Perforated DiverticulitisPerforated Diverticulitis
Kiyanda Baldwin MDKiyanda Baldwin MDKiyanda Baldwin, MDKiyanda Baldwin, MD
SUNY Downstate M&MSUNY Downstate M&M
Lutheran Medical CenterLutheran Medical Center
4/15/20104/15/2010
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C t tiCase presentation62 y/o F presented to LMC on 3/7/10 with left lower abdominal pain x 24 hr.
“If I have surgery I’m going to die”
D i h/ i i di h Denies h/o constipation or diarrhea
Denies BPRDenies BPR
Denies change in appetite or weight loss
Denies having previous colonoscopy
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Case presentationCase presentation PMH – Morbid obesity, Hypotension (baseline SBP ~90‐100), CHF (EF 20%), A. Fib, ESRD on HD, DM, Asthma, CAD/MI
PSH – B/L hip replacement, CABG 2000, stent 2008.
Meds: coumadin, carvedilol, lantus, albuterol prn
All: NKDA All: NKDA
SH: lived at home with home attendant, on disability, denies tobacco, etoh, illicit drug use
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C t tiPE:
Case presentation Vitals: T 99.2, BP 107\66, HR 88, Sat 98, Weight 123 kg,
Height 5`7”g 5 7
CVS: S1S2 RRR
Chest : CTA B/L
Abd: soft, obese, moderate LLQ tenderness, no R/G,
+BS, no masses appreciated
Rectal: good tone no masses appreciated guiaic ‐ Rectal: good tone, no masses appreciated, guiaic ‐
Ext: motor in tact x4, 2+ distal pulses x4
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C t tiLabs:
Case presentation CBC 11.9\11\35.5\136 Neu 84%
BMP \ \ \ \ 8\ BMP 139\4.4\101\30\38\2.4
LFTs AST\ALT\AlP\Bil 19\17\52\0 8 LFTs AST\ALT\AlP\Bil ‐ 19\17\52\0.8
Coags 28\14\1.4g \ 4\ 4
Lac acid 0.9
ABG 7.43\92\38.9\98%\28.9\2
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Hospital courseHospital courseD L C l Di i li i lik l l d f i Dx‐ Lt Colon Diverticulitis, likely sealed perforation
Admitted to POU with IV fluids + Zosyn / Flagyly gy
Day 2 – improved, WBC 11.98.57.9, afebrile
Day 3 – worse, tender abdomen, hypotensive
Free air on CXR
To OR for explorative laparotomy To OR for explorative laparotomy
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Operative Course Exp laparotomy – midline
Air evacuated upon peritoneum openingAir evacuated upon peritoneum opening
~ 100 cc purulent fluid, perforation distal left colon
L h i l i h d l ( H L. hemicolectomy with end colostomy ( Hartmann
procedure)
During OR course patient required pressor support
(vasopressin, levophed , & neosynephrine)
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Postop coursePostop courseI ICU i d i t b t d i d i l t In ICU: remained intubated, required maximal pressor support (3 drugs)
Profound septic shock complicated by cardiogenic shock later Profound septic shock complicated by cardiogenic shock later
Acidosis :
ABG 7 15\32\251\11\99%\-16 Transient improvement w/ IV ABG 7.15\32\251\11\99%\-16. Transient improvement w/ IV bicarb.
Swan Ganz placedS a Ga p aced
CO 5.3, CI 2.6, PAWP 17, CVP 17, SVR 497 (10am)
CO 3.2 ,CI 1.66, PAWP 11, CVP 12, SVR 219 ( 7pm), , , , ( p )
Troponin elevation to 2.5, LA 15
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Postop course (continued)
Despite maximal pressor support patient's hypotension progressively worsened
Postop day 1 (18 hours after surgery) patient coded x 2, second code was unsuccessful .
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COMMENTSCOMMENTS
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Colonic Diverticulae False diverticula False diverticula
mucosa and muscularis mucosa have herniated through the colonic wallg
Pulsion diverticula resulting from high intraluminal pressure
b h l Occur between the taeniae coli points where the main blood vessels penetrate the colonic wall (presumably creating an area of colonic wall (presumably creating an area of relative weakness in the colonic muscle)
Sabiston/Maingot
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Diverticulitis
results from a perforation (either macroscopic or microscopic) of a diverticulum
leads to contamination inflammation and leads to contamination, inflammation, and infection
Sabiston
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Complicated Diverticulitis Abscess
Obstruction
Diffuse peritonitis (free air)
Fistulas between the colon and adjacent structures
Sabiston
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Hinchey Classification Stage I: colonic inflammation with an associated pericolic abscessp
Stage II: colonic inflammation with a gretroperitoneal or pelvic abscess
Stage III: purulent peritonitis
Stage IV: fecal peritonitis
Sabiston/Maingot
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Treatment of Perforated Diverticulitis with Generalized Peritonitis: Past, Present, and FuturePeritonitis: Past, Present, and Future
What’s the surgical “gold standard” for perforated diverticulitis?
Vermeulen & Lange, World J Surg 2010
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Three stage procedure Early 1900s – three stage procedure :
Diversion and drainage Resection ( in 3‐6 months ) Colostomy reversal
No antibiotics
Mortality >25%
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Two stage procedure
Mid 1900’s –two stage procedure: resection with diversion
d d h f d f l Understanding that perforated segment of colon remains as source of ongoing contamination
Using antibiotics
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H t dHartmann procedure Since mid‐1900’s standard practice changed to
Hartmann procedurep
2000 American Society of Colon and Rectal
Surgeons no longer recommended non
resectional approach as standard
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Hartmann procedure
Second stage ( reversal of colostomy ) will never be performed in ~30% of patients
Could be technically challenging with significant morbidity and mortality
So is there another option?
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O t dOne stage procedure Since 1960’s (Madden, Surg Gynecol Obstet 1961)
Resection of perforated sigmoid colon with primary anastomosis (PA)anastomosis (PA)
PA with or w/out diverting ileostomy not inferior to HP
Salem & Flum, Dis Colon Rectum 2004Constantinidas et al. Dis Colon Rectum 2006
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Why Not Single Stage ? Fear of anastomotic leakage defers many surgeons
Outcomes remain suboptimal: morbidity 25 50% mortality 10 20% for Hartmann’s and PRA respectivelymortality 10 20% for Hartmanns and PRA respectively
Didn’t really catch on as standard of care
So what’s next ?
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New !New !
New !New ! New !
Nonresectional laparoscopic lavage6 fi t t 1996 first reports
Patients without gross fecal peritonitis P d i l d Procedure includes:
laparoscopic peritoneal lavage, inspection of the colon inspection of the colon pelvic‐abdominal drainage
Morbidity/mortality ~ 5%y/ y 5 Reduce length of stay on first admission Avoid ostomy and it’s complicationsy p Requires skilled laparoscopic surgeon … & guts
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From the Department of Digestive Surgery, Trousseau Hospital, Tours, France.
Am Coll Surg 2008;206:654–657.
All ti t ith f t d di ti liti i i 2000 2004All patients with perforated diverticulitis requiring surgery 2000-2004
Indications: Diffuse peritonitis, septic shock, failure of conservative t t t ft 48h l i b ( Hi h 2 ) f ibl f IRtreatment after 48hr, pelvic abscess ( Hinchey 2 ) unfeasible for IR drainage
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Laparoscopic Technique
Laparoscopic full lavage, requiring at least 10 L
Pus drained and adhesions left untouched
P l i d i l ft i l Pelvic drain left in place
No ileostomy or colostomy y y
Postoperative bowel rest & 21 days of antibiotics
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Results 24 patients (mean 55 years), 23 were “first timers”
ASA I and II
3 on steroids, 10 had previous surgery
N t lit No mortality
Return of bowel function in 2-10 days (mean 3 days)
2 patients had abscesses that required IR drainage (Hinchey III)
Mean hospital stay 12 days Mean hospital stay 12 days
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B i i h J l f S 8 British Journal of Surgery 2008; 95: 97–101
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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis
Prospectively collected database 2000 - 2007
1257 Pts admitted with diverticulitis
100 Pts recruited
Median age 62 5 ASAIII M:F 2:1 1 on steroids Median age 62.5, ASAIII, M:F 2:1, 1 on steroids
None had h/o diverticulitis
All had generalized peritonitis + perf on imaging
8 Pts with fecal peritonitis had Hartmann procedure
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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis
Irrigation of peritoneal cavity with 4L or more until drainage clearuntil drainage clear
Two non‐suctional Penrose drains
IV Abx 72Hr then PO 1 week7
Clears POD 1, solid according to clinical gprogression
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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis
Results:Results:
82 Pts (89%) recovered without morbidity82 Pts (89%) recovered without morbidity
4% morbidity (2 pelvic abscesses)
Mortality 3% ( 2 ‐MOF, 1 ‐ PE)
resumed diet after 2 days and discharged after 8
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Laparoscopic peritoneal lavage for generalized peritonitis dueto perforated diverticulitis
Follow up:
88 pts underwent colonoscopy/Ba enema in 6 weeks6 weeks
M di f/ Median f/u 3 years 2 pts were readmitted for acute diverticulitis and responded w/ Abx.p
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H ’Hartmann’s Procedure isProcedure is
G ld S d d!Gold Standard!
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