Drexel University College of Medicine Colonic Diverticular Disease David E. Stein, MD Division of...

Drexel University College of Medicine

Colonic Diverticular Disease

David E. Stein, MD

Division of Colorectal Surgery

Department of Surgery

Mrs P.

• 64 y/o female in the ER with LLQ pain, nausea and vomiting– History– Physical– ? Labs– ? Work-up

Diverticular Disease

• Diverticulum is a saccular protrusion of mucosa through the colonic wall

• False vs True

• Pulsion

Prevalence

Asymptomatic diverticulosis• <45 years old: one-third; >80 years old: two-thirds

Hemorrhaging diverticulosis: 4%

Diverticulitis• >5 years disease: 10%• >20 years disease: 35%

Parks 1975, Kubo 1985, Horner 1958

Asymptomatic diverticulosis

Hemorrhaging diverticulosis

Acute diverticulitis

Subacute diverticulitis

Complicated diverticulitis

Asymptomatic Diverticulosis

• Differentiated from IBS

• Doubtful role for operative therapy

• High-fiber diet• Anti-spasmodic agents

Hemorrhaging Diverticulosis

Management• Assess hemodynamics• Establish baseline

laboratory values• Replace volume

Investigations• Exclude upper gastrointestinal source• Proctoscopy• Colonoscopy• Radionuclide scintigraphy• Mesenteric angiography

Colonoscopy

Prerequisites• Active or intermittent bleeding• Hemodynamically stable• Tolerant of intestinal lavage

Accuracy: 70-92%

Amenable to therapy: 17-39%

Jensen 1988, Rossini 1989, Richter 1995

Radionuclide Scintigraphy

Modalities• Technetium-99m sulfur colloid• Technetium-99m-labeled red blood cells

Effectiveness• Incorrect localization: 48-60%• Incorrect operation: 42%

Hunter 1990, Bentley 1991, Voeller 1991

Mesenteric Angiography

Effectiveness• Localization of bleeding site: 57-72%• Reduced operative mortality: 9-14% vs. 37-50%

Therapeutic options• Vasopressin infusion• Embolization

Britt 1983, Browder 1986, Uden 1986, Koval 1987

Mesenteric Angiography

Vasopressin infusion• Initial control: 70-92%• Rebleed rate: 22-71%

Embolization• Initial control: 71-100%• Rebleed rate: 0-12%

Browder 1986, Guy 1992, DeBarros 1997, Szomstein 1997

Operative indications• Persistent hypotension• Transfusion requirements:

– 6 units of blood over initial 24 hours– 10 units of blood

• Rebleeding within 7 days of cessation

Acute Diverticulitis

Differential diagnosis• Malignancy• Inflammatory bowel disease• Ischemic colitis• Urologic/gynecologic disorders

History and Physical

• Patients may have antecedent history of thinning bowel movements

• Patients may know they have “pockets”• All colonic pain is hypogastric – so bandlike pain

across the lower abdomen is common • No endoscopy or contrast enemas in the acute

phase – CT Scan

Investigations:• Ultrasonography• Water soluble contrast enema• Computerized tomography (CT)

Ultrasonography

Diagnostic criteria• Hypoechoic wall thickening, hyperechoic

diverticulae, hyperechoic halo

Effectiveness• Positive predictive value: 96%• Negative predictive value: 98%

Schwerk 1992

Contrast Enema

Diagnostic criteria• Mild: segmental narrowing, tethered mucosa,

mass effect• Severe: extraluminal gas/contrast

Effectiveness• Sensitivity: 94%; accuracy: 77%

Johnson 1987, Smith 1990

Contrast Enema

Computerized Tomography

Diagnostic criteria• Mild: Localized wall thickening (>5 mm),

pericolic fat inflammation• Severe: abscess, extraluminal gas/contrast

Effectiveness• Sensitivity: 93-97%

Cho 1990, Ambrosetti 1997

Computerized Tomography

Outpatient management• Low-residue, low-fiber diet• Oral antibiotics

Inpatient management• Bowel rest• Intravenous antibiotics

Follow-up management (6 weeks)• Exclude malignancy

– endoscopy– contrast enema

• Exclude complicated diverticulitis– contrast enema– computerized tomography

First episode outcome• Fail medical therapy: 20%• Secondary complications: 20%

Recurrent episode(s) outcome• Secondary complications: 60%

Ambrosetti 1997, Farmakis 1997, Kohler 1999

Mild diverticulitis:• Fail medical therapy: 4%• Secondary complications: 14%

Severe diverticulitis:• Fail medical therapy: 30%• Secondary complications: 39%

Ambrosetti 1997

Special circumstances• Patients <50 years of age

– obese males

• Patients with compromised immune systems– transplant candidates

Schauer 1992, Ambrosetti 1994, Vignati 1995

Operative Indications

Failed medical therapy

Resolved first episode• Severe diverticulitis• Age <50 years• Current or future immunosuppression

Resolved second episode

Complicated diverticulitis

Subacute Diverticulitis

Diverticulae, pain, altered bowel habits

Pathology:• Acute/chronic inflammation: 82%

Clinical course:• Resolution of symptoms: 70%• Resolution of pain: 84%

Horgan 2000

Complicated Diverticulitis

Perforation

Fistula

Obstruction

Perforation

Considerations• Stage of peritonitis• Peri-operative factors• Operative alternatives• Outcome

Staging Systems

Intra-operative systems• Hughes 1963• Hinchey 1978• Killingback 1983• Sher 1997

Peri-operative systems• Setti Carraro 1999• Biondo 2000

Hinchey Stage I

Confined abscess• Paracolic• Intra-mesenteric

Hinchey 1978

Hinchey Stage II

Distant abscess• Pelvic• Retroperitoneal• Intra-abdominal

Hinchey 1978

Hinchey Stage III

Purulent peritonitis• Non-communicating• Obliterated neck of

diverticulum

Hinchey 1978

Hinchey Stage IV

Fecal peritonitis• Communicating• Freely perforated

diverticulum

Hinchey 1978

Peritonitis Severity Score

• Age• Underlying disease• Immunosuppressed• Hinchey peritonitis

Biondo 2000

• ASA score• Pre-operative organ

failure

Preferred Staging Systems

Hinchey peritonitis score• American Society of Colorectal Surgeons• American College of Gastroenterology

Modified Hinchey peritonitis score• European Association of Endoscopic Surgery

Stollman 1999, Wong 2000, Kohler 1999

Operative Preparation

• Broad-spectrum antibiotics• Percutaneous drainage of abscesses• Stoma marking and counseling• Reversal of deficits• Invasive monitoring• Ureteral stents

Ambrosetti 1992

Diversion and Suture Closure

• Suture closure of perforation

• Omental pedicle• Proximal colostomy• Optional drainage

Resection and Colostomy

• Resection of perforation

• Mucus fistula or closure

• Proximal colostomy• Optional drainage

Resection and Anastomosis

• Resection of diseased segment

• On-table lavage• Primary anastomosis

Resection and Diverted Anastomosis

• Resection of diseased segment

• On-table lavage• Primary anastomosis• Proximal stoma

Resection and Anastomosis (I, II)

Stage Nondiverted Diverted Morbidity Mortality

I 53 4 22% 0%

II 15 11 30% 8%

Belmonte 1996

Operative Alternatives (III, IV)

Procedure Mortality

Diversion and suture closure 26%

Resection and colostomy 12%

Resection and anastomosis 9%

Resection and diverted anastomosis 6%

Krukowski 1984

Resection and Anastomosis (III, IV)

Author N Morbidity Mortality

Gregg 1987 17 48% 0%

Alanis 1989 34 50% 3%

Smirniotis 1992 6 33% 17%

Saccomani 1993 11 45% 4%

Total 68 47% 4%

Operative Mortalitiy (III, IV)

Procedure Stage III* Stage IV

Diversion and suture closure 0/21 6/10

Resection and colostomy 6/25 2/6*P <0.05

Kronborg 1993

Laparoscopy

E.A.E.S. consensus statement:

… in Hinchey I and II patients, the laparoscopic approach is not the first choice, but may be justified if no gross abnormalities are found …

… no place today for laparoscopic resections in Hinchey III and Hinchey IV patients …

Kohler 1999

Summary: Hinchey Stage I

1. Non-operative management• Elective resection and anastomosis• Observation

2. Percutaneous abscess drainage• Elective resection and anastomosis

3. Urgent laparotomy/laparoscopy• Resection, lavage, and anastomosis

Summary: Hinchey Stage II

1. Non-operative management and abscess drainage• Elective resection and anastomosis

2. Urgent laparotomy/laparoscopy• Resection, lavage, and anastomosis • Resection, lavage, and diverted anastomosis

Summary: Hinchey Stage III

1. Emergent laparotomy• Resection and colostomy• Resection, lavage, and diverted anastomosis• Resection, lavage, and anastomosis• Diversion and suture closure

Hinchey Stage IV

1. Emergent laparotomy• Resection and colostomy• Resection, lavage, and diverted anastomosis

Fistula

Colovesical

Colocutaneous

Colovaginal

Coloenteric

Colovesical Fistula

Symptoms• Cystitis: 70-80%• Lower abdominal pain: 30-90%• Pneumaturia: 60%• Fecaluria: 40-70%• Bowel symptoms: 65%

Pheils 1972, Woods 1988

Colocutaneous Fistula

Etiology: post-operative: 95%; spontaneous: 5%

Signs: Fever, mass, obstruction, peritonitis, fistula

Factors associated with persistent fistula• Sepsis: 45%• Residual sigmoid colon: 40% • Crohn’s disease/carcinoma

Fazio 1987

Colovaginal Fistula

Symptoms• Abdominal pain• Pus/stool/flatus passed per vagina

Signs• Vaginal os: ~75%• Pelvic mass

Woods1988

Diagnosis

Colovesical fistula• Cystoscopy: 92%• Barium enema: 5-80%• Cystogram: 30%• Sigmoidoscopy• Computerized tomography

Woods 1988

Diagnosis

Colocutaneous/colovaginal fistula• Fistulogram• Vaginogram• Barium enema• Endoscopy• Computerized tomography

Treatment

Non-operative therapy

Operative therapy• Separation of organs by blunt dissection• Primary resection• Individualized repair of defect• Omentopexy

Amin 1984

Obstruction

Etiology: perforation, recurrent episodes of diverticulitis, small bowel adhesions

Symptoms: abdominal pain, distention, constipation

Diagnosis: water-soluble contrast enema

Obstruction

Non-operative therapy

Operative therapy• Emergent

– colostomy– resection with colostomy– resection, lavage, and anastomosis +/- loop ileostomy

• Elective– resection with anastomosis

Summary

Diverticulosis is a common, age-related condition.

Hemorrhaging diverticulosis usually resolves but may warrant therapeutic angiography or resection.

Operative treatment of acute diverticulitis is reserved for failed therapy, first episodes with special circumstances, and most second episodes.

Summary

Operative treatment is warranted for most episodes of complicated diverticulitis, including perforation, fistula, and obstruction.

The diseased bowel should be resected from supple colon proximally to rectum distally; excision of all diverticulae is unnecessary.

Colonic Diverticular Disease

David E. Stein, MD

Division of Colorectal Surgery

Department of Surgery

Drexel University College of Medicine Colonic Diverticular Disease David E. Stein, MD Division of...

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