Improved Outcomes in Colon and Rectal Surgery part 27 pps

 improved outcomes in colon and rectal surgery 23. Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B. Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum 2000; 43(1): 35–43. 24. Winde G, Reers B, Nottberg H et al. Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. Eur J Surg 1993; 159(5): 301–5. 25. Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 1994; 81(6): 904–6. 26. Mann CV, Hoffman C. Complete rectal prolapse: the ana- tomical and functional results of treatment by an extended abdominal rectopexy. Br J Surg 1988; 75(1): 34–7. 27. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis Colon Rectum 1999; 42(5): 655–60. 28. Allen-Mersh TG, Turner MJ, Mann CV. Effect of abdominal Ivalon rectopexy on bowel habit and rectal wall. Dis Colon Rectum 1990; 33(7): 550–3. 29. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia. 30 years’ experience. Dis Colon Rectum 1985; 28(2): 96–102. 30. Huber FT, Stein H, Siewert JR. Functional results after treat- ment of rectal prolapse with rectopexy and sigmoid resec- tion. World J Surg 1995; 19(1): 138–43. 31. Husa A, Sainio P, von Smitten K. Abdominal rectopexy and sigmoid resection (Frykman-Goldberg operation) for rectal prolapse. Acta Chir Scand 1988; 154(3): 221–4. 32. Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg 2003; 197(2): 177–81. 33. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg 2002; 89(1): 35–9. 34. Purkayastha S, Tekkis P, Athanasiou T et al. A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum 2005; 48(10): 1930–40. 35. Zittel TT, Manncke K, Haug S et al. Functional results after laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg 2000; 4(6): 632–41. 36. Himpens J, Cadiere GB, Bruyns J, Vertruyen M. Laparoscopic rectopexy according to Wells. Surg Endosc 1999; 13(2): 139–41. 37. Dulucq JL, Wintringer P, Mahajna A. Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full- thickness rectal prolapse. A prospective study. Surg Endosc 2007; 21(12): 2226–30. 38. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JR. Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum 2000; 43(5): 638–43. 39. Kessler H, Jerby BL, Milsom JW. Successful treatment of rectal prolapse by laparoscopic suture rectopexy. Surg Endosc 1999; 13(9): 858–61. 40. Bruch HP, Herold A, Schiedeck T, Schwandner O. Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 1999; 42(9): 1189–94. 41. Kellokumpu IH, Vironen J, Scheinin T. Laparoscopic repair of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function. Surg Endosc 2000; 14(7): 634–40. 42. Baker R, Senagore AJ, Luchtefeld MA. Laparoscopic-assisted vs. open resection. Rectopexy offers excellent results. Dis Colon Rectum 1995; 38(2): 199–201. 43. Benoist S, Taffinder N, Gould S, Chang A, Darzi A. Functional results two years after laparoscopic rectopexy. Am J Surg 2001; 182(2): 168–73. 44. Kairaluoma MV, Viljakka MT, Kellokumpu IH. Open vs. lap- aroscopic surgery for rectal prolapse: a case-controlled study assessing short-term outcome. Dis Colon Rectum 2003; 46(3): 353–60. 45. Steele SR, Goetz LH, Minami S et al. Management of recur- rent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum 2006; 49(4): 440–5. 46. Pikarsky AJ, Joo JS, Wexner SD et al. Recurrent rectal pro-Recurrent rectal pro- lapse: what is the next good option? Dis Colon Rectum 2000; 43(9): 1273–6. 249 24 Operative and nonoperative therapy for diverticular disease R Scott Nelson and Alan G Thorson Unlike other diseases in this text diverticular disease is a common problem with multiple presentations. CHALLENGING CASE #1 A 52-year-old male presents to the Emergency Department with complaints of left lower quadrant (LLQ) abdominal pain for the last 16 hours. The patient describes the pain as esca- lating in nature, unrelieved with a bowel movement. History is unremarkable except for hypertension, which is treated with a beta-blocker. The patient denies any similar symptoms previ- ously. Abdominal exam reveals a mildly distended abdomen, with tenderness to the left lower quadrant, but no guarding or rigidity. A basic metabolic profile is normal and complete blood count reveals a leukocytosis at 14,000. CT scan of the abdomen and pelvis with oral and rectal contrast demonstrates thicken- ing of the sigmoid colon with mesenteric thickening but no identifiable abscess or perforation. CASE MANAGEMENT In a 52-year-old male patient with the aforementioned findings, a clinical and radiographic diagnosis of acute uncomplicated diver- ticulitis is confirmed. Treatment should consist of broad spectrum antibiotics, typically, Ciprofloxacin and Flagyl, IV fluids, and bowel rest. Admission to the hospital is based on physical examination, comorbidities, and CT findings. Treatment should be continued until the patient’s pain has resolved or symptomatic improvement is noted, and then oral intake may resume. Antibiotics are typically continued for 7–10 days following resolution of pain. CHALLENGING CASE #2 A 67-year-old female presents to the ED with a two day history of escalating LLQ pain and evidence of diverticulosis on colonos- copy 10 years ago. Physical exam reveals a tender LLQ without peritoneal signs, and fullness to palpation. WBC count is elevated at 17,000 and a CT scan shows a thickened inflamed sigmoid colon with a 3 cm abscess on the medial aspect of the colon. Case #2 Management Any patient diagnosed with a diverticular abscess, elevated WBC count, and pain, should be admitted to the hospital and started on intravenous fluids and antibiotics. The risk of requiring an emer- gent operation secondary to failure of conservative management is 0–30%. Patients with an abscess >2–3 cm should also be evaluated for percutaneous drainage. Following these measures the patient should be followed to assess clinical improvement. Resolution based on physical exam and bowel activity can dictate further conservative treatment. Elective surgery should be scheduled in the near future based on the patient’s overall health and ability to undergo an operation. Failure of conservative therapy deems that an operation be completed during that hospitalization. CHALLENGING CASE # 3 65-year-old male admitted for acute uncomplicated diverticu- lar disease is started on antibiotic therapy. After 3 days of I.V. antibiotic therapy and IV fluid the patient’s pain resolves. He is switched over to oral antibiotics and started on a low residue diet. The patient describes the same pain, increasing in the LLQ over the next 24 hours. He is once again made NPO and I.V. antibiot- ics are restarted. This time, attempts to switch the patient to oral antibiotics are successful and he is discharged home. However 10 days later he returns with LLQ pain again and CT scan continues to show uncomplicated diverticulitis. He is restarted on oral anti- biotics and his pain resolves. Case #3 Management Chronic diverticulitis should be treated with an operation. There are not many studies in the literature dedicated to just chronic diverticular disease; however, it is a subject that probably does not need such study. Patients with pain that is clearly attribut- able to a surgical disease and that persists despite maximal medi- cal therapy are candidates for an operation and should have the problem dealt with. CHALLENGING CASE #4 A 72-year-old female presents to her primary care physician for the 4th time in 6 months with a urinary tract infection (UTI). The patient has no known history of abdominal pain, and no previous history of frequent UTI, and now has noticed pneumaturia. The culture shows multiple organisms, including E. Coli. The last pre- vious colonoscopy 2 years ago demonstrated diverticula, but was otherwise normal. Abdominal exam reveals no abnormal find- ings. What would be the best way to proceed in the diagnosis and treatment of this individual? Case #4 Management This patient should undergo confirmatory testing and CT scan. If the diagnosis is unsuccessful with barium enema, cystoscopy can also be attempted. If the patient is a candidate for surgery and the suspicion remains without confirmation, operative treatment is indicated. Laparoscopic resection has been shown to be possible in these types of cases as well. CHALLENGING CASE #5 A 34-year-old female 2 weeks after a renal transplant for poly- cystic kidney disease complains of anorexia and vague abdomi- nal tenderness, more on the left side. Bowel movements which had been normal have now stopped over the last three days. A palpable kidney in the LLQ is not overly tender, and renal function does not seem abnormal for the time since opera- tion. No changes have been made in her immunosuppressive medication. 2 improved outcomes in colon and rectal surgery Case #5 Management Prophylactic colectomy for diverticulosis is not recommended before transplant. However, the incidence of diverticulitis follow- ing transplant is higher than the general population, though still relatively rare in the transplant population overall. Additionally patients receiving immunosuppressive therapy are at a higher risk for complicated diverticulitis and, more importantly, delay in diagnosis significantly increases their morbidity and mortal- ity. Patients with polycystic kidney disease also show higher rates of diverticulosis and diverticulitis as opposed to other popula- tions. These patients require aggressive diagnostic evaluation with CT scan and if diverticulitis is confirmed, aggressive surgical management. INCIDENCE OF DIVERTICULOSIS AND DIVERTICULITIS It is estimated that nearly 30% of the U.S. population will have evi- dence of diverticulosis by age 60. That number increases to 60% by the time an individual reaches 80 years of age. (1) However, of these patients, only 10–25% will develop symptomatic diver- ticulitis and of those who become symptomatic only 10–20% of individuals will require hospitalization. Of patients who are hospitalized with symptomatic disease, 20–50% will require an operation. (2) Overall, <1% of patients with diverticula will ulti- mately require surgical management. In recent years there has been a shift in the treatment of patients with diverticulitis as more are treated as outpatients with oral antibiotics than with hospitalization. (2) Left sided diverticula predominant among the more western countries including the United States, Canada, United Kingdom, Europe and Brazil. While left-sided disease is still more common, right-sided disease is associated more with eastern countries such as Japan, China, Korea, and Singapore.(3) The male to female ratio appears to be about equal. CLASSIFICATION In order to determine how best to treat patients presenting with diverticular disease, classification of the severity of the disease is necessary. Diagnostic modalities have changed substantially within the last 40 years and along with it our paradigms of treat- ment. Park, in the late 60s and early 70s along with fellow con- temporaries including Larson, and Haglund (4–6) attempted to evaluate the natural history of diverticulitis in order to classify the severity of disease. Many of the guidelines and recommendations by various societies for the treatment of diverticulitis are based on this original work. However, their diagnosis of the disease was based on barium enema, physical examination, and pathology reports. While all three methods are sufficient to make a diagno- sis, the improved sensitivity and specificity of newer technology has changed the way we diagnosis, classify and treat this disease today. In recent years, criteria for the classification of diverticulitis has changed from findings on barium enema, history and physi- cal examination and colonoscopy to findings based on computed tomography (CT) scanning. These scans now provide practical and predictive information that assist in the classification and severity of the disease process. A number of useful classification systems have been developed to assist the physician in deciding on a course of treatment.(1, 7, 8) These classification systems can be based on CT scans findings (Table 24.1 and Figures 24.1, 24.2 and 24.3), intraoperative findings (Table 24.2), or a more global view of the disease (Table 24.3). Ambrosetti has done extensive work on CT findings of diver- ticular disease and developed a classification system based on the appearance of the inflamed colon. (7) His work is simple and divides patients into two groups; uncomplicated or complicated. (Table 24.1) Other studies have looked at the size of the abscess and amount of mesenteric air to determine if those are predictors of failure of nonoperative therapy.(8) Another useful method of evaluating diverticulitis was reported in 1978 by Hinchey. This is based on findings at the time of sur- gery and the decision for determining the correct surgical inter- vention was based on this classification system.(9) This simple formula divided the intraoperative findings into four categories based on the amount and type of peritonitis. (Table 24.2) However not all diverticular disease can be classified by CT scan or at the time of an operation. In a recent description of the Table 24.1 Ambrosetti classification of diverticulitis based on CT findings. Ambrosetti CT Classifications Uncomplicated—colonic wall thickening, pericolic fat stranding, inflammatory changes Complicated—Extracolonic air, abscess, perforation Table 24.2 Intra-operative classification. Hinchey Classifications Type I—Diverticulitis with no or local peritonitis Type II—Diverticulitis with a small pericolic abscess Type III—Diverticulitis with local purulent or fecal peritonitis Type IV—Diverticulitis with diffuse purulent or fecal peritonitis Table 24.3 Definitions of diverticular disease. Diverticulitis Defined: I. Diverticulosis 1. Asymptomatic II. Diverticulitis 1. Noninflammatory A. Symptoms without inflammation 2. Acute A. Complicated Perforation, Abscess, Phlegmon, Fistula, Bleeding B. Uncomplicated (Simple) Localized, thickening, fat stranding 3. Chronic A. Recurring or persistent disease Symptoms with systemic signs (may be intermittent) B. Atypical Symptoms without systemic signs 4. Complex A. Fistula, Stricture, Obstruction 5. Malignant A. Severe, fibrosing 251 operative and nonoperative therapy for diverticular disease disease, Thorson and Goldberg described the disease based on the type of presentation, timing and duration of the disease, and complexity.(10) (Table 24.3) Acute Uncomplicated Diverticulitis Nonoperative Treatment Multiple reports have cited the successful treatment of uncom- plicated diverticulitis in all patients, regardless of age.(11–16) However, the treatment can be quite variable as cited in a recent survey among members of the American Society of Colon and Rectal Surgeons (ASCRS). (12) This survey found that the treat- ment of patients with uncomplicated diverticulitis varied widely between type and number of antibiotics used, feeding sched- ule, and admission to the hospital. Further study into the nat- ural history of the disease, with respect to both the short- and long-term outcomes of patients with uncomplicated diverticu- litis, is overwhelmingly in favor of conservative treatment with- out operation. (13, 15–18) It is estimated that with conservative treatment 70–100% of patients will improve. Patients are even being treated as outpatients with oral antibiotics, sports drinks, and frequent follow-up in an effort to limit cost related to uncomplicated disease. (19) Outcome Measures Economic and morbidity models have been developed to evalu- ate the cost and risk/benefit ratio of early versus late operation for patients with uncomplicated diverticulitis. These studies deter- mined that waiting, until after the 3rd or even 4th attack of docu- mented diverticulitis, was both cost effective and less morbid on a population based model, than performing an early elective oper- ation. (9, 20) Traditional teaching about diverticulitis suggested that patients suffering more than two episodes of uncomplicated diverticulitis should undergo an elective operation. In fact, most of the consensus data on elective resection after two documented episodes comes from literature that was published before the use of CT scanning and modern day antibiotic therapy. Because of these and other studies, the American Society of Colon and Rectal Surgeons (ASCRS) has revised its previous recommendations of resection. The 2006 revised practice parameters now read, “The decision to recommend surgery should be influenced by the age and medical condition of the patient, the frequency and sever- ity of the attacks, and whether there are persistent symptoms after the acute episode.” (1) These new recommendations have changed the traditional perspective taken on this disease process and forces those involved in the care of patients with this disease to reevaluate the literature and possibly modify their practice. Thus today, surgeons must individualize the recommendation for operation for each patient. One must take into account the patient’s history, physical exam and diagnostic radiographic find- ings, response to medical therapy and other comorbidities before making recommendations for an operation. Progression of Disease One of the most feared complications of diverticular disease is the need for an emergent operation with possible fecal diver- sion. The increased morbidity and mortality to patients is not insignificant when an emergent operation is required. However, the need for emergent fecal diversion most commonly occurs with a first episode of diverticulitis and is very rarely associated with recurrent disease. It has been estimated that only 1 in every 2,000 pt/years of follow-up will require an emergent resection after resolution of an episode of medically treated diverticulitis. (17) A recent meta-analysis reviewing the outcomes of medi- cally versus surgically treated uncomplicated diverticulitis dem- onstrated that recurrent hospitalization was more frequent in the medically treated group than in a surgically treated one. Mortality rates for uncomplicated disease were generally low though, regardless of the treatment chosen, especially in patients less than 50 years of age. (21) In addition to the fear of an emergent operation and possible stoma, elective operation has long been recommended based on risk of recurrence. In the 1950s it was reported that morbidity and mortality were higher with recurrent attacks of acute inflam- mation and early interval resection was a means of avoiding those problems.(22–24) Recent studies have repeatedly shown that recommendations for prophylactic operation to prevent the need for an emergent operation are unfounded. In patients with uncomplicated diverticulitis, Chautems followed 118 patients after a first attack of uncomplicated diverticulitis for 9.5 years. Of these patients, 71% had no recurrent episodes and of those that did, none required emergent surgery.(25) In a population based study of over 20,000 patients admitted with nonoperatively man- aged diverticulitis only 5.5% required an emergent colectomy or colostomy. Younger patients in this study were found to be at higher risk than their older counterparts.(18) Other studies have also demonstrated that the risk of patients requiring an emergent operation from recurrent disease is much lower than previously thought. (Table 24.4) The number of patients who would benefit from prophylactic colectomy to prevent a future emergent opera- tion consistently remains <5%. A step-wise progression of diverticular disease from diverticulo- sis to uncomplicated diverticulitis followed by complicated diver- ticulitis and finally complex disease such as fistula or obstruction is not the natural progression of this disease. Patients may present at any stage of the disease ranging from asymptomatic to colovesicu- lar fistula without a history of previous attack. Janes reported that the idea that patients should undergo elective resection to avoid a colostomy is incorrect; such a concept can scare patients into “elective surgery.”(17) Prophylactic sigmoid resection based on the premise of preventing the possibility of future colostomy does not appear to be founded on evidence-based principles. Age Most studies define “young” patients as those <50 years of age. Younger patients have been thought to have more virulent dis- ease, with a higher risk for recurrence and emergent operation. Recent publications have questioned whether or not this is the case.(7, 15, 29–31) Nelson et al. observed that in 234 patients >50 years of age, with a mean follow-up of 4 years after a CT scan diagnosed episode of acute uncomplicated diverticulitis, only 10 patients (4.2%) returned with a complicated episode; of these, 5 (2.1%) required an emergent colectomy and colostomy. (29) Anaya published a review of 25,058 patients hospitalized for an initial episode of diverticulitis. Of the 20,136 patients treated 22 improved outcomes in colon and rectal surgery nonoperatively, 19% developed a recurrence, with those >50 years of age having a slightly higher recurrence rate (27% vs. 17%, p < .001). They projected that a policy of routine, elective colectomy in a younger population after an initial episode would require 13 elective operations to prevent one emergent colectomy. In this large series, 73% of young patients resolved with medical man- agement and never suffered a recurrence. Only 7% of all patients <50 ever require an emergent operation. The risk of all patients of any age requiring an emergency operation was 5.5%.(18) These recurrence rates are significantly lower than previous estimations which were >30% for younger patients. Very few patients requiring an emergent operation had been previously diagnosed with or suffered from diverticulitis. An estimated 75% to 96% of patients presenting with peritonitis and requiring an emergent operation have never been diagnosed with the disease previously. This supports the notion that operating on patients with a history of acute diverticulitis to prevent complications of acute disease is ineffective at achieving that goal.(2, 26–28) Although it seems intuitive that patients with more years to live relative to their older counterparts are at a higher risk of recurrence, there is little evidence available to suggest that younger patients have a more virulent disease process that war- rants aggressive surgical intervention. Despite the split over recurrence, most groups recommend initial conservative treat- ment. As mentioned before, risk/benefit models recommend withholding resection until after three or four recurrent doc- umented episodes. There has also been a suggestion that no surgical treatment should be offered despite the number of uncomplicated episodes.(8) Nonoperative therapy for patients with uncomplicated diver- ticulitis has been shown to be safe and effective in a majority of this population. The ASCRS practice parameter on diverticular disease also affirms that there is no clear consensus regarding whether younger patients treated for diverticulitis are at increased risk for complications or recurrent attacks.(1) Risk of Recurrence The risk of recurrence following an attack of uncomplicated diverticulitis is low. The range of recurrent episodes of diverticu- litis after one uncomplicated attack is 1.4–18%. (13, 15, 16) Janes (17) reviewed 94 papers in an effort to review the evidence for rec- ommendations put forth for elective resection after two attacks of diverticulitis. They concluded that there is inadequate evidence to suggest that complications are more likely to occur with each suc- cessive hospital admission, or that the likelihood of a successful response to medical treatment decreases (Table 24.5). Table 24.5 Natural history studies of uncomplicated diverticular disease as reviewed by Janes.(1) 1st Admit 1st Admit 2nd Admit 2nd Admit Ref Year # Pts F/U Diagnosis All Operations Emergent Operation Recurrence Emergent Operation Parks (4) 1969 455 1–16 Y BE, Path 138 Most 78 20 Larson (5) 1976 132 9 Y BE, Path 33 NR 29 9 Haglund (6) 1979 392 6 Y BE, Path 97 97 73 0 Ambrosetti (32) 1994 226 25 M CT, CE 66 NR 42 8 Ambrosetti (33) 1997 423 46 M CT, CE 112 33 27 NR Makela (34) 1998 366 10 years CE, path, Scope 101 55 57 19 Biondo (30) 2002 327 24–90 months CE, CT, Path 103 78 52 4 Table 24.4 Number of patients requiring urgent surgery who had a previous history of diverticular disease. Emergent Operation Emergent Operation Pts Who Would Have Benefited From Prophylactic Colectomy Ref Yr # pts Elective OR All Pts Pts with hx of diverticulosis Pts with a hx of diverticulitis F/U in years Alexander (26) 1983 673 13 80 37 (5.4%) 10 Nylamo (27) 1990 113 3 48 2 (1.7%) 10 Lorimer (28) 1997 154 28 126 15 (5%)* 8 Somasekar (2) 2002 108 0 104 28 (2.7%)* 5 * Patients who had been hospitalized previously with diverticulitis. 253 operative and nonoperative therapy for diverticular disease Acute Complicated Diverticulitis Outcome Measures When determining how best to treat patients presenting with acute diverticulitis two questions need to be answered. First, what category of diverticulitis is present based on history and physical examination and CT scan findings. Second, what is the feasibility and indication for operation versus medical therapy? With the advent and availability of CT scanning and its wide spread use for typical symptoms of diverticulitis we are better able to classify the disease. A patient presenting with an acute complicated episode of diverticulitis typically will have findings of abscess, phlegmon, or localized perforation on CT scan. In a recent review of patients presenting with complicated diverticulitis, 29.5% were found to have a paracolic abscess, 22.3% an acute phlegmon, 13.4% a fis- tula, 22.6% an obstruction or stricture and 44% a contained or free perforation.(35) Peritonitis, free intraabdominal air, or obstruction unrelieved by other methods is an indication for operation. Patients with signs of peritonitis or hemodynamic instability are not candi- dates for medical management and should be resuscitated and taken to the operating room. However, many patients present- ing with an abscess, localized and contained perforation, or phlegmon are candidates for conservative therapy. These indi- viduals should be evaluated for possible percutaneous drainage with radiographic guidance. Once stabilized, patients with com- plicated diverticulitis should have a complete colon evaluation and most should be scheduled for an elective operation. The American Society of Colon and Rectal Surgeons (ASCRS) have recommended that, “Elective colon resection should typically be advised if an episode of complicated diverticulitis is treated nonoperatively.”(1) However, there is a growing body of evi- dence to suggest that select patients with complicated disease may be safely managed if they respond to more conservative measures. Ambrosetti attempted a prospective trial of surgery versus observation after the 1st complicated attack of diverticulitis but abandoned the trial after 19 months as only 4 of the 52 (8%) had a recurrence.(36) Faramakis followed 120 patients from 30 centers over 5 years with complicated diverticulitis, defined as abscess, fis- tula, obstruction, or free perforation. Of these patients, 32% developed a severe complication and 10 patients died. However, many of these patients were treated nonoperatively because they were not felt to be surgical candidates and three times as many patients died from cardiovascular or pulmonary complications, compared to those who died from complications of diverticular disease.(37) One small study followed 28 patients after identification of complicated disease on CT scan. Ten patients were percutaneously drained and the rest were treated conservatively. Two patients ulti- mately required operation during their initial hospitalization and 18 patients (24%) had recurrence. They concluded that most patients could be managed without an operation or drainage. (38) However, until more evidence substantiates a clear path to follow, operative resection remains the standard for most patients presenting with complicated disease. Risk of Recurrence—Indications for surgical treatment Patients presenting with peritonitis should undergo an urgent operation after appropriate resuscitation. Patients presenting with complicated disease without peritonitis should initially be treated conservatively with IV Fluids, NPO, antibiotics, and per- cutaneous drainage of any abscess. Evaluation in a recent study identified 511 patients diagnosed with complicated diverticulitis. Of these patients, 99 were diagnosed by CT scan with abscess and 16 of these underwent percutaneous drainage. Of those patients with continued nonoperative treatment, even after percutaneous drainage, a recurrence rate of 42% was noted with an increased probability of emergent procedure. Based on these findings it was recommended that all patients with complicated findings on CT scan undergo an elective operation.(8) Salem reviewed all hospitalized patients for the state of Washington. After evaluating over 25,000 patients, percutaneous drainage and medical management were found to decrease the need for emergency operative interventions.(39) Other studies have shown that complicated disease is not a result of multiple uncomplicated episodes. Salem, et.al., demon- strated that of 77 patients followed with complicated diverticuli- tis, only eight had two or more previous episodes. A majority of patients (79.4%) with fistula, perforation, bleeding, and abscess had no previous episodes of diverticulitis. They concluded that simple acute diverticulitis is not a good predictor for the develop- ment of further complications from diverticular disease as only a minority of patients with complications had previous episodes of diverticulitis.(13) Chapmen found that only 21% of patients presenting with free perforation and peritonitis had a previous history of disease. (40) Somasekar reviewed 108 patients admitted with complicated diverticulitis. Of these, 104 required emergent surgery but only 28 patients had a previous history of uncomplicated diverticuli- tis. However, only 3 (2.7%) of these 28 patients had suffered two previous episodes and would have qualified for an operation under the standard guidelines (2) Hart performed a case con- trolled study of patients presenting with perforated diverticulitis and found that 78% had no previous history.(41) Timing for Surgical Intervention Complicated diverticulitis is at this time an indication for opera- tion. Circumstances may arise that would make continued obser- vation a wiser decision based on the age and comorbidities of the patient, but until further evidence is available operation contin- ues to be the standard of care. Pain is a valuable indicator for the patient’s recovery, and pro- vides a marker for evaluation. Attempts at initiating PO intake and switching antibiotic therapy may be confidently made based on the patient’s symptoms or lack of resolution of those symptoms. Once the patient is pain free and has undergone an adequate preoperative evaluation, surgery can be undertaken. Before any surgical procedure patients should undergo endoscopic evalua- tion of the colon in order to rule out other disease processes that may need to be taken care of at the same time. Optimal timing for performing an operation after medical treatment of a complicated 24 improved outcomes in colon and rectal surgery episode of diverticulitis has occurred and has never been studied. However, it seems prudent to offer an elective operation within 6 to 8 weeks to allow the inflammatory process to settle and pro- vide an opportunity for safest operation. Laparoscopic surgery will also be easier without the inflammatory component of the acute setting. Chronic Diverticulitis Indications for Medical versus Surgical Treatment Chronic diverticulitis is typically defined as uncomplicated acute diverticular disease that resolves with antibiotic therapy only to flare again once antibiotics are discontinued. It is not a particu- larly common entity within the spectrum of diverticular disease. Patients initially respond well to antibiotic therapy but fail to fully resolve their symptoms, or have frequent recurrences within weeks of each other. Patients may experience multiple flares of the disease that resolve spontaneously but continue to plague the patient for weeks to months. Indications for surgical treatment Chronic diverticulitis is an indication for operation. However, the correct diagnosis of recurrent or chronic diverticulitis must be secure. Chronic abdominal pain unrelated to diverticular disease has been described and an operation for pain without confirma- tory findings is doomed to failure. Barium enema may be the colon clearing test of choice in this situation as colonoscopy can be associated with an increased risk of perforation in the face of smoldering diverticular disease. Best Timing for surgical intervention Ideally, patients should be continued on their antibiotics up to the time of operation. A bowel prep should be instituted in these patients and their nutritional status be reassessed depending on the amount of time they have had a chronic smoldering infection and been unable to eat. A good starting place is to simply evaluate the amount of weight lost over the recent past. Patients may be candidates for either laparoscopic or open surgery, as both have been shown to be safe and effective in the hands of well practiced surgeons. Complex Diverticulitis Indications for surgical treatment Complex diverticulitis is defined as patients with colonic fis- tula, stricture or obstruction. Colovesicular fistulas are the most common fistula, but colosalpingo, colocutaneous, colo-colo, colovaginal, and coloenteric fistulas all have been reported as a complication of diverticular disease. Bleeding divertula is not typically associated with the inflammatory state of diverticulitis and thus falls outside the scope of this chapter. About 1–2% of patients with diverticulitis develop an internal fistula.(6) Symptoms of fistula depend on the location. Dysuria, fecaluria, and pneumaturia are the most common presenting signs for colovesicular fistula. At times, symptoms go unnoticed and a delay in diagnosis for a prolonged period of time is not uncommon. Rarely, some patients who present with complex diverticulitis have never formally been diagnosed with previous episodes of diverticulitis. This may be because the patient never sought medical attention despite having some symptoms, or the symptoms were mistaken for gastroenteritis, or other such ail- ment. Complications of diverticular disease appear to be related more to the severity of the attack at a specific location than from progression from simple to complex disease in an orderly fash- ion. This inflammatory process may range from uncomplicated to complex. Contrast enema has been described as one of the ways to diag- nose an abnormal connection between the colon and another organ. However various reports put the success rate between 34–83%.(42, 43) Vaginography or cystoscopy are two other ways to confirm the diagnosis. If suspicions are still present with rel- evant symptoms, and CT scan confirms diverticulitis, operation can be offered without confirmatory testing. Whatever the source, patients with complex diverticulitis should undergo an operation to correct the problem, unless the patient is not a surgical candidate. These patients who are not surgical candidates can be managed on suppressive antibiotics. One important concept to remember is that fistulas do not rep- resent an emergency. If the patient is appropriately draining, and does not appear to be septic, there is no emergency to the opera- tion. Complex fistulas have been managed with a single opera- tion successfully in as many as 90% of cases, both with open and laparoscopic techniques.(44–46) Obstruction from diverticular disease is quite different. Patients who present completely obstructed from diverticular disease will require urgent decompression. Depending on the stability of the patient, multiple options including resection and primary anasto- mosis with or without proximal diversion, Hartmann procedure, Turnbull colostomy, or stent placement are available for the sur- geon. These patients may carry an extensive history of diverticular disease. Ruling out other sources of obstruction, specifically colon cancer, is important. If the patient has not been screened appro- priately, one may choose to perform intraoperative colonoscopy depending on the patient’s condition and state of the bowel. If this is impossible during the operation, as is frequently the case, then follow up colonoscopy should be undertaken after the operation. IMMUNOSUPPRESSED PATIENTS Risk of developing diverticulitis Difficulty arises in attempting to diagnosis diverticulitis in an immunocompromised patient because many fail to manifest the classical signs and symptoms of the disease. Patients who are considered to be immunosuppressed include transplant recipi- ents, those with an immunodeficiency syndrome, or those taking immunosuppressive medications for arthritis, autoimmune dis- eases, or inflammatory bowel disease. Patients who are especially problematic are those that are receiving prednisone in dosages >20 mg/day. They present with fewer symptoms, have a longer time to operation, and higher mortality (85%) when compared with patients receiving lower doses (13%).(47) Thus, any patient taking higher doses of an immunosuppressive medication must be considered immunosuppressed and evaluated accordingly. These patients are much more likely to present with a free perforation than their nonimmunocompromised patients.(48–50) Correlation 255 operative and nonoperative therapy for diverticular disease between a delay of diagnosis and mortality has also been demon- strated in these patients. Transplant patients make up an ever growing population that requires immunosuppressive medication. The incidence of trans- plant diverticulitis varies by the type of transplant performed; however, all studies show a low incidence of the disease. One report reviewed 2,000 patients over a period of 30 years following renal transplants and reported a 0.5% risk of any colonic prob- lems including diverticulitis.(51) Many studies have reported an incidence of diverticulitis among both lung and heart transplant patients that varies from 0.75% to 4%. However the hospital admission rate for diverticu- litis in a “normal” population is 25–50 per 100,000 admissions (0.025–0.053%), which is much less than in a transplant popula- tion.(51–53) From 1985 to 1996, a review of six series including 986 of heart and lung transplant patients showed an incidence of 0.75%. The authors concluded that pretransplant screening of diverticulosis is not justified in the absence of symptoms.(54) Other authors have evaluated their experience with compli- cated diverticulitis in renal transplant patients. Of 1,211 patients, 13 patients had episodes of diverticular disease for a 1.1% inci- dence. They concluded that the problem is rare but the clinical presentation is atypical.(55) One of the major benefits among the transplant population was the introduction of cyclosporine because of the decreased steroid requirement. It has been demonstrated that a nearly 50% decrease in the rate of complicated diverticulitis was accomplished in patients who were treated with cyclosporine; however, this did not reach statistical significance due to small sample size.(55) Prophylactic Sigmoid Resection Most authors recommend that patients with symptomatic diver- ticulitis with appropriate confirmation undergo sigmoid resec- tion before transplant. Diverticulosis without symptoms though does not require further investigation and is not an indication for prophylactic resection. However, these patients are at a slightly higher risk than the general population and should be monitored closely.(55) Postoperative mortality is high in immunocompro- mised patients who develop acute diverticulitis requiring opera- tive intervention. An increased index of suspicion is necessary in treating immunocompromised patients. An approach incorpo- rating an aggressive evaluation with medical support and early surgical exploration is generally warranted. One specific population deserves mention and those are patients with polycystic kidney disease. These patients appear to have a higher incidence of complicated diverticulitis than other transplant patients, and one study concluded that these individu- als warrant more aggressive diagnostic evaluation for any symp- toms. Pretransplant screening and prophylactic sigmoid resection deserve further study.(55) OPERATIVE MANAGEMENT What manner of operation is best? Three operations are typically recommended for patients requir- ing a sigmoid resection. Open sigmoid resection, laparoscopic sigmoid resection, or hand assisted laparoscopic resection (HAL). Despite the recent eruption of literature and discussion about the benefits of laparoscopic colectomies, only 5–10% of all colecto- mies are currently performed using a laparoscopic technique.(56) However, with increased training and utilization, it is anticipated that this number will continue to increase substantially. Open colectomy is the gold standard for comparison. Laparoscopic colectomy has gained increased prominence fol- lowing the successful application of this technique for other pro- cedures. While it is still in its infancy, it is fast becoming the main choice for a growing number of patients and surgeons. Many large studies have been undertaken to assess the safety of laparo- scopic colectomy as well as its economic feasibility. Reported benefits of laparoscopic colectomy include shorter hospital stay, less postoperative pain, earlier return of bowel func- tion, and quicker return to daily activities. Other reported benefits include less wound, respiratory, gastrointestinal, and cardiopul- monary complications when compared to open surgery.(57–60) The downsides of laparoscopic surgery include surgeon specific initial higher complication rates and conversion rates associated with a steep learning curve, longer operating room time, and higher cost for operations.(58) However, a recent study looking directly at total cost for open sigmoid resection versus laparo- scopic sigmoid resection by Senagore (59), revealed that overall total costs were significantly lower for laparoscopic patients, and that operating room costs were not different between the two types of surgery. They concluded that laparoscopic resection was a cost effective means of managing sigmoid diverticular disease. A key factor to keeping the costs equivalent between open and laparoscopic resection was the minimization of conversion and complication rates. A conversion rate of 6.6% was observed in this study. However, many factors go into a study like this including rou- tine postoperative care, and surgeon and patient comfort levels with earlier discharge. Despite this, slow but steady progress in training of younger surgeons and greater familiarity with the new techniques will more than likely make laparoscopic surgery the standard of care in the future, much as laparoscopic cholecystec- tomy has become. Hand Assisted Laparoscopic (HAL) Colectomy has also been compared against laparoscopic resection and been found to be equivalent as far as outcome of patients.(56, 61) Benefits of HAL have been shorter operating times when compared with straight laparoscopic surgery as well as lower conversion rates. One recent study identified an advantage to using HAL colectomy with com- plicated diverticulitis and laparoscopic resection for uncompli- cated diverticulitis.(56) The cost of utilizing a hand port was not significantly different when offset by the faster operating room time.(61) Much depends on the ability of the surgeon to complete the case without conversion. Conversion rates increase the total cost of the operation as well as the potential morbidity rates for the patient. In an article by Belizon (60) an analysis was made of patients undergoing conversion to an open operation. Postoperative mor- bidity was significantly higher for laparoscopic resection pro- cedures that were converted to open after 30 minutes into the 2 improved outcomes in colon and rectal surgery operation. Wound complications and greater length of stay in the hospital were the two most common findings. Obesity, adhesions, bleeding, and inflammation beyond area of operation were the most common predictors for conversion. The best operation for an individual seems to be the opera- tion the surgeon can perform. However, with advancing mini- mally invasive techniques that can be implemented at a similar cost structure, it behooves all surgeons to continue to educate and modify their practices to provide the best care possible to their patients. Which Operation is Best? Three different operations have been proposed for the treatment of complicated diverticulitis with peritonitis. The first operative approach described was the three stage procedure encompass- ing drainage with stoma, followed by resection and anastomosis with continued diversion, and finally by restoration of continu- ity. The second approach involved resection and diversion or the traditional Hartmann procedure (HP). However, this approach is being challenged by the third approach of resection with primary anastomosis. Primary resection with anastomosis (PRA) can be performed with or without a covering stoma, and/or on-table lavage. The three stage procedure will not be discussed here as it is not considered standard of care and should be used only in very infrequent situations. In 1921, Hartman advocated his two stage resection which was superior and quickly became the standard of care. However early in the 1960s there were eight reports with a total of 50 patients that underwent resection and primary anastomosis for general- ized peritonitis with a low mortality of 10%.(63) Not much debate is raised now with respect to patients presenting with recurrent or chronic diverticulitis. They are typically managed in an elective fashion with primary anastomosis. Patients are still traditionally given a bowel preparation before surgery, at least in the United States, and probably will for some time though there is a growing swell within the literature questioning its necessity. Patients who present with acute symptoms, typically Hinchey stages III or IV, are taken to the operating room urgently. These patients constitute approximately 3.2 per 100,000 patients.(63) These patients present a dilemma, because typically they are older, have a high number of comorbidities, and suffer a greater number of complications. In a recent review by Salem reviewing 98 articles on the outcome of complicated diverticulitis based on the type of operation performed, they identified 1,051 patients who underwent a Hartmann procedure from 54 studies, and 569 patients having undergone a primary anastomosis from 50 studies. (Tables 24.6 and 24.7) Of the patients undergoing a pri- mary anastomosis, 16% had covering stomas and 10% had on- table lavage. The mortality rates of those in the Hartmann group (19.6%) were much higher than those undergoing a primary anastomosis (9.9%). The anastomotic leak rate in patients with a primary anastomosis ranged from 6.3% to 19.3%. If a diverting proximal stoma was performed at the time of a primary anas- tomosis the anastomotic dehiscence rate fall to 6.3%. Wound infections were also more frequently seen in the Hartman group (24.2%) versus the primary anastomosis group (9.6%). Again, patients with covering stomas had the lowest wound infection rate at 4%. Patients undergoing a Hartmann procedure also required a larger second operation than those who had PRA with or with- out a covering stoma. Complications from a Hartmann reversal were associated with a mortality of 0.8%, a wound infection rate of 4.9% and an anastomotic leak rate of 4.3%. These patients also experienced stoma complications (10.3%) that required medi- cal attention. The conclusion was the primary anastomosis is no worse than a Hartmann procedure and has several advantages including higher restoration of continuity rate, less hospitaliza- tion, and fewer infectious complications.(64) Multiple studies have evaluated the morbidity and mortality of the Hartmann procedure as well as the risks incumbent with takedown. Most seasoned surgeons realize that at times restoration of continu- ity can be more of a challenge to both patient and surgeon than the original operation. This was demonstrated in a recent multicenter prospective trial involving 415 patients with complicated diverticuli- tis. Two hundred forty-eight patients underwent resection with pri- mary anastomosis. The other 167 had a Hartmann procedure. The mortality rate for those undergoing primary anastomosis was 4.0% while those with resection and diverting colostomy was 23.4%. After case adjustment, the data suggested that the Hartmann procedure was associated with a 1.8 fold increase in likelihood of death. This was not statistically significant. However a 2.1 fold increase in morbidity was found between the two groups and this was significant. In part this is due to the fact that surgeons typically reserved a Hartmann procedure for those older patients with more comorbidities and thus predisposed to a poorer outcome.(65) Risks associated with Hartmann Reversal Reversal of a Hartmann colostomy also carries with it a signifi- cant risk that must be entertained when considering this opera- tion for patients who will desire continuity in the future. Failure Table 24.7 Outcomes of Hartmann and Hartmann Reversal. Salem et al. (61) # of Patients Mortality Wound Infection Stoma Complications Leaks Hartmann 1,051 198 (18.8%) 70 (24.2%) 12 (10.3%) NA Hartman Reversal 787 6 (0.8%) 7 (4.9%) NA 20 (4.3%) Table 24.6 Outcomes of primary anastomosis in patients with complicated diverticulitis—Salem et al.(61) Primary Primary Primary Primary with Anastomosis Anastomosis Anastomosis Anastomosis Overall Alone with Stoma lavage Mortality 9.9% 8.1% 9.2% 9.6% # of Studies 48 29 17 3 # of Cases 548 297 109 52 Anastomotic Leak 13.9% 19.3% 6.3% 9.6% # of Studies 29 14 8 3 # of Cases 353 145 64 52 Wound Infection 9.6% 16.4% 4% 12% # of Studies 17 6 3 2 # of Cases 219 55 25 50 257 operative and nonoperative therapy for diverticular disease to reverse the colostomy has been reported in 20–50% (61) of patients and leak rates on reversal fall around 2–30% (61, 63) Mortality has been reported anywhere from 0–10% and wound infection rates range from 12–50%. A strong interest in primary anastomosis has been revived in the literature, with papers describing the successful outcomes of patients undergoing this type of operation. However, few papers are prospective, less are randomized, and such a trial is still needed today to definitively answer the questions of safety and efficacy. Multiple trials though have shown that the outcomes of primary anastomosis are indeed as safe as a Hartman and in many cases better. In a recent review, Constantinides et al. reviewed the out- comes of patients undergoing Hartmann (66), primary resection with anastomosis (PRA) (135 patients) and primary resection with anastomosis and diversion (126 patients). Patients under- going a Hartmann procedure had a morbidity and mortality of 35% and 20% respectively. Primary anastomosis showed a slightly higher morbidity and mortality at 55% and 30%, while those with a primary anastomosis with diverting stoma demon- strated a morbidity and mortality rate of 40% and 25% respec- tively. Stomas were permanent in 27% of patients undergoing a Hartmann procedure and 8% of those having a primary anasto- mosis with diversion. They concluded that primary anastomosis with defunctioning stoma may be an optimal strategy for selected patients. Hartmann procedure should be reserved for patients with an extremely high risk of perioperative complications and only after consideration of long-term implications.(63) Patients undergoing on-table lavage have been analyzed as well, which showed similar outcomes to those who did not undergo on-table lavage. Regenet, described 60 patients, all Hinchey III or greater, in whom 27 underwent primary anastomosis with intra- operative lavage and 33 who had a Hartmann procedure. In this prospective observational study they found that the Hartmann procedure took much less time to perform, but that the mortal- ity and morbidity for both groups were equal. Three patients in the intraoperative lavage group had an anastomotic leak (11%). A Hartmann reversal occurred in 69% of the patients. The rever- sal had its own associated morbidity of 24%, an anastomotic leak rate of 7%, and no deaths. Postoperative stay after primary anas- tomosis and intraoperative lavage was 18.4 days and Hartmann Procedure was 38 days. They concluded that primary anasto- mosis with intraoperative lavage and a Hartmann Procedure are both adequate approaches for generalized peritonitis complicat- ing diverticulitis.(17) Covering stomas have been recommended by most studies when primary anastomosis is performed because of the variable anastomotic leak rate. Both diverting colostomies and ileostomies have been described with equal success. Most of the poor out- comes noted are not necessarily due to the operation performed, but the comorbidities and peritonitis associated with the patient and disease. These risks play more into the outcome of patients than the type of operation performed. Complications of Operation Predictors of Morbidity and Mortality—Scoring Systems Multiple scoring systems have been evaluated in attempts to pre- dict outcome and risk in patients undergoing both elective and emergent colon resection for diverticulitis. With an increasing interest in outcomes by doctors, patients, and payers, predictive scoring systems may be one of the many ways surgeons, hospitals, and systems are evaluated. Developed by Copeland in 1991, the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) was developed as a tool to compare mor- bidity and mortality in a wide range of general surgical proce- dures. This was to facilitate surgical audit and the comparison of hospital performance. It has been further adapted for patients undergoing colon and rectal surgery and named cr-POSSUM (Table 24.8). The idea was to adjust risk of a surgical procedure based on the patient’s physiological condition and therefore allow a more accurate comparison of a unit (or individual’s) performance. Oomen has been one of the physiological and operative sever- ity score (POSSUM) score’s biggest proponents and has done a number of studies attempting to validate the system. When Table 24.8 The cr-POSSUM scoring system. Physiologic Parameters Age <61 62–70 >71 Cardiac No Failure Treatment for angina or HTN Edema, cardiomyopathy, coumadin Cardiomegaly, Raised JVD Systolic BP 110–130 131–170 >170 <90 Pulse 50–80 80–100 100–120 <50 Hgb 13–16 11.5–12.9 10–11.4 <10 or >18 Urea 7.6–10 10.1–15 >15 Operative Parameters Type of Operation Minor Moderate Major Complex Major Peritoneal Contamination None Cloudy Pus Fecal Malignancy Status None, T1–2 T 3,4 Mal + Nodes Mal + Mets Timing of OR Elective Urgent Emergent < 2 hours . after 30 minutes into the 2 improved outcomes in colon and rectal surgery operation. Wound complications and greater length of stay in the hospital were the two most common findings. Obesity,. scoring systems have been evaluated in attempts to pre- dict outcome and risk in patients undergoing both elective and emergent colon resection for diverticulitis. With an increasing interest in. operation contin- ues to be the standard of care. Pain is a valuable indicator for the patient’s recovery, and pro- vides a marker for evaluation. Attempts at initiating PO intake and switching antibiotic