[email protected] Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la...

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Dr. Carlo Augusto SartoriDr. Carlo Augusto SartoriCastelfranco V.to (TV)Castelfranco V.to (TV)

““Quando e come operare la malattia diverticolare del colon”Quando e come operare la malattia diverticolare del colon”

““Possibilità di trattamento chirurgico laparoscopico”Possibilità di trattamento chirurgico laparoscopico”

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Laparoscopic colonic resections for Laparoscopic colonic resections for diverticular diseasediverticular disease

Results of a single center series of 105 pts. Results of a single center series of 105 pts. Surgical strategy and technique Surgical strategy and technique

Laparoscopic colonic resections for Laparoscopic colonic resections for diverticular diseasediverticular disease

Results of a single center series of 105 pts. Results of a single center series of 105 pts. Surgical strategy and technique Surgical strategy and technique

Osp. Ital. Chir.Osp. Ital. Chir. 9: 111-120; 2003 9: 111-120; 2003

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Cases N°:Cases N°: 105105 Cases N°:Cases N°: 10510544 m44 m44 m44 m

61 f61 f61 f61 f

Mean age :Mean age : 68.3 (min.30, max.81) 68.3 (min.30, max.81)Mean age :Mean age : 68.3 (min.30, max.81) 68.3 (min.30, max.81)

Laparoscopic left colon resections for Laparoscopic left colon resections for diverticulitis. Personal experience: 105 casesdiverticulitis. Personal experience: 105 cases


Left colectomiesLeft colectomies:: 8484

Segmental resectionsSegmental resections : : 2121

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ASA 1ASA 1 48 (45,7%)48 (45,7%)

ASA 2ASA 2 50 (47,7%)50 (47,7%)

ASA 3ASA 3 7 (6,6%) 7 (6,6%)

ASA 4ASA 4 0 (0%) 0 (0%)

Hinchey ClassificationHinchey Classification

I pericolic abscessI pericolic abscess

II pelvic abscessII pelvic abscess

III purulent peritonitisIII purulent peritonitis

IV fecal peritonitisIV fecal peritonitis

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Indications for surgeryIndications for surgeryIndications for surgeryIndications for surgery

- 2 or more diverticulitis episodes2 or more diverticulitis episodes 56,2% 56,2%

- 1 severe diverticulitis episode in patients < 50 years 10,5%1 severe diverticulitis episode in patients < 50 years 10,5%

- StenosisStenosis 5,7% 5,7%

- Fistula with urinary bladderFistula with urinary bladder 2,9% 2,9%

- Ileo-colic fistulaIleo-colic fistula 1,9% 1,9%

- Hinchey IHinchey I Peridiverticular abscess Peridiverticular abscess 14,3% 14,3%

- Hinchey IIHinchey II Pelvic abscess 1,9% Pelvic abscess 1,9% (percutaneous drainage and surgery)(percutaneous drainage and surgery)

- Hinchey IIIHinchey III Previous peritonitis 1,9% Previous peritonitis 1,9% (laparoscopic lavage and resection after 6-8 weeks )(laparoscopic lavage and resection after 6-8 weeks )

- PerforationPerforation 3,8% 3,8%

- Acute bleeding Acute bleeding (embolization and surgery)(embolization and surgery) 0,9% 0,9%

Patients affected by stercoral peritonitis (Hinchey IV) were excluded from present study.

Recurrent diverticulitis Recurrent diverticulitis or severe in young or severe in young patientspatients

UrgencyUrgency

StenosisStenosis

Abscess and fistulaAbscess and fistula

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Surgical strategySurgical strategy

- - Primary identification of embryonary planes Primary identification of embryonary planes and ligation of the vessels with dissection from and ligation of the vessels with dissection from right to left and from up to bottomright to left and from up to bottom

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Diffuse diverticular diseaseDiffuse diverticular diseaseStandard left colectomyStandard left colectomy

Diverticular disease localized Diverticular disease localized in the sigmoid colon in the sigmoid colon Sigmoid resection with Sigmoid resection with preservation of the origin of preservation of the origin of IMA and left colic arteryIMA and left colic artery

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Diverticular disease with fistulaleaving the treatment of the fistula at the endleaving the treatment of the fistula at the end

- Ileo-colic fistulaIleo-colic fistula

- Colo-vaginal or colo-vescical fistulaColo-vaginal or colo-vescical fistula

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- - Small pericolic abscess Small pericolic abscess (Hinchey I)(Hinchey I)

- Antibiotic therapyAntibiotic therapy

- TPNTPN

- Elective laparoscopic colectomyElective laparoscopic colectomy

- Voluminous abscess (over 5 cm.) (Hinchey II)

- Percutaneous drainage US or CT-guidedPercutaneous drainage US or CT-guided

- Antibiotic therapy and TPNAntibiotic therapy and TPN

- Elective laparoscopic colectomyElective laparoscopic colectomy

Diverticular disease with abscessDiverticular disease with abscess

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Diverticular disease with peritonitisDiverticular disease with peritonitis

Localized peritonitisLocalized peritonitis

Diffuse purulent peritonitisDiffuse purulent peritonitis

Fecal peritonitisFecal peritonitis

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T 1T 1

T 3T 3T 2T 2

T 4T 4

T 5T 5

EMICOLECTOMIA SINISTRAEMICOLECTOMIA SINISTRA

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Surgical technique 1Surgical technique 1

- Preparation of the patientPreparation of the patient

- Preparation of the operating fieldPreparation of the operating field

- Position of the surgeonsPosition of the surgeons

- Exposure of the operating fieldExposure of the operating field

- Identifying Gerota’s fascia and sectioning the vesselsIdentifying Gerota’s fascia and sectioning the vessels

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Surgical technique 2Surgical technique 2

- Lowering of the splenic flexureLowering of the splenic flexure

- Sectioning of the mesorectum and the rectumSectioning of the mesorectum and the rectum

- Service minilaparotomy, extraction of the operative Service minilaparotomy, extraction of the operative specimen and execution of the colo-rectal anastomosisspecimen and execution of the colo-rectal anastomosis

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- Operating time- Operating time 163,3 min (range 80-300 min)163,3 min (range 80-300 min)

- Conversion rate - Conversion rate 0,9% (1 case cirrhosis, severe 0,9% (1 case cirrhosis, severe diverticular diverticular disease)disease)

- I.op blood loss- I.op blood loss 66 ml (range 30-150 ml) 66 ml (range 30-150 ml)

- Post-op blood loss- Post-op blood loss 0,9% (1 case 2 units of blood) 0,9% (1 case 2 units of blood)

- Operating time- Operating time 163,3 min (range 80-300 min)163,3 min (range 80-300 min)

- Conversion rate - Conversion rate 0,9% (1 case cirrhosis, severe 0,9% (1 case cirrhosis, severe diverticular diverticular disease)disease)

- I.op blood loss- I.op blood loss 66 ml (range 30-150 ml) 66 ml (range 30-150 ml)

- Post-op blood loss- Post-op blood loss 0,9% (1 case 2 units of blood) 0,9% (1 case 2 units of blood)

Results: 105 casesResults: 105 casesResults: 105 casesResults: 105 cases

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- I.op. complications- I.op. complications 00

- Average lenght of specimen- Average lenght of specimen 25,05 cm.25,05 cm.

- Histological examination:- Histological examination:

- DeathsDeaths

Results:Results: Results:Results:

2 (1,9%) adenocarcinomas2 (1,9%) adenocarcinomas

1 (0,9%) villous adenoma with1 (0,9%) villous adenoma with severe displasiasevere displasia

1 (0,9%) pulmonary 1 (0,9%) pulmonary embolism on the 4thembolism on the 4thpostoperative daypostoperative day

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ResultsResults

Post-operative complicationsPost-operative complications 12 pts12 pts 11,4%11,4%

- bleeding from anastomosis- bleeding from anastomosis 1 1 0,9% 0,9%

- ileal perforation (reoperated) 1- ileal perforation (reoperated) 1 0,9% 0,9%

- intraperitoneal bleeding- intraperitoneal bleeding 1 1 0,9% 0,9%

- wound infections- wound infections 6 6 5,7% 5,7%

- abdominal fluid collection- abdominal fluid collection 3 3 2,8% 2,8%

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ResultsResults

- Anastomotic leaks- Anastomotic leaks 0% 0%

- Restoring intestinal function- Restoring intestinal function 2,1 days 2,1 days

- Oral liquid diet- Oral liquid diet 2,4 days 2,4 days

- Average hospital stay- Average hospital stay 9,2 days 9,2 days (range 7-18)(range 7-18)

Last 50 cases: average number of days effectively Last 50 cases: average number of days effectively required for hospital treatment: 5,2 days required for hospital treatment: 5,2 days (range 4-12)(range 4-12)

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Results: monocentric studiesResults: monocentric studies

AuthorsAuthors yearyear PtsPts ConversionsConversions LeaksLeaks StenosisStenosis Operative Operative times (min)times (min)

Hospital Hospital stay (days)stay (days)

BruceBruce 19961996 2525 12.0%12.0% 4.0%4.0% 0%0% 397397 4.24.2

SherSher 19971997 1818 39.0%39.0% 5.0%5.0% 0%0% 215215 5.05.0

TrebuchetTrebuchet 19991999 170170 4.0%4.0% 2.9%2.9% 5.9%5.9% 141141 8.58.5

BerthouBerthou 19991999 110110 8.0%8.0% 1.0%1.0% 4.0%4.0% 166166 8.08.0

SalaSala 20002000 4545 7.4%7.4% 2.8%2.8% 0%0% 162162 7.97.9

SartoriSartori 20032003 105105 0.9%0.9% 0%0% 0.9%0.9% 163163 9.29.2

SchwandnerSchwandner 20042004 396396 6.8%6.8% 1.6%1.6% 2.7%2.7% 193193 11.811.8

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Results: multicentric studiesResults: multicentric studies

AuthorsAuthors yearyear PtsPts ConversionsConversions LeaksLeaks StenosisStenosis Operative Operative times (min)times (min)

Hospital Hospital stay (days)stay (days)

FranklinFranklin 19971997 5454 27.%27.% 0%0% 1%1% -- 10.710.7

KockerlingKockerling 19991999 304304 7.2%7.2% 1.4%1.4% -- 164164 --

BuillotBuillot 20022002 179179 13.9%13.9% 1.1%1.1% 0.5%0.5% 223223 1313

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Average operative time for Average operative time for colectomy for diverticulitiscolectomy for diverticulitisAverage operative time for Average operative time for colectomy for diverticulitiscolectomy for diverticulitis

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Conversions:Conversions: 17 (4,7%)17 (4,7%)

12,8

1,70,9

0

2

4

6

8

10

12

14

First period Second

period

Third period

%

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TIPI DI CONVERSIONETIPI DI CONVERSIONE

Conversioni “precoci”Conversioni “precoci”

Conversioni “tardive”Conversioni “tardive”

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CAUSE DI CONVERSIONECAUSE DI CONVERSIONE

Di principioDi principio Laparoscopia esplorativaLaparoscopia esplorativa

Di necessitàDi necessità Per impossibilità tecnica di proseguire in Per impossibilità tecnica di proseguire in LAPSLAPS

Per una complicanza intra-operatoriaPer una complicanza intra-operatoria

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Conversione di necessitàConversione di necessità

tempi operatoritempi operatori

morbilitàmorbilità

costicosti

Cause di conversioneCause di conversioneConversion rates in laparoscopic colorectal surgeryA predicitive model with 1253 patients

PP Tekkis, AJ Senagore, CP Delaney

Departement of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation

Surg. Endosc. 2005 19:47-54

%conversione

Grado ASA 3-4 13,8

Obesità BMI >28,5 15,4

Tipo intervento: resezione bassa retto 15,3

ascesso o fistola 31,6 e 29,3

esperienza del chirurgo 13,2 vs 8,7

% media di conversione su 1253 pazienti 10.0%

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Risk factors for conversion

Le Moine, Br J Surg, 2003Le Moine, Br J Surg, 2003

Converted Converted

N = 24N = 24Not convertedNot converted

N = 144N = 144PP

Sigmoid stenosisSigmoid stenosis** 10 (41.7)10 (41.7) 28 (19.4)28 (19.4) 0.0250.025

Pathological examinationPathological examination

DiverticulosisDiverticulosis

DiverticulitisDiverticulitis

Abscess/perforationAbscess/perforation

CancerCancer

9 (37.5)9 (37.5)

4 (16.7)4 (16.7)

10 (41.7)10 (41.7)

1 (4.2)1 (4.2)

82 (56.9)82 (56.9)

22 (15.3)22 (15.3)

34 (23.6)34 (23.6)

00

0.0350.035

Conversion rate/yearConversion rate/year

19941994

1995-19991995-1999

2000-20012000-2001

8 (44.4)8 (44.4)

15 (14.9)15 (14.9)

1 (2)1 (2)

1010

8686

4848

0.0020.002

* Diagnosed at BE or colonoscopy* Diagnosed at BE or colonoscopy

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Laparoscopy: DiverticulitisLaparoscopy: Diverticulitis

Gonzalez et al, Surg Endosc 2004 Gonzalez et al, Surg Endosc 2004

Laparoscopy Laparoscopy n = 95 n = 95

Open Open n = 80 n = 80

DemographicsDemographics Age (years)Age (years) Sex (male:female)Sex (male:female) BMI (Kg/mBMI (Kg/m22))

67 67 ++ 1.7 1.747:4847:4831 31 ++ 6 6

62 62 ++ 1.5 1.532:4832:4828 28 ++ 2 2

IndicationsIndicationsDiverticulitisDiverticulitis PerforatedPerforated Fistula Fistula StrictureStrictureDiverticulosisDiverticulosis

787812127711

1717

58 58 13139900

22 22

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Laparoscopy: DiverticulitisLaparoscopy: DiverticulitisResultsResults

Gonzalez et al, Surg Endosc 2004Gonzalez et al, Surg Endosc 2004

Laparoscopy Laparoscopy n = 95n = 95

Laparotomy Laparotomy n = 80n = 80

Operative time (min)Operative time (min) 170 170 ++ 7 7 156 156 ++ 6 6

Intraoperative complicationsIntraoperative complications 5 (5)5 (5) 5 (6)5 (6)

Estimated blood loss (cc) *Estimated blood loss (cc) * 204 204 ++ 17 17 341 341 ++ 50* 50*

Transfusions *Transfusions * 3 (4)3 (4) 11 (14)*11 (14)*

Time to first BM (h) *Time to first BM (h) * 67 67 ++ 7 7 88 88 ++ 5* 5*

Length of stay (d) *Length of stay (d) * 7 7 ++ 1 1 12 12 ++ 2* 2*

Postoperative complications *Postoperative complications * 17 (19)17 (19) 25 (31)*25 (31)*

MortalityMortality 1 (1)1 (1) 3 (4)3 (4)

* (p< 0.05) - n (%)* (p< 0.05) - n (%)

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Results-Open versus LaparoscopyResults-Open versus LaparoscopyMorbidityMorbidity

0

10

20

30

40

50

Hinchey I

Open

Laparoscopy

Hinchey IIA and IIBHinchey IIA and IIBOverallOverall LateLateexperienceexperience experienceexperience

0 00 0

29

43

29*

13

** P<0.05 P<0.05

Morbidity Morbidity (%)(%)

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

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Results-Open versus LaparoscopyResults-Open versus LaparoscopyHospital stayHospital stay

Days

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

0

2

4

6

8

10

Hinchey I Hinchey IIA

Open

Laparoscopy

Converted7*

5

*

** p<0.05 p<0.05§ §

P<0.01P<0.01

10§ 9

5

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Laparoscopy: Diverticular diseaseLaparoscopy: Diverticular disease

VariableVariable LaparoscopicLaparoscopicOpenOpen

Age (years)Age (years) 5959 5252

Weight (pounds)Weight (pounds) 165165 172172

ASA classASA class 2.32.3 2.12.1

PerforatedPerforated 77 55

AbscessAbscess 1818 1818

Operative time (minutes)*Operative time (minutes)* 190190 108108

Blood loss (ml)Blood loss (ml) 340340 308308

Coogan et al, Surg Endosc 1997Coogan et al, Surg Endosc 1997

(P<0.001)(P<0.001)

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VariableVariable LaparoscopicLaparoscopicOpenOpen

Oral intake (days)*Oral intake (days)* 0.80.8 5.15.1

Hospital stay (days)**Hospital stay (days)** 3.83.8 9.39.3

OR cost ($)OR cost ($) 15,20015,200 7,2007,200

Hospital cost ($)Hospital cost ($) 1,7001,700 6,8006,800

Total cost ($)Total cost ($) 17,00017,00015,80015,800

*p<0.0001*p<0.0001**p<0.001**p<0.001

Laparoscopy: Diverticular diseaseLaparoscopy: Diverticular disease

Coogan et al, Surg Endosc 1997Coogan et al, Surg Endosc 1997

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Author/yearAuthor/year nn Lap/OpenLap/Open OR ($)OR ($) Hospital ($)Hospital ($)

Dwivedi/02Dwivedi/02 66 66 8888

Lap Lap OpenOpen

9,5669,566** 7,3067,306

13,953 13,953 14,86314,863

Senagore/02Senagore/02 61 61 7171

Lap Lap OpenOpen

1,6941,694** 1,4261,426

3,4583,458** aa 4,3214,321**

Lawrence/03Lawrence/03 56 56 215215

Lap Lap OpenOpen

------ 17,414 17,414 25,70025,700

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

Laparoscopy: Diverticular diseaseLaparoscopy: Diverticular diseaseCostsCosts

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BMIBMI No. of No. of patientspatients

Age (yr: mean-Age (yr: mean-range)range) Gender (M:F)Gender (M:F)

Normal weightNormal weightGroup IGroup I18.5-24.918.5-24.9

2929 58.4 (37-78)58.4 (37-78) 16:1316:13

OverweightOverweightGroup 2Group 2

25.0-29.925.0-29.92727 55.2 (31-83)55.2 (31-83) 14:1314:13

ObeseObese

Group 3Group 3

30.0-39.930.0-39.92121 54.1 (33-86)54.1 (33-86) 14:1314:13

Morbidly ObeseMorbidly Obese>40>40 00 ------ ------

Tuech et al. Surg Endosc 2001Tuech et al. Surg Endosc 2001

Laparoscopy: DiverticulitisLaparoscopy: DiverticulitisObesityObesity

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Group 1Group 1

(n=29)(n=29)Group 2Group 2(n=27)(n=27)

Group 3Group 3(n=21)(n=21)

Anastomotic leak Anastomotic leak (a)(a) 11 00 11

Wound infectionWound infection 22 22 33

Pulmonary infectionPulmonary infection 00 11 00

Postoperative ileusPostoperative ileus 11 00 00

Urinary infectionUrinary infection 11 11 00

TOTAL (%)TOTAL (%) 5 (17.2)5 (17.2) 4 (14.8) 4 (14.8) (b)(b) 4 (19) 4 (19) (c)(c)

a.a. Anastomotic leak resolved with conservative drainageAnastomotic leak resolved with conservative drainageb.b. Group 1 vs. Group 2 – p=0.54Group 1 vs. Group 2 – p=0.54c.c. Group 1 vs. Group 3 – p=0.57Group 1 vs. Group 3 – p=0.57

Tuech et al. Surg Endosc 2001Tuech et al. Surg Endosc 2001


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Group 1Group 1

(n=29)(n=29)Group 2Group 2(n=27)(n=27)

Group 3Group 3(n=21)(n=21)

Mean hospital stay (d) 8.2 8.5 (a) 9.8 (b)

Inpatient rehabilitation 4/29 3/27 (c) 3/21

a.a. Hospital stay Group 1 vs. Group 2: p=0.31Hospital stay Group 1 vs. Group 2: p=0.31b.b. Hospital stay Group 1 vs. Group 3: p=0.14Hospital stay Group 1 vs. Group 3: p=0.14c.c. Inpatient rehabilitation Group 1 vs Group 2: p=0.54Inpatient rehabilitation Group 1 vs Group 2: p=0.54d.d. Inpatient rehabilitation Group 1 vs Group 3: p=0.63Inpatient rehabilitation Group 1 vs Group 3: p=0.63

Tuech et al. Surg Endosc 2001


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> 75 yrs < 75 yrs

n= 22n= 22 n = 63n = 63

Mean age (yrs)Mean age (yrs) 77.2 (75-82) 77.2 (75-82) 53.7 (38-74)53.7 (38-74)

Gender (M:F)Gender (M:F) 10:1210:12 28:3528:35

Operative time (min)Operative time (min) 234234 183183

IV analgesiaIV analgesia (days)(days) 5.45.4 5.25.2

Morbidity (%)Morbidity (%) 1818 1414

Mortality Mortality 00 00

Conversion (%)Conversion (%) 99 66Hospitalization (days)* 13.1 8.8

Teuch et al. Hepatogast 2001Teuch et al. Hepatogast 2001

** p=0.003p=0.003

Laparoscopy: ElderlyLaparoscopy: Elderly

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LaparoscopicLaparoscopic Open Open p value p valuen= 22n= 22 n = 24 n = 24

Mean age (yrs)Mean age (yrs) 77.2 (75-82) (76-84) NS77.2 (75-82) (76-84) NS

Gender (M:F)Gender (M:F) 10:1210:12 10:14 10:14 NS NS

Operative time (min)Operative time (min) 234234 136 136 NS NS

IV analgesiaIV analgesia (days)(days) 5.45.4 8.2 8.2 0.001 0.001

Morbidity (%)Morbidity (%) 1818 50 50 0.02 0.02

Mortality Mortality 00 0 0 NS NS

Inpatient rehabilitationInpatient rehabilitation 66 15 15 0.01 0.01

Hospitalization (days)Hospitalization (days) 13.113.1 20.2 20.2 0.003 0.003

Teuch et al. Surg Endosc 2000Teuch et al. Surg Endosc 2000

Laparoscopy: ElderlyLaparoscopy: Elderly

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Laparoscopy: DiverticulitisLaparoscopy: DiverticulitisEmergencyEmergency

18 patients- acute perforation18 patients- acute perforationLaparoscopic lavage and suctionLaparoscopic lavage and suction

++ Omental patch closure Omental patch closure7.5 days in hospital7.5 days in hospital4-34 month follow-up4-34 month follow-upSubsequent elective resection Subsequent elective resection with primary anastomosis with primary anastomosis possiblepossible

Franklin et al., Surg Endosc 1997Franklin et al., Surg Endosc 1997

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90% SuccessElective resection- 4-5 days in hospital5% MorbidityBetter than LaparotomyApplicable in complex cases as well (Fistula, Abscess, Perforation)

Franklin et al., Surg Endosc 1997Franklin et al., Surg Endosc 1997

Laparoscopy: DiverticulitisLaparoscopy: DiverticulitisEmergencyEmergency

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ConclusionsConclusions

- Surgical treatment of complicated diverticular Surgical treatment of complicated diverticular disease carried out laparoscopically gives good disease carried out laparoscopically gives good results in terms of morbidity and mortality and results in terms of morbidity and mortality and confers many advantages over the traditional confers many advantages over the traditional approachapproach

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- Laparoscopy requires its own specific surgical Laparoscopy requires its own specific surgical strategystrategy

- The surgical team must be expert in The surgical team must be expert in laparoscopic surgery and in colo-rectal surgerylaparoscopic surgery and in colo-rectal surgery

- EEmergency cases should be performed only mergency cases should be performed only by by experienced laparoscopic surgeonsexperienced laparoscopic surgeons

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- The technique must be standardized so that The technique must be standardized so that the incidence of complications, operating time the incidence of complications, operating time and the rate of conversions to open surgery and the rate of conversions to open surgery can be minimizedcan be minimized

[email protected] Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la...

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