Diverticulitis AbscessDiverticulitis Abscess

Tryggvi StefánssonTryggvi StefánssonCentrallasarettet in Västerås Centrallasarettet in Västerås

andandLandspitali University HospitalLandspitali University Hospital

Reykjavík/IcelandReykjavík/Iceland

PerforationPerforation

Abscess Abscess Purulent peritonitisPurulent peritonitis Faecal peritonitisFaecal peritonitis

IncidenceIncidence

HartHart Cambridge UKCambridge UK 1995-19971995-1997 4/100000/year4/100000/year

MäkeläMäkelä Oulu, FinlandOulu, Finland 1986-2000 1986-2000 3,8/100000/year3,8/100000/year

AbscessAbscess

Diverticulitis abscesses are rare.Diverticulitis abscesses are rare.

Individual experience not enough.Individual experience not enough.

IncidenceIncidence

AmbrosettiAmbrosetti Geneva Geneva 1986-19971986-1997 1/100000/year1/100000/year

Risk factors for perforated Risk factors for perforated diverticulitis diverticulitis

Industrialized countries with high prevalence of diverticulosisIndustrialized countries with high prevalence of diverticulosis Increases with advanced ageIncreases with advanced age Men > WomenMen > Women Immune suppressionImmune suppression CorticosteroidsCorticosteroids NSAIDNSAID Opioids, smoking, alcoholism, red meat, fiber deficiency (??)Opioids, smoking, alcoholism, red meat, fiber deficiency (??)

Morris, Postgrad Med J, 2002 Morris, Postgrad Med J, 2002

obesityobesityDobbins, Colorectal dis, 2005Dobbins, Colorectal dis, 2005

Renal failureRenal failure

LocationLocation

Paracolic or PelvicParacolic or Pelvic

Retroperitoneal, Retrorectal, Psoas Retroperitoneal, Retrorectal, Psoas muscle, Hip, Buttock, Flank, Leg, muscle, Hip, Buttock, Flank, Leg, Inguinal region, ScrotumInguinal region, Scrotum

Stabile, Am J Surg, 1990Stabile, Am J Surg, 1990

Neff, Radiology, 1987Neff, Radiology, 1987

Ravo, Am J Gastroenterol, Ravo, Am J Gastroenterol, 19851985

BacteriasBacterias

19 patients:19 patients: Polymicrobial (E-coli, Bacteroides, Polymicrobial (E-coli, Bacteroides,

Enterococcus, Klebsiella) in 17Enterococcus, Klebsiella) in 17 E-coli in 1E-coli in 1 B Fragilis in 1B Fragilis in 1

Stabile Am J Surg 1990Stabile Am J Surg 1990

AbscessAbscess

AbscessAbscess

AbscessAbscess

Treatment OptionsTreatment Options

Bowel RestBowel Rest AntibioticsAntibiotics PAD (Percutaneous Abscess Drainage)PAD (Percutaneous Abscess Drainage) SD (Surgical Drainage)SD (Surgical Drainage) One Stage (Res+ ana +/- ostomy)One Stage (Res+ ana +/- ostomy) Two Stages (Hartmanns procedure)Two Stages (Hartmanns procedure) Three Stages (Drainage+ostomy)Three Stages (Drainage+ostomy)

Results of operationsResults of operations

Lahey clinic 1967-1982 Lahey clinic 1967-1982 MortalityMortality

Res and anaRes and ana 1%1% Res, ana with stomaRes, ana with stoma 0%0% HartmannHartmann 16%16% Three StagesThree Stages 14%14%

Hackford AW, Dis Colon Rectum, 1985Hackford AW, Dis Colon Rectum, 1985

Results of operationsResults of operations

Of 37 patients operated with a Of 37 patients operated with a

2-stage operation for an abscess 2-stage operation for an abscess

13 patient could have been operated 13 patient could have been operated in a single stage operation if they in a single stage operation if they had undergone PADhad undergone PAD

Mueller PR, Radiology, 1987Mueller PR, Radiology, 1987

Goal of DrainageGoal of Drainage

Downstage-Single stageDownstage-Single stagePatient can recover, Bowel Prep, Clean op fieldPatient can recover, Bowel Prep, Clean op field

Bacteria culture.Bacteria culture. Only treatment.Only treatment.

How to drainHow to drain

CT guided Transabdominal, trans CT guided Transabdominal, trans sacral (PAD)sacral (PAD)

US guided transabdominal (PAD), US guided transabdominal (PAD), transvaginal, transrectaltransvaginal, transrectal

EUS guided through the sigmoid wallEUS guided through the sigmoid wall Surgical drainageSurgical drainage Blind transrectal or transvaginalBlind transrectal or transvaginal

Contraindications to PADContraindications to PAD Abscess not localized Abscess not localized Access not safeAccess not safe Generalized peritonitisGeneralized peritonitis PneumoperitoneumPneumoperitoneum ObstructionObstruction Blood dyscrasias/Bleeding diathesisBlood dyscrasias/Bleeding diathesis Persistent symptoms after drainagePersistent symptoms after drainage Faeculent DrainageFaeculent Drainage (Immunocompromized and high mortality score)(Immunocompromized and high mortality score)

Diverticular disease.Diverticular disease.

Management of the difficult surgical caseManagement of the difficult surgical caseWilliams and Wilkins 1998Williams and Wilkins 1998

Published Results of PADPublished Results of PAD Neff CC Radiology 1987Neff CC Radiology 1987

16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm 11 single stage op in 10d-6w 11 single stage op in 10d-6w 3 inop, drainage only.3 inop, drainage only. 1 sigm fistula 3 stage1 sigm fistula 3 stage 1 resp insuff-died1 resp insuff-died

Published Results of PADPublished Results of PAD Mueller PR, Radiology 1987:Mueller PR, Radiology 1987:

24 patients, pelvic abscesses24 patients, pelvic abscesses14 single stage op within 10 days14 single stage op within 10 days5 two-stage op because of inflammation5 two-stage op because of inflammation2 no initial op but res within 8 months2 no initial op but res within 8 months1 just drain1 just drain

Stabile BE, Am J Surg, 1990:Stabile BE, Am J Surg, 1990:19 patients with parac or pelvic abscesses (8,9cm)19 patients with parac or pelvic abscesses (8,9cm)14 (74%) single stage operation after PAD.14 (74%) single stage operation after PAD.3 Urgent colostomy and surgical drainage.3 Urgent colostomy and surgical drainage.2 refused operation (one died).2 refused operation (one died).

Drainage Drainage

Drainage Drainage Infected part of the colon is left behind. Infected part of the colon is left behind.

Risk for complications like persistent fistula, DVT, Risk for complications like persistent fistula, DVT, Atelectasis, pneumonia and other infections. Atelectasis, pneumonia and other infections.

If the patient deteriorate in spite of drainage the op risk If the patient deteriorate in spite of drainage the op risk will be higher.will be higher.

Hartmann opHartmann op The patient is drained and deviatedThe patient is drained and deviated

Choice of TreatmentChoice of Treatment

11 The AbscessThe Abscess

* * SizeSize

**** LocationLocation

****** BacteriasBacterias

22 The PatientThe Patient

** Morbidity, mortality scoring systems.Morbidity, mortality scoring systems.

** ** Anastomose healingAnastomose healing

33 The SurgeonThe Surgeon

** TrainingTraining

**** Hospital Hospital

****** Emergency/ElectiveEmergency/Elective

Size of AbscessSize of Abscess

< 3-5 cm< 3-5 cm Bowel rest and AntibioticsBowel rest and Antibiotics

> 5 cm> 5 cm Bowel rest, Antibiotics and Bowel rest, Antibiotics and DrainageDrainage

Ambrosetti Dis Colon Rectum 2005Ambrosetti Dis Colon Rectum 2005Siewert AJR 2006Siewert AJR 2006

LocationLocation

Abscesses >5cm:Abscesses >5cm:

Pelvic: Pelvic: Drainage. Drainage.

Resected when the acute Resected when the acute inflammation inflammation has faded.has faded.

Paracolic: Paracolic:

Drainage.Drainage.

Conservative treatment. Conservative treatment. Resection only if symptoms persist.Resection only if symptoms persist.

Ambrosetti, Dis Colon Rectum, 2005Ambrosetti, Dis Colon Rectum, 2005

AntibioticsAntibiotics

Broadspectrum antibiotics (G neg Broadspectrum antibiotics (G neg and anaerobes)and anaerobes)

Cefuroxim, MetronidazolCefuroxim, Metronidazol

Ciprofloxacin, MetronidazolCiprofloxacin, Metronidazol

TienamTienam

MeronemMeronem

TacozinTacozin

PatientPatient

Mortality and Morbidity scoreMortality and Morbidity score ASA, APACHE, POSSUMASA, APACHE, POSSUM

Anastomose healingAnastomose healingNormalNormal: : Young and healthyYoung and healthy

ImpairedImpaired: : Old, Malnourished, Renal Old, Malnourished, Renal failure, AIDS, Steroid dependent, failure, AIDS, Steroid dependent, Chemotherapy, Diabetes, Chronic Chemotherapy, Diabetes, Chronic alcoholics, alcoholics, High BMI, Transplant patientsHigh BMI, Transplant patients

SurgeonSurgeon

Training:Training: In training, General Surgeon, In training, General Surgeon, Colorectal SurgeonColorectal Surgeon

Hospital:Hospital: Radiology equipment, Radiologist, ICU, Radiology equipment, Radiologist, ICU, AssistanceAssistance

Emergency/Elective: Emergency/Elective: Rate of complications Rate of complications higher in emergency operationshigher in emergency operations

Team decisionTeam decision

Colorectal SurgeonColorectal Surgeon RadiologistRadiologist CardiologistCardiologist AnaesthetistAnaesthetist ............

Abscess treatmentAbscess treatment Normal healing of anastomosis and a favorable mortality scoreNormal healing of anastomosis and a favorable mortality score <5 cm: <5 cm: Bowel rest and Broadspectrum antibioticsBowel rest and Broadspectrum antibiotics

Those who dont respond: Those who dont respond: DrainageDrainagePersist after drainage:Persist after drainage: Res and AnaRes and Ana

>5cm in pelvis: >5cm in pelvis: Drainage with a later res and anaDrainage with a later res and ana >5cm above the pelvis:>5cm above the pelvis: DrainageDrainage

Persist after drainage:Persist after drainage: Res and Res and AnaAna

Impaired healing of anastomosisImpaired healing of anastomosis1) Bowel rest, Broadspectrum antibiotics and Drainage1) Bowel rest, Broadspectrum antibiotics and Drainage2) Res and Ana + loop Ileost or Hartmanns op2) Res and Ana + loop Ileost or Hartmanns op

Impaired healing of anastomosis and unfavorable mortality scoreImpaired healing of anastomosis and unfavorable mortality score Hartmann operation directlyHartmann operation directly

SummarySummary

Young and healthy patientsYoung and healthy patients tolerate tolerate conservative treatment.conservative treatment.

Immunocompromized with unfavorable Immunocompromized with unfavorable mortality scoremortality score may not tolerate may not tolerate conservative treatment-need more active conservative treatment-need more active surgical treatment.surgical treatment.