the colostomy closed

40. Reversal of colostomy is not always
safe…..

41. Emergency Surgery : Primary anastomosis
with defunctioning better than Hartmann’s
 Probability estimates from 6879 patients from 12 studies
 6619 Hartmann’s
 135 Primary Anastomosis
 126 Anastomosis with defunctioning
 Stoma permanent in 27% of Hartmann’s, 8% of PA with
defunctioning
 The probability of morbidity and mortality was 55% and 30% for
PRA, 40% and 25% for PADS, and 35%and 20% for HP,
respectively.
 Primary anastomosis with defunctioning stoma preferred option
 Constantinides 2007

42. The role of LPL: Laparoscopic
peritoneal Lavage
 Prospective 100 patients
 perforated diverticulitis and generalised peritonitis
 8 pts Hinchey IV converted to Hartmann’s
 92 had LPL
 2 pts with pelvic abscess & recurrent intervention
 Morbidity 4%
 Mortality 3%
 Only 2 patients had recurrent diverticulitis (median follow up 36
months)
 LPL may be adequate treatment of perforated diverticulitis
 Myers 2008

43. Systematic review of LPL (laparoscopic
peritoneal Lavage) on Hinchey III
 230 patients selected for data extraction.
 All patients had purulent peritonitis (Hinchey III)
 and treated with LPL laparoscopic pertoneal lavage.
 Morbidity was 12.73%
 overall failure rate of 1.3%.
 2.6% patients were readmitted in acute setting
 only 0.8 % required surgery
 LPL may be the only treatment required for Hinchey III !
 Scarpinata & Papagrigoriadis 2013

44. Table 1 Study design and patient characteristics
Year Author N Study design Type of study ASA Age (mean)
2005 Mutter et al 15 10 Case series Retrospective I-III 60
2006 Taylor et al 11 10 Case series Retrospective III-IV 57
2008 Bretagnol et al 17 18 Cohort Prospective I-II 56
2008 Myers et al 10 67 Cohort Prospective II-IV 62
2008 Franklin et al 12 32 Case series Retrospective II-III 60
2009 Favuzza et al 14 6 Case series Retrospective III-IV 49
2009 Lam et al 16 5 Cases series Retrospective II-IV 65
2009 Karoui et al 13 35 Cohort Prospective III-IV 56
2010 White et al 22 11 Case series Retrospective III-IV 61
2012 Liang et al 18 36 Cohort Prospective I-IV 63
NR: not reported

45. Table 2 Authors experience for laparoscopic peritoneal lavage in Hinchey III peritonitis
LOS Mortality Morbidity Seconda resection Length of
ry follow up
Autho
rs (mean) (%) (%) Read ission
m (N.) (% ) (months)
Mutt et a 15
er l 9 0 0 1 67 NR
Taylor e a 11
t l 7 0 0 0 73 15
Bre nol et a 17
tag l 12 0 8 0 100 NR
Myerset a 10
l 8 3 8 2 0 36
Franklin et a 12
l 7 0 20 0 50 96
Favuzzaet a 14
l 8 0 14 1 83 NR
Lam e a 16
t l 11 0 33 1 50 6
Kar e a 13
oui t l 8 0 28 1 71 21
White et a 22
l 14 0 12 0 64 20
Liang e a 18
t l 8 0 4.3 0 45 NR

46. After discharge…
 Is there a risk of recurrence?
 Can we prevent it from happening?
 Is there a benefit if we diagnose it
early?

47. Recurrent diverticulitis
– Mueller MH, Eur J  Greenberg AS,
Gastroenterol 2005 Aliment Pharmacol
– 252 patients, 7 years Ther 2005
fup  149 young patients
– 34% recurrence of <40, 5 years fup
medically treated  Surgical treatment
diverticulitis, 13 recurrence 15%
patients had surgery,
2 DD related deaths.
 Medical treatment
recurrence 55%

48. Recurrent diverticulitis
 Nelson RS Am J Surg 2008
 99 inpatients treated medically
 46/99 recurrence
 20 had surgery

49. Can we predict recurrence?
 Poletti
PA, AJR 2004
 168 patients, 18 months fup
 32% recurrence of diverticulitis
 CT scan with abscess or pockets of
gas> 5 mm was predictor of recurrence

50. Conclusions
 Antibiotics: more evidence needed
 Antibiotics & CT drainage for Hinchey I-II
 LPL may be adequate & definitive treatment
for Hinchey III peritonitis
 Laparoscopic surgery is safe and cost
efficient for all presentations of diverticular
disease
 Laparoscopic surgery may have some
advantages over open surgery
 Hartmann’s should be avoided if patient
fitness allows for primary anastomosis with
defunctioning

51. Uncertainties
 Selectioncriteria for elective surgery
 Risk assessment of individual patients

52. Thank you