Diverticulitis:HowManyAttacksareTooMany?

RahulNarang,MDColorectalSurgeonAssistantProfessorofSurgery

BASICS

PathophysiologyDiverticularDisease

• Increasedintraluminalpressure

• Sigmoidcolonmostcommonlyinvolved(95%)• Smallestdiameter• Laplace’slaw:generates

highestpressure

• Incidenceofdiverticulardiseaseincreaseswithage:– 30%atage60– 60-80%atage80

RiskFactors

• LowfiberDiet

• Smoking

• Constipation

• Obesity

• NSAIDS

Complications

• Obstruction

• Bleeding

• Fistula

• Sepsis,Perforation

• Mayco-existwithIBD Specimen showing blood in diverticulae

ClinicalClassification• Uncomplicatedvs.Complicated• Uncomplicated• Pericolicsoft-tissuestranding,colonicwallthickening,phlegmon

• Complicated:Acutediverticulitis+• Abscess• Obstruction• Perforation• Fistula

SignificanceofDiverticulitis

• SignificantprobleminWesternCountries

• Oneofthemostcommoncausesofacutesurgicaladmission

• 152,000yearlyhospitalizations

• Annualcostsofdiverticulardiseaseestimatedat$2.7billionperyear

Sandler RS et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1511.

• NationwideInpatientSampleduringtheperiod1991-2005:

– Ratioofhospitaldischargesfordiverticulitisincreasedfrom5.1to7.6casesper1000inpatients.

– Patientsunderwentsurgeryforuncomplicateddiverticulitisdeclinedfrom17.9%to13.7%(P <0.001).

• Imaging:CTScan

Management:AcuteUncomplicatedDiverticulitis

• ConservativeManagement• Nonoperative:Bowelrest,Antibiotics

• POorIVdependingonseverity:Anaerobic/GNcoverage

• OutpatientorInpatient

• Successfulin>70%pts

Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44.

ANTIBIOITICSANDFAILURESREQUIRINGEMERGENCYSURGERY

Long-termoutcomein445PatientsafterDiagnosisofDiverticularDisease.

• Retrospectivecohortstudy,DanishPatientRegisterandNationalRegister

• M/F=30/70,medianage75years

Moreno AM et al. Colorectal Dis 2007

• 73%receivedconservativetreatmentprimarily

• 35.3%hadsufferedclinicalrecurrenceofDD,ofthese15.9%weresubsequentlyoperated.

• 3.6%ofthepatientsdiedofcausesrelatedtodiverticulitis.– Possiblehigh-riskgroupsforrecurrenceweremalesandtheirageabove70years.

Moreno AM et al. Colorectal Dis 2007

Long-termoutcomein445PatientsafterDiagnosisofDiverticularDisease.

•DIVERTrial:MulticenterRCT

•132Patients,5HospitalsinSpain

•Outpatientvs.HospitalTreatmentofUncomplicatedDiverticulitis(CTConfirmed)+Abx

•Samerateoftreatmentfailure

•Overallhealthcarecostperepisodewas3timeslowerinoutpatientgroup

•NodifferenceinQOL

•ImportantcostssavingwithoutnegativeinfluenceonQOL

Blondo S, Ann Surg 2014

RiskofEmergencyColectomyandColostomyinPatientswithDiverticularDisease.

• Retrospectivecohortstudy

• 25,058patients

• Only5.5%ofpatientshadrecurrenthospitalizationsduringwhichanemergencycolectomy/colostomywasperformed

Anaya, D et al. Ann Surg 2005

SOHOWMANYATTACKSISTOOMANY?

ElectiveSurgeryfortheTreatmentofAcuteUncomplicatedDiverticulitis

• In1999PracticeParametersoftheASCRSandEAESrecommendedelectivesurgery– After2episodesofuncomplicatedacutediverticulitis– After1episodeinyoungpatients

ASCRS = American Society of Colon and rectal Surgeons EAES = European Association for Endoscopic Surgery

Stollman NH. Am J Gastroenterol. 1999;94(11):3110-3121; Kohler L. Surg Endosc. 1999;13: 430-436; Rafferty J. Dis Colon Rectum. 2006; 49: 939–944

• In2006theASCRS recommendedthatelectivesurgeryshouldbemadeonanindividualbasisafterafavorableresponsetoconservativetreatment

ASCRS = American Society of Colon and rectal Surgeons EAES = European Association for Endoscopic Surgery

Stollman NH. Am J Gastroenterol. 1999;94(11):3110-3121; Kohler L. Surg Endosc. 1999;13: 430-436; Rafferty J. Dis Colon Rectum. 2006; 49: 939–944

ElectiveSurgeryfortheTreatmentofAcuteUncomplicatedDiverticulitis

• ClinicalPracticeGuidelineTaskForceofASCRS(2014):

“Thedecisiontorecommendelectivesigmoidcolectomyafterrecoveryfromuncomplicatedacutediverticulitisshouldbeindividualized.“

• Uncomplicateddiverticulitistreatednonoperatively

– reportlowerrecurrenceratesrangingfrom13%to23%

– lowratesofsubsequentcomplicateddisease

– needforemergencyoperation(<6%)

Hall JF, Dis Colon Rectum 2011Eglinton, Br J Surg 2005Broderick – Villa G, Arch Surg 2005Anaya DA, Arch Surg 2005

• Afterrecoveringfromaninitialepisodeofdiverticulitis,theestimatedriskofneedingemergencysurgerywithstomaformation:– 1in2000patient-yearsoffollow-up.

– Whichmeans - 18ptswouldundergoelectivecolectomytoprevent1emergencysurgeryforrecurrentdiverticulitis.

• Thepracticeofrecommendingelectivecolectomytopreventafuturerecurrencerequiringstomaformationisnotsupportedshouldbediscouraged

Janes S, Br J Surg 2005Anaya DA, Arch Surg 2005

2ormoreattacks?• Patientswithmorethan2episodesarenotatanincreasedriskformorbidityandmortalityincomparisonwithpatientswhohavehadfewerepisodes

• Theimpactofdeclineinelectivesurgeryfordiverticulardiseasedemonstrated– Increaseinabscessformation– Noriseintherateofemergencycolectomy

Chapman JR, Ann Surg 2006Ricciardi R Dis Colon Rectum 2009

SpecialConsiderations

• Transplantpatients,patientsmaintainedonchroniccorticosteroidtherapy,immunosuppressedpatients,patientswithchronicrenalfailureorcollagen-vasculardisease– Morelikelytohavefailureofmedicalmanagement– Greaterriskofrecurrencedisease– Highmortalityratewithmedicaltherapyalone

• Surgeonsshouldmaintainalowthresholdtorecommendoperativeinterventionasdefinitivetreatmentwiththefirsthospitalizationforacutediverticulitisinthesepatients

Hwang SS, Dis Colon Rectum 2010Klarenbeek BR, Ann Surg 2010

ComplicatedDiverticulitis

• Electivecolectomyshouldtypicallybeconsideredafterthepatientrecoversfromanepisodeofcomplicateddiverticulitis

ComplicatedDiverticulitis

• Neitherphlegmonnorextraluminalgasaloneseenonimagingisconsideredcomplicateddisease

• Mesocolicabscessesof≥5cmorpelvicabscesseswithorwithoutpercutaneousdrainageà electivecolectomyshouldtypicallybeadvised– retrospectivedata(smallnumbers)haveshowsrecurrenceratesashighas40%

Ambrosetti P, Dis Colon Rectum 2000Kaiser AM, Ann J Gastroenterol 2005

ComplicatedDiverticulitis

• Diverticulitisiscomplicatedbystrictureorfistulaformationà electiveorsemi-electiveresectionisgenerallynecessarytoprovidesymptomaticrelief

Klarenbeek BR, Ann Surg 2010

DiverticulitisinYoungPatients

• <Age50

• Noclearconsensus

Nelson et al. Management of Diverticulitis in Younger Patients. Dis Colon Rectum 2006; 49:1341-45. Guzzo J, Hyman N. Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum 2004;47:1187-91.

DiverticulitisinYoungPatients• Longerlifespan– highercumulativeriskforrecurrent

attacks– However, overallrateofrecurrenceremainedrelativelylowà27%

– After1st attackinyoungpatientsà only7.5%requiredsubsequentemergencysurgery• AnayaDA,ArchSurg 2005

– RetrospectivedatacollectedonyoungpatientswithCT-confirmedinitialepisodesofdiverticulitisdemonstrated• Low2.1%rateofemergencysurgeryatsubsequentattacks

– NelsonRS,DisColonRectum2006

Treatment

FIBER• Highfiberintakeusedtotreatincreasedspasmand

increasedsegmentalcontractionsbyBritishin1970s

• DietaryAllowancesnowrecommend22-28gofdietaryfiberascorrectintakeinwomenand28to34ginmen–varieswithsize

• Butwesterndietaryfiberstudyrevealsintakevariesbetweenaveragesof8-10ginmost

• Invegandietsasmuchas40-50g/day

Burkitt DP, Phil. Dietary Guidelines2010.

IndicationforElectiveSurgery

• 291patients111(38%)treatedconservatively,180(62%)underwentsurgery(108acuteand72elective)

• Conservativelygroupdiverticulitisrecurrencerate48%(88patients).

Klarenbeek BR, Ann Surg, 2010.

• Indicationsforelectivesurgerywere:– recurrentattacksofdiverticulitiswithpersistentcomplaints(36%)

– complaintsofstenosis(40%)– fistula(14%)– persistentabscesses(3%)– recurrentdiverticularbleeding

• Usingimmunosuppressiontherapy,chronicrenalfailure,collagen-vasculardiseases:have5-foldgreaterrisk(36%vs.7%)ofaperforationinrecurrentepisodesofdiverticulitis.

Klarenbeek BR, Ann Surg, 2010.

ElectiveSigmoidResection

• Open,Lap,Robotic

• SigmoidResection– ProximalMargin:compliantbowel

• Includethickened,woodyorgrosslydiseasedbowel•Notalldiverticulabearingcolonmustberemoved

– Distal:upperrectum

•Open 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

Laparoscopy:Diverticulitis

Laparoscopy Laparotomy pO.Rcharges($) 10,589 8,207 0.05Hospitalcost($) 11,500 13,400 0.29Hospitalcharges($)29,981 36,745 0.11Morbidity(%) 14 14 0.11Mortality 0 0

•Liberman, Surg Endosc 1996

EmergentSurgicalIntervention• AccordingtocurrentASCRSguidelines• Sigmoidresection,endcolostomy,closureofdistalstump• OverallMorbidityupto29%• Mortality10-20%• LongLOS(20+days)• Colostomyclosuretechnicallydifficult• “Temporary”colostomiesoftenneverclosed(30%-75%)

• ThishasbeenchallengedbyEuropeanAssociationforEndoscopicSurgeryrecommendations+severalstudies

• AlternativetoHPinclude:PA+/-Diversion&LapLavage

Rafferty J, et al. Standards Committee of American Society of Colon and Rectal Surgeons. Practice Parameters for Sigmoid Diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44

Rafferty et al, DCR 2006

•Practice Parameters for Sigmoid Diverticulitis

•The Standards Committee of The American Society of•Colon and Rectal Surgeons

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

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

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

BottomLine!

• Mostperforationsandcomplicationsdonotoccurafterrecurrences,happenatfirstattack

• ConservativemanagementofrecurrentnonperforateddiverticulitisassociatedwithlowratesofMorbidity&Mortalitywithmildcourse

Chapman J, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005;242:576–581. Chapman JR, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg. 2006;243:876–880

TakeHomeMessage•Asfewpatientswillactuallyrequireurgentsurgery,shouldlimitdiscussionregardingthisuncommoncomplication

•Insteadshouldfocusondiscussionofrisksandbenefitsofsurgery,QOLimplications,andthehigherlikelihoodofsimilarepisodesasthereasonto,ornotto,considersurgery

•Potentialpoorfunctionaloutcomesandpersistentabdominalsymptomsafterelectivesigmoidcolectomyfordiverticulitisshouldbeconsideredaswell.

ThankYou