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Div disease dukes club

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  • 1. Acute Diverticulitis: Lap , open orconservative? Savvas Papagrigoriadis MD MSc FRCS Consultant Surgeon King’s College Hospital, London
  • 2. 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
  • 3.  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.
  • 4. 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
  • 5. Complications:Free perforation Generalized peritonitis - septicaemia Free gas in the abdomen Pneumoperitoneum - abdominal distention Treatment: Urgent laparotomy High mortality
  • 6. 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
  • 7. 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)
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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.
  • 12. 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.
  • 13. Elective surgery is justified only if it decreasesemergency 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
  • 14. 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?
  • 15. 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
  • 16. The patient with acute diverticulitis: outpatienttreatment 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)
  • 17. 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
  • 18. 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 ?
  • 19. 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
  • 20. Laparotomy v. Laparoscopy
  • 21. 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
  • 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. 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
  • 24.  Cochrane systematic review Meta-analysis 11 non randomised, 1 RCT Elective laparoscopic resection safe Laparoscopic: lower overall morbidity and minor complications  Cirrochi 2011
  • 25. 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
  • 26.  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
  • 27. 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
  • 28. Risk factors of lap surgery fordiverticulitis 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
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. Single Port Laparoscopic Surgery Aim to minimize trauma and improve cosmetics Right and left hemicolectomy No significant data yet on outcomes & benefits
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. Emergency Surgery: Options of operations
  • 38. 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
  • 39. Reversal of colostomy is not alwayssafe…..
  • 40. Emergency Surgery : Primary anastomosiswith 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
  • 41. The role of LPL: Laparoscopicperitoneal 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
  • 42. Systematic review of LPL (laparoscopicperitoneal 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
  • 43. 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 63NR: not reported
  • 44. 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 NRTaylor e a 11 t l 7 0 0 0 73 15Bre nol et a 17 tag l 12 0 8 0 100 NRMyerset a 10 l 8 3 8 2 0 36Franklin et a 12 l 7 0 20 0 50 96Favuzzaet a 14 l 8 0 14 1 83 NRLam e a 16 t l 11 0 33 1 50 6Kar e a 13 oui t l 8 0 28 1 71 21White et a 22 l 14 0 12 0 64 20Liang e a 18 t l 8 0 4.3 0 45 NR
  • 45. After discharge… Is there a risk of recurrence? Can we prevent it from happening? Is there a benefit if we diagnose it early?
  • 46. 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%
  • 47. Recurrent diverticulitis Nelson RS Am J Surg 2008 99 inpatients treated medically 46/99 recurrence 20 had surgery
  • 48. 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
  • 49. 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
  • 50. Uncertainties Selectioncriteria for elective surgery Risk assessment of individual patients
  • 51. Thank you