Chronic Sigmoid Diverticulitis: Indications for surgery · PDF fileSigmoid Diverticulitis:...

Sigmoid Diverticulitis: Indications for surgery and review of the

modern literature David Radvinsky, MD

PGY-4 SUNY Downstate

July 24, 2014

www.downstatesurgery.org

Case Presentation • 60 yo F with a 10 yr history of diverticular disease

o LLQ pain x 1 day – similar to previous episodes • 2 prior episodes of acute diverticulitis over the past 6 months

treated with oral antibiotics o 12 hours following colonoscopy o Colonoscopy in preparation for interval sigmoidectomy

• tattooing of the involved area of colon – preserve area or resection

o (+)subjective fevers (-) diarrhea, blood per rectum o (-) pyuria, fecaluria, pneumaturia

• PMH: HLD, COPD, DM, allergic asthma, fibromyalgia • PSH: tubal ligation • Allergies: Loratadine, pseudophedrine • Meds: nexium, colace, gabapentin • SH: 15 pack year smoking hx – quit 9 years prior


Physical Exam • T 98.3 HR 74 R 20 BP 120/75 SpO2 – 100% on RA • Gen: AAOx3, NAD • CVS: RRR • Resp: CTA b/l • GI: soft, non-distended, mild tenderness in LLQ

no CVA tenderness, no masses, hernias, or organomegaly

• Rectal: no gross blood, soft stool in vault

• Labs:


Hospital Course • CT - Infiltrative changes in the proximal sigmoid

colon suggestive of mild acute diverticulitis – no focal collections.

• Admitted to the medical service for acute uncomplicated diverticulitis o Started on Levaquin and Flagyl o Made NPO and placed on IVF until pain resolved o Diet advanced HD#2 o Discharged HD#3 on oral abx o Follow up with surgery as an outpatient for interval

sigmoidectomy.


Questions? www.downstatesurgery.org

Presenter

Presentation Notes

Tattooing pre-operatively for interval sigmoidectomy to limit margin of resection Why only now did she schedule surgery – if 10 year hx

Sigmoid Diverticulitis • Epidemiology • Anatomy • Physiology • Risk Factors • Diagnosis • Treatment

o Acute Diverticulitis o Chronic and Recurrent Diverticulitis o Current Data


Epidemiology • Age-specific incidence of diverticulosis

o < 30 years - <2% o 30–39-years – 5% o > 50 years - 30-50% o > 80 years – 60%

• Incidence of developing diverticulitis – 4 – 25% • 300,000 admissions in US over the last decade • $1.8 billion of annual direct medical costs • 1.5 million outpatient visits yearly. • Diverticulosis is a disease of affluent society and

refined food products – decreased dietary fiber.


Presenter

Presentation Notes

Over 300,000 admissions in the US over the last decade have been for acute diverticulitis with 1.8 billion of annual direct medical costs. The incidence of diverticulosis increases tremendously with age, reaching over 60% by the age of 80, although some say that number is closer to 100%. The progression to diverticulitis is relatively

Pathologic Anatomy • False diverticula

o Herniation of the mucosa and submucosa through the circular muscular layer

• Herniations occur at well-defined points o along either side of the mesenteric tenia and on the 2 antimesenteric teniae, o where the vasa recta penetrate the circular muscular layer


Pathophysiology • Increased intraluminal pressure causes mucosal and

submucosal outpouching through the muscular layer adjacent to the vasa recta – acquired pulsion diverticulum.

• Stasis or obstruction of the diverticulum lead to bacterial overgrowth and derangement of the colonic microenvironment.

• Localized tissue inflammation and venous stasis which leads to ischemia

• Contained perforation and formation of a peridiverticular abscess or free perforation with peritonitis.

• Inflammatory process can also form fistula into adjacent organs such as the small bowel, bladder, and vagina.

• The most commonly isolated organisms are anaerobes and Gram-negative aerobes, especially E. coli.


Risk Factors • DIET

o Low Fiber, High fat o Nut, corn, and popcorn myth debunked as increased cause

of diverticulosis and complications of diverticular disease

• SMOKING o Increased risk of symptomatic diverticulosis and perforation/

abscess compared to non-smokers

• OBESITY o Increased risk with increasing BMI o Physical activity decreases diverticular complications

• MEDICATIONS

o Aspirin, NSAIDS, Opioids, and Corticosteroids increase chance for diverticulitis and diverticular bleeding.


Presenter

Presentation Notes

Studied 47,228 US males in the Health Professionals Follow-up Study cohort who were aged 40–75 years and free of diverticular disease, gastrointestinal cancer, and inflammatory bowel disease at baseline in 1986. Men reporting newly diagnosed diverticular disease on biennial follow-up questionnaires were sent supplemental questionnaires outlining details of diagnosis and treatment. DIET (Crowe et al.. BMJ. 2011) RR of 0.69 (95% CI 0.55 to 0.86) among vegetarians compared with meat eaters RR of 0.59 (95% CI 0.46 to 0.78) for high fiber diet (Strate et al., JAMA 2008) Increased nut (HR = 0.8) and popcorn (HR = 0.72) intake was associated with lower risk of diverticulitis SMOKING (Hjern et al., al BrJ Surg. 2011) Current smokers - RR 1.23 (95 % CI 0·99 to 1·52) risk of symptomatic diverticular disease. Smokers RR - 1.89 - (95 % CI 1·15 to 3·10) developing a diverticular perforation/abscess OBESITY (Rosemaret et al.,Dis Colon Rectum. 2008) RR of 1.3 (95% CI, 1.08-2.94) for BMI 25-30 RR of 2.0 (95% CI, 1.30-2.97) for BMI of >30 (Strate et al., Gastroenterology. 2009) RR of 1.8 (95% CI, 1.08-2.94 )for diverticulitis for BMI > 30) RR of 3.1 (95% CI, 1.45-7.00) for diverticular bleed for BMI > 30 (Strate et al. Am J Gastroenterol. 2009) – physical activity decreases diverticular complications� MEDICATIONS (Strate et al.,. Gastroenterology. 2011) (Morris et al., Br J Surg. 2003) Aspirin - HR of 1.25 (95% CI, 1.05-1.47) for diverticulitis � HR of 1.70 (95% CI, 1.21-2.39) for diverticular bleeding NSAIDS – HR of 1.72 (95% CI, 1.40-2.11) for diverticulitis� HR of 1.74 (95% CI, 1.15-2.64) for diverticular bleeding Opioids – OR of 1.8 (95 % CI, 1.1 to 3.0) for diverticulitis Corticosteroids – OR of 3.7 (95% CI. 2.0 to 6.8) for diverticulitis

Diagnosis • Clinical presentation – fever, LLQ abdominal

pain/tenderness, leukocytosis o Previous episodes o Alterations in bowel habit, urinary symptoms

• Colovesicular fistula - fecaluria, pneumaturia, pyuria

• Imaging o CT scan with PO and IV contrast

• Staging – Hinchey classification • 98% sensitive and 99% specific

• Differential o bowel obstruction, UTI, appendicitis, IBS, IBD, ischemic bowel, neoplasia,

gynecologic disorders

• Uncomplicated vs. complicated o Inflammation in the absence of abscess, fistula, stricture, perforation, or

obstruction o Oral antibiotics if patient can tolerated a PO diet


Presenter

Presentation Notes

Results from the aVoD (swedish acronym standing for antibiotics in uncomplicated diverticulitis”) study group support this alternative pathogenesis. their multicenter trial randomly treated 623 inpatients with CT-confirmed uncomplicated left-sided diverticulitis with intravenous fluids or intravenous fluids and antibiotics. They found that antibiotic therapy did not prevent complications, accelerate recovery, or prevent recurrences. this study, the only randomized trial to evaluate the need for antibiotics in uncomplicated diverticulitis, did not accrue all eligible patients over the interval and did not address whether or not hospitalization is necessary or if outpatient treatment without antibiotics is appropriate. A recent Cochrane review including 3 randomized trials similarly found no significant difference between antibiotics and no antibiotics for the treatment of uncomplicated diverticulitis.

• Hinchey classification

o Acute complicated diverticulitis

o Grading system to reflect the degree of perforation:


Treatment of Acute Complicated Diverticulitis • Hinchey I/II: antibiotics+/- percutaneous drainage • Hinchey III/IV: Surgical intervention

o Hartmann’s procedure - sigmoid colectomy with end colostomy and rectal stump.

• Wound infection of 24% • Mortality rate of 18% • 30-45% never have their stoma reversed

o Resection and primary anastomosis with defunctioning stoma • Similar mortality rate • Increased rate of stoma reversal • Better long term quality of life • Anastomotic leak rates about 6% in suitable patients.

o Laparoscopy and peritoneal lavage – for Hinchey II/III • Damage control - Bridge to elective resection with primary anastomosis • Low conversion rates (5%) • Decreased length of stay • Complication rate 20% • Overall mortality rate of 0.25 per cent


Presenter

Presentation Notes

Primary anastomosis by appropriately trained surgeons should be considered for perforated/complicated diverticulitis requiring resection, but that a non-restorative procedure has a place where an anastomosis is unsafe. This will come down to the judgment of the treating surgeon, taking into account the clinical status of the patient and underlying co-morbidities.

Follow up • Follow up with flexible endoscopy or colonoscopy?

o Following an episode of diverticulitis patients should have an additional colonoscopy screening to rule out a colorectal malignancy

o De Vries et al. 2014 • 1.16% chance of concurrent CRC • 10% low grade adenoma • 2.2% advanced adenoma

o Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required

• Interval Sigmoidectomy? o After the second episode of uncomplicated diverticulitis? o Individualized


Presenter

Presentation Notes

2,490 patients with uncomplicated diverticulitis.

• Systematic review of recent primary reports on the decision making, technical aspects, and outcomes of surgery for acute, recurrent, and chronic sigmoid diverticulitis

o (1) What are the indications for surgical resection?

o (2) Should a specific surgical approach or technique be recommended?

o (3) What are the outcomes of surgical treatment?


Presenter

Presentation Notes

University of Michigan

• Acute Diverticulitis – 6 studies o Urgent surgery was performed for those with sepsis and

diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage.

o 15-20% of patients undergo colectomy during their index hospitalization for acute diverticulitis.

o High morbidity – more patients undergoing non-operative therapy in absence of signs of sepsis.

o Resection following non-operative treatment of acute diverticulitis?

• Following non-operative management risk of recurrence is higher than for those who undergo urgent colectomy

• Large majority of patients with complication of abscess will eventually require surgical intervention – either acutely or electively

• Newer literature showing that non-operative treatment no more likely than those with uncomplicated disease to have future recurrence or complication


• Recurrent and Chronic Diverticulitis – 11 studies o Old adage - Elective resection recommended after 2 episodes of

uncomplicated diverticulitis or 1 episode in young patients. o Recurrence after first episode of uncomplicated diverticulitis is 10-35% and

re-recurrence 1-5%. o Severity of attacks generally does not increase.

• 3-5% of a patients experience a complicated episode after uncomplicated episode.

o Free perforation occurred in 25% of patients presenting with their first episode of acute diverticulitis, but only 12% with their second, 6% with their third, and 1% thereafter. (Ritz et al.)

o Patient specific risk factors for recurrence and complications – 14 studies • No longer age but severity of initial episode as risk factor for recurrence. • Family history, retroperitoneal abscess, length of colon segment

involved • Immunosuppression, collagen vascular disease, glucocorticoid use.


Presenter

Presentation Notes

reasons to consider elective resection

• Individualized approach to consider elective resection o Severity of prior episodes o Patient-specific factors o Ongoing symptoms – Colectomy relieved symptoms in 77-89% of patients in 2 reports o Number of episodes and age of onset should be considered secondary o Prophylactic surgery to prevent severe septic complications is not necessary in most

cases.

• Technical considerations o Acute – Hartmann’s vs. Primary anastomosis – 3 RCT

• Short term outcomes comparable • Reasonable and safe in selected patients • Oberkofler et al – primary anastomosis vs. Hartmann’s

o Mortality 9 vs. 13% o Complications 75% vs. 67% o Stoma closure 90% vs. 58% o Complications of stoma closure 0% vs. 20%

o Laparoscopic vs. open • Decreased incidence of major complication, reduced hospital stay, reduced

postoperative pain, and improved quality of life at 6 months. o Margins of resection (Thaler K et al., Dis Colon Rectum. 2003)

• Most important contributor to the likelihood of recurrent diverticulitis after resection

• Presence of colocolonic anastomosis with retained distal sigmoid colon increased 4 fold compared with creation of colorectal anastomosis.


Presenter

Presentation Notes

patient demographics, duration of preoperative symptoms, previous admissions and abdominal surgery, surgical access (laparoscopic or open), postoperative complications, splenic flexure mobilization, anastomotic technique (handsewn or stapled), specimen length, inflammation at proximal resection margin, and anastomotic level (colosigmoid or colorectal).

• Urgent colectomy for those in sepsis or peritonitis • Non-operative management for acute complicated

diverticulitis without evidence of sepsis or peritonitis. • Interval colectomy should be based on severity of initial

presentation, persistence of symptoms and patient specific factors – not number of episodes or age.

• Data to support primary anastomosis with proximal diversion over Hartmann’s when clinical conditions allow

• Insufficient evidence for laparoscopic washout • Margins of resection at the level of distal anastomosis

has a large determinant of recurrence – recommend colorectal anastomosis

Conclusions www.downstatesurgery.org

References • Schwartz's Principles of Surgery, 9th ed., 2009 • Current Surgical Therapy – Cameron. 11th ed., 2014 • Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid Diverticulitis: A Systematic Review. JAMA.

2014;311(3):287-297. • Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic

Review. JAMA Surg. 2014;149(3):292-303. • Prasad S, Ewigman B. Let them eat nuts--this snack is safe for diverticulosis patients. J Fam Pract. 2009 Feb;

58(2):82-4. • Peery AF, Barrett PR, Park D, et al A high-fiber diet does not protect against asymptomatic

diverticulosis. Gastroenterology. 2012;142(2):266-272. • Rosemar A, Angerås U, Rosengren A. Body mass index and diverticular disease: a 28-year follow-up study in

men. Dis Colon Rectum. 2008;51(4):450-455. • Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and

diverticular bleeding. Gastroenterology. 2009;136(1):115-122. • Thaler K, Baig MK, Berho M, et al. Determinants of recurrence after sigmoid resection for uncomplicated

diverticulitis. Dis Colon Rectum. 2003;46(3):385-388. • Shaikh S, Krukowski ZH. Outcome of a conservative policy for managing acute sigmoid diverticulitis.Br J Surg.

2007;94(7):876-879. • Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does not

mandate routine elective colectomy. Arch Surg. 2005;140(6):576-581, discussion 581-583. • Chapman J, Davies M, Wolff B, et al. Complicated diverticulitis: is it time to rethink the rules. Ann Surg.

2005;242(4):576-581, discussion 581-583. • Westwood DA, Eglinton TW, Frizelle FA. Routine colonoscopy following acute uncomplicated diverticulitis. Br J

Surg. 2011;98(11):1630-1634. • DharmarajanS,HuntSR,BirnbaumEH, Fleshman JW, Mutch MG. The efficacy of nonoperative management of

acute complicated diverticulitis. Dis Colon Rectum. 2011;54(6):663-671. • Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg. 1986;151(2):269–

271 • Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal

Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. 2006;49(7):939–944.


Thank You www.downstatesurgery.org

Which of the following statements is TRUE regarding surgical treatment of diverticular disease? • (A) A single episode of uncomplicated sigmoid

diverticulitis mandates resection. • (B) Two separate episodes of uncomplicated sigmoid

diverticulitis mandate resection. • (C) Surgical resection should include all areas of

diverticulosis. • (D) The distal resection margin should be at the peritoneal

reflection. • (E) The proximal resection margin should be located in an

area without hypertrophy of the muscularis propria.


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