Advantages of Laparoscopy for Diverticulitis

Advantages of Laparoscopy for Advantages of Laparoscopy for Diverticulitis Diverticulitis

Steven D. Wexner, M.D., FACS, FRCS, FRCS (Ed)Steven D. Wexner, M.D., FACS, FRCS, FRCS (Ed)Cleveland Clinic FloridaCleveland Clinic Florida

Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal SurgeryChief of Staff, Cleveland Clinic FloridaChief of Staff, Cleveland Clinic Florida

Professor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic FoundationProfessor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic FoundationClinical Professor of Surgery, University of South Florida Clinical Professor of Surgery, University of South Florida

College of MedicineCollege of Medicine

Cleveland Clinic FloridaCleveland Clinic FloridaWestonWeston

Cleveland Clinic FloridaCleveland Clinic FloridaWestonWeston

AdvantagesAdvantages– Operative timeOperative time– MorbidityMorbidity– Hospital Length of StayHospital Length of Stay

Special considerationsSpecial considerations– Presence of complications Presence of complications – ConversionConversion– Advantages for elderlyAdvantages for elderly– Advantages for obeseAdvantages for obese– CostCost

Advantages of Laparoscopy: Advantages of Laparoscopy: DiverticulitisDiverticulitis

Laparoscopy: DiverticulitisLaparoscopy: Diverticulitis

Modified Hinchey* Grading SystemModified Hinchey* Grading System

I.I. Pericolic abscessPericolic abscessIIA.IIA. Distant abscess amenable to percutaneous Distant abscess amenable to percutaneous drainagedrainageIIB.IIB. Complex abscess associated with fistulaComplex abscess associated with fistulaIII.III. Generalized purulent peritonitisGeneralized purulent peritonitisIV.IV. Fecal peritonitisFecal peritonitis

*Adv Surg 1978*Adv Surg 1978

Author/year n Lap/OpenOp time

(min)Morbidity

(%)Hospital stay

(days)

Kholer/9827 34

Lap Open

165* 121

16 61.7

7.9* 14.3

Dwivedi/0266 88

Lap Open

212* 143

18 23.8

4.8* 8.8

Senagore/0261 71

Lap Open

109 101

1.6* 12.6

3.1* 6.8

Lawrence/0356

215Lap

Open 170**

140 9*

27 4.1**

9.0

*p<0.05 **p<0.001

Case-Controlled SeriesCase-Controlled Series

Advantages of less morbidity and shorter Advantages of less morbidity and shorter hospitalizationhospitalization

Laparoscopy: DiverticulitisLaparoscopy: Diverticulitis Retrospective/prospective Retrospective/prospective results – Hospital Stayresults – Hospital Stay

Author/yearAuthor/year nn Hospital stay Hospital stay (days)(days)

Eijsbouts/97Eijsbouts/97 4141 6.56.5

Carbajo/98Carbajo/98 2222 5.55.5

Stevenson/98Stevenson/98 100100 44

Bokobza/98 (A) Bokobza/98 (A) 136136 ------

Bouillot/98Bouillot/98 5050 1010

Smadja/99Smadja/99 5454 6.46.4

Sirisier/99Sirisier/99 6565 7.67.6

Vargas/99Vargas/99 6969 4.24.2

Berthou/99Berthou/99 110110 8.28.2

Trebuchet/01Trebuchet/01 170170 8.58.5

Bouilott/02Bouilott/02 179179 9.39.3

Author/yrAuthor/yr nn Setting surgerySetting surgery Op timeOp time Morbidity (%)Morbidity (%) Hospital stay Hospital stay (days)(days)

Sher/97Sher/9766

1212Hinchey IHinchey I

Hinchey IIa/bHinchey IIa/b215215213213

0033.333.3

5566

Kockerling/99Kockerling/992492495555

ChronicChronicHinchey I/IV Hinchey I/IV

159 159 182182

14.8 28.914.8 28.9 ------------

Schlachta/ 99Schlachta/ 99808070702222

OtherOtherChronicChronicAcute Acute

165 150 165 150 165 165

12.812.818181818

555566

Bergamashi/00Bergamashi/0040403434

IntracorporealIntracorporealLap. assistedLap. assisted

180180** 244244

1515****14.7 14.7

------------

Eijsbouts/00Eijsbouts/0035353535

Lap. AssistedLap. AssistedFacilitated resec. Facilitated resec.

195 150 195 150

20 20 8.68.6

------------

Pugliese/04Pugliese/04494941411212

Hinchey IHinchey IHinchey IIHinchey IIHinchey IIIHinchey III

187187193193200200

1414<1<15050

9910.510.51010

*p<0.001*p<0.001 ***p<0.05*p<0.05

Laparoscopy: DiverticulitisLaparoscopy: Diverticulitis Retrospective/Prospective Results - MorbidityRetrospective/Prospective Results - Morbidity

The more complicated the diverticular disease, the tendency for higher morbidity The more complicated the diverticular disease, the tendency for higher morbidity and longer lengths of hospital stayand longer lengths of hospital stay

Author/yearAuthor/year nn LSR/OSRLSR/OSR Op time (min)Op time (min)MorbidityMorbidity

(%)(%)

Bruce/96Bruce/962525

1717LSRLSR

OSROSR 397397**** 115 115 1212

11

Liberman/97Liberman/971414

1414LSRLSR

OSROSR192 192

1831831414

1414

Kholer/98Kholer/982727

3434LSRLSR

OSROSR 165165** 121 121 1616

61.761.7

Dwivedi/02Dwivedi/026666

8888LSRLSR

OSROSR 212212**

1431431818

23.823.8

Senagore/02Senagore/026161

7171LSRLSR

OSROSR109109

1011011.61.6**

12.612.6

Lawrence/03Lawrence/035656

215215LSR LSR

OSROSR 170**170**

1401409*9*

2727

*p<0.05*p<0.05 ***p<0.001*p<0.001

Laparoscopy: Diverticulitis - Comparative StudiesLaparoscopy: Diverticulitis - Comparative Studies

Laparoscopy: DiverticulitisLaparoscopy: Diverticulitis 1/95-1/98: 1118 patients1/95-1/98: 1118 patients Laparoscopic colorectal surgery study groupLaparoscopic colorectal surgery study group 509 sigmoid colectomies509 sigmoid colectomies 304 diverticulitis304 diverticulitis 249 (81.9%)249 (81.9%)

– PeridiverticulitisPeridiverticulitis– Recurrent inflammationRecurrent inflammation– StenosisStenosis

26 Hinchey I26 Hinchey I 9 Hinchey II9 Hinchey II 2 Hinchey III2 Hinchey III

Köckerling et al., Surg Endosc 1999Köckerling et al., Surg Endosc 1999


StageStage Conversion Conversion Mean operative time Mean operative time MorbidityMorbidity (n (%))(n (%)) (min (range))(min (range)) (%) (%)

TotalTotal 22/304 (7.2)22/304 (7.2) 164 (65-410)164 (65-410) 1717

ChronicChronic 12/249 (4.8)12/249 (4.8) 159 (65-395)159 (65-395) 14.814.8

Hinchey I-IVHinchey I-IV 10/55 (18.2)10/55 (18.2) 182 (90-410)182 (90-410) 28.928.9

II 8/26 (30.7)8/26 (30.7) 183 (100-410)183 (100-410) 33.333.3

IIII 1/9 (11.1)1/9 (11.1) 198 (90-320)198 (90-320) 37.537.5

III/IVIII/IV 0/2 (0)0/2 (0) 110 (100-120)110 (100-120) 5050

Köckerling et al., Surg Endosc 1999Köckerling et al., Surg Endosc 1999

0

1

2

3

4

5

6

7

8

Open Laparoscopy

Hinchey I

Hinchey IIA

Hinchey IIBMean age, 59.5 years

Mean age, 69.5 years

Mean age, 67.9years

Mean age, 54.3years

Mean age,65.9years

Mean age,67.7years

# # patientspatients

Sher et al, Surg Endosc. 1997Sher et al, Surg Endosc. 1997

Laparoscopy: DiverticulitisLaparoscopy: DiverticulitisComparative Study Comparative Study

n = 18n = 18

MorbidityMorbidity

05

101520253035404550

Hinchey I

OpenLaparoscopy

Hinchey IIA and IIB Overall Late experience experience

0 00 0

29

43

29*

13

* P<0.05* P<0.05

MorbidityMorbidity (%)(%)

Laparoscopy: Diverticulitis - Comparative StudiesLaparoscopy: Diverticulitis - Comparative Studies


Open vs. LaparoscopyOpen vs. LaparoscopyHospital stayHospital stay

012345

6789

10

Hinchey I Hinchey IIA

Open

Laparoscopy

Converted7*

5

10†

5

9*

Days

* p<0.05 † p<0.01

LaparoscopyLaparoscopy: Diverticulitis


Open vs. LaparoscopyOpen vs. LaparoscopyAuthor/year n Lap/Open Op time

(min)Morbidity

(%)Hospital stay

(days)

Bruce/96 25 17

Lap Open

397** 115

12 1

4.2 6.8

Liberman/96 14 14

Lap Open

192 183

14 14

6.3** 9.2

Coogan/97 59 52

Lap Open

190 108

- 3.8 9.3

Kholer/98 27 34

Lap Open

165* 121

16 61.7

7.9* 14.3

Dwivedi/02 66 88

Lap Open

212* 143

18 23.8

4.8* 8.8

Senagore/02 61 71

Lap Open

109 101

1.6* 12.6

3.1* 6.8

Lawrence/03 56 215

Lap Open

170** 140

9* 27

4.1**

9.0

*p<0.05 **p<0.001

Laparoscopic Open p valuen= 22 n = 24

Mean age (yrs) 77.2 (75-82) 78 (76-84) NS

Gender (M:F) 10:12 10:14 NS

Operative time (min) 234 136 NS

IV analgesia (days) 5.4 8.2 0.001

Morbidity (%) 18 50 0.02

Mortality 0 0 NS

Inpatient rehabilitation 6 15 0.01

Hospitalization (days) 13.1 20.2 0.003

Teuch et al. Surg Endosc 2000

Laparoscopy: ElderlyLaparoscopy: Elderly

Costs:Costs: o open vs. Laparoscopy pen vs. Laparoscopy

Author/year n Lap/Open OR ($) Hospital ($)Bruce/96 25

17Lap

Open--- 10,230*

7,068

Liberman/97 14 14

Lap Open

10,589* 8,207

11,528 13,426

Coogan/97 27 34

Lap Open

15,200 7,200

17,000 15,800

Dwivedi/02 66 88

Lap Open

9,566* 7,306

13,953 14,863

Senagore/02 61 71

Lap Open

1,694* 1,426

3,458* a 4,321*

Lawrence/03 56 215

Lap Open

--- 17,414 25,700

*p*p<<0.050.05 a = Total direct cost/case


There is good evidence (Level 2) that There is good evidence (Level 2) that laparoscopy for diverticulitis results in earlier laparoscopy for diverticulitis results in earlier dischargedischarge


Despite longer operative time, the morbidity Despite longer operative time, the morbidity rate for the laparoscopic approach to rate for the laparoscopic approach to diverticulitis in the most recent studies is diverticulitis in the most recent studies is equivalent or better than the open approach equivalent or better than the open approach (Level 2 evidence)(Level 2 evidence)

Laparoscopy: Diverticulitis Laparoscopy: Diverticulitis ConclusionConclusion

Elective laparoscopy for diverticular disease confers Elective laparoscopy for diverticular disease confers many advantages over the traditional approachmany advantages over the traditional approach

Based upon these data, laparoscopy is our preferred Based upon these data, laparoscopy is our preferred approach to the treatment of sigmoid diverticulitisapproach to the treatment of sigmoid diverticulitis

Rafferty et al, DCR 2006

Practice Parameters for Sigmoid DiverticulitisPractice Parameters for Sigmoid Diverticulitis

The Standards Committee of The American Society ofThe Standards Committee of The American Society ofColon and Rectal SurgeonsColon and Rectal Surgeons

The laparoscopic approach is appropriate in selected patients. Level of The laparoscopic approach is appropriate in selected patients. Level of Evidence III, Grade of Recommendation AEvidence III, Grade of Recommendation A

Laparoscopic colectomy may have advantages over open laparotomy, Laparoscopic colectomy may have advantages over open laparotomy, including less pain, smaller scar, and shorter recovery. There is no increase including less pain, smaller scar, and shorter recovery. There is no increase in early or late complications.in early or late complications.

Cost and outcome are comparable to open resection. Laparoscopic surgery is Cost and outcome are comparable to open resection. Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with acceptable in the elderly and seems to be safe in selected patients with complicated diseasecomplicated disease

Advantages of Laparoscopy for Diverticulitis

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