Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis

Laparoscopic colectomy for complex diverticular disease: a justifiable choice?

BACKGROUND

Surgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease.

METHODS

Consecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated.

RESULTS

A total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; p = 0.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; p < 0.0001) and surgical (28 vs. 14%; p = 0.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; p = 0.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1 day.

CONCLUSIONS

The laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.

Current indications and role of surgery in the management of sigmoid diverticulitis

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

Ergonomics and Technical Aspects of Minimal Access Surgery in Acute Surgery

BACKGROUND

Following the general trend in the evolution of minimal access surgery (MAS), the place of laparoscopy for diagnostic and therapeutic procedures in the emergency setting is well defined. As for all laparoscopic procedures, the ergonomic and technical aspects of MAS in acute surgery are important issues.

METHODS

Review of the literature.

RESULTS

The ergonomic and technical aspects of emergency laparoscopy include the surgeon's and the patient's position; the operating room setup, including the table, the monitor, and the specific equipment; patient preparation adapted as required to potential changes necessary as adapted to the pathology and conversion; the trocar setup, also adapted to the organ and pathology. Specific needs and variations can be necessary, dependent on the patient status, body build, and the pathology being treated. The operating room used for acute surgery should be adapted to evolving laparoscopic techniques, as well as new intraoperative diagnostic and therapeutic modalities.

CONCLUSION

High-tech equipment and associated procedures have modified the needs for a modern operating room setup. Laparoscopic procedures for emergency surgery must make use of well-known ergonomic principles and be adapted to the patient and the pathology.

Laparoscopic right hemicolectomy for ileocolic intussusception secondary to caecal neoplasm

Intussusception in adults is a rare cause of abdominal pain. Unlike its paediatric counterpart, intussusception in adults is associated with obvious pathology. We describe a case of ileocolic intussusception extending to the splenic flexure. We were able to reduce the intussusception partially and pedicle was stapled carefully. The specimen was delivered through a small incision and right hemicolectomy was performed adhering to oncological principles. We recommend laparoscopic-assisted surgery is considered for adult intussusceptions.

Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis

OBJECTIVE

Despite the high prevalence of hospitalization for left iliac fossa tenderness, there is a striking lack of randomized data available to guide therapy. The authors hypothesize that an oral antibiotic and fluids are not inferior to intravenous (IV) antibiotics and 'bowel rest' in clinically diagnosed acute uncomplicated diverticulitis.

METHOD

A randomized controlled trial was constructed in two District General Hospitals. All clinically diagnosed patients presenting with acute uncomplicated diverticulitis were eligible for the study. Oral and IV regimens utilizing ciprofloxacin and metronidazole were compared. The primary outcomes studied were surrogates for resolution of symptoms (including tenderness on day 3 and length of stay) and failure of oral therapy. Secondary endpoints studied were serial constitutional and biomarker trends.

RESULTS

There were 41 patients in the oral arm and 38 in the IV arm (n = 79). No patient had to be converted to IV antibiotics from the oral group. There was a complete resolution of symptoms in both groups. Tenderness was equivalent in both groups on day 3. Among secondary endpoints, a serial decrease in C reactive protein was the best serological predictor of resolution for both groups.

CONCLUSION

Oral antibiotics are not inferior to intravenous antibiotics in achieving resolution of clinically diagnosed diverticulitis.

Left sided diverticulitis presenting as a right lumbar fistula: a case report

The formation of fistulae is a recognised complication of diverticulitis. This case report describes sigmoid diverticulitis presenting as a right psoas abscess with a colocutaneous fistula. The report highlights the role of appropriate imaging and a high index of suspicion in anyone presenting with a discharging lumbar abscess, especially when the focus of infection may be from a contra-lateral source.

Emergency management of diverticulitis

The most common indications for emergency operative intervention in the treatment of sigmoid diverticulitis are peritonitis and failure of medical therapy. Primary resection and diversion (Hartmann's procedure) followed by delayed colostomy closure is the current standard of emergency surgical care. Guidelines for best operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. Primary resection and anastomosis with or without proximal diversion and laparoscopic lavage are alternatives to Hartmann's procedure that may provide an improved outcome in properly selected patients. Ongoing changes in the historical paradigm of the surgical approach to this disease mandate the need for large multicentered prospective randomized trials to determine the best surgical strategy under emergent conditions for the treatment of diverticulitis. The current literature is reviewed with suggestions for a management algorithm.

[Conservative laparoscopic treatment of diverticular peritonitis]

GOAL

To evaluate the results of a strategy of conservative laparoscopic treatment of peritonitis due to perforated diverticulitis for all patients, without exception for intraoperative findings or general patient condition, and to study the feasibility of eventual second-stage laparoscopic colectomy.

MATERIALS AND METHODS

Between January 2003 and May 2007, 25 consecutive patients were urgently hospitalized with acute peritonitis due to perforated diverticulitis. All patients underwent laparoscopic peritoneal lavage and debridement; when there was a large perforation (ten cases), suture closure under laparoscopic control was performed. The Hinchey classification of peritonitis was Stage I in 2, Stage IIB in 8, Stage III in 9, and Stage IV in 6.

RESULTS

Postoperative morbidity occurred in 12% of cases. Mean operative time was 71 minutes. Conversion to open laparotomy was not required. Complications included residual abscess (drained percutaneously with CT guidance), urinary tract infection, and prolonged drainage via the drain tract. Mortality was zero. Mean hospital stay was 13.8 days. Sixteen patients (64%) subsequently underwent laparoscopic colectomy as a second stage procedure.

CONCLUSION

Conservative laparoscopic treatment of acute peritonitis due to perforated diverticulitis is a reliable alternative to open laparotomy in many cases; eventual laparoscopic colectomy at a subsequent stage is possible in the majority of patients.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?

OBJECTIVE

Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis.

METHOD

All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal.

RESULTS

Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037).

CONCLUSIONS

Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Acute complicated diverticulitis managed by laparoscopic lavage

PURPOSE

The classic surgical treatment of acute complicated sigmoid diverticulitis with peritonitis is often a two-stage operation with colon resection and a temporary stoma. This approach is associated with high mortality and morbidity and the reversal of the stoma is in many cases not performed because of concurrent diseases and age. Recently, several studies have experimented with laparoscopic lavage as a treatment of acute complicated diverticulitis. The aim of this review was to give an overview of the literature for this new approach and to determine the safety compared with Hartmann's procedure for patients with acute complicated sigmoid diverticulitis.

METHODS

A PubMed search was performed for publications between 1990 and May 2008. The terms acute, perforated, diverticulitis, lavage, drainage, and laparoscopy were used in combination. The EMBASE and Cochrane databases were also searched.

RESULTS

Eight studies met the inclusion criteria and reported 213 patients with acute complicated diverticulitis managed by laparoscopic lavage. None of these studies were randomized. The patients' mean age was 59 years and most patients had Hinchey Grade 3 disease. All patients were treated with antibiotics and laparoscopic lavage. Conversion to laparotomy was made in six (3%) patients and the mean hospital stay was nine days. Ten percent of the patients had complications. During the mean follow-up of 38 months, 38% of the patients underwent elective sigmoid resection with primary anastomosis.

CONCLUSION

Primary laparoscopic lavage for complicated diverticulitis may be a promising alternative to more radical surgery in selected patients. Larger studies have to be made before clinical recommendations can be given.

Benefits of laparoscopic peritoneal lavage for complicated sigmoid diverticulitis

BACKGROUND

The traditional therapy for perforated sigmoid diverticulitis with peritonitis is emergency colectomy usually with colostomy. We report laparoscopic exploration with peritoneal lavage as an alternative in seven patients who required emergency surgery for diverticulitis.

METHODS

Six patients presented with diffuse peritonitis and one with a failure of percutaneous therapy. All patients were explored laparoscopically and the peritoneal cavity was lavaged with saline in addition to receiving intravenous antibiotics. Patient demographics, clinical response, length of stay, and complications were recorded.

RESULTS

Six patients had resolution of peritonitis resolved and patients were discharged from the hospital. One of these patients who developed a pelvic abscess required a percutaneous drainage postoperatively. This patient ultimately returned 3 months later with recurrent symptoms and underwent colectomy with primary anastomosis. One patient failed to improve initially and underwent colectomy with primary anastomosis on the same admission. Five patients subsequently had elective sigmoid resections, four laparoscopic and one open. Mean length of stay was 7.7 days. There was no mortality.

CONCLUSION

We conclude that laparoscopic exploration and peritoneal lavage can be performed safely in patients with diffuse, purulent peritonitis. Using this approach, most patients with purulent peritonitis can avoid emergent laparotomy with the risk of colostomy, and the need for a second surgery.

Treatment of left-sided colonic emergencies: a comparison of US, UK and Australian surgeons

BACKGROUND

This study sought to identify and compare the current practice of surgeons in Australia, the UK and the US when presented with a left-sided colonic emergency.

METHODS

Questionnaires were posted to 500 US, 500 UK and 500 Australian surgeons. Demographic data were collected regarding the surgeon's age and surgical interest, as well as their preferred method of managing left-sided colonic emergencies (namely obstruction and perforation in stable and unstable patients). The results were analysed using the chi-squared test.

RESULTS

Completed questionnaires were received from 224 UK surgeons (45%), 180 US surgeons (36%) and 259 Australian surgeons (52%). All the US surgeons had an interest in gastrointestinal surgery, while 31% of the UK surgeons and 22% of Australian surgeons had an interest in colorectal surgery. In a haemodynamically stable patient with a good anaesthetic risk presenting with a complete sigmoid obstruction, significantly more UK (84%) and Australian surgeons (70%) would perform a resection and anastomosis than US surgeons (54%, p<0.0001). Of those with a colorectal interest, 97% of UK surgeons and 80% of Australian surgeons would opt for resection and anastomosis. In a haemodynamically stable patient with a good anaesthetic risk with a perforation of the sigmoid colon and purulent peritonitis, 46% of UK surgeons, 32% of Australian surgeons and 33% of US surgeons would opt for resection and anastomosis, and among colorectal surgeons, 68% of UK surgeons and 50% of Australian surgeons would opt for resection and anastomosis.

CONCLUSIONS

The management of left-sided colonic emergencies varies depending on geographic location and degree of colorectal subspecialization. While the literature suggests that single-stage procedures are accepted and safe, the reasons for this variation are explored.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age <or= 50 years). Much of the older literature suggests that young patients experience a more virulent course with diverticulitis. Previous studies have shown misclassification and selection bias. As a result leading to a bias for more severe cases to be recognized mild cases may not be included. Young patients appear more likely to undergo operations to resolve an uncertain diagnosis. Recent studies have raised doubts about a virulent course with diverticulitis suggesting that recurrence may be associated with disease severity on CT scan, and supporting a conservative approach to diverticular disease. The diagnosis of diverticulitis is often delayed in younger patients because it is not considered, resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated. There is a lack of evidence to support the hypothesis that elective surgery should follow a single attack of diverticulitis. Any increased risk appears be a chronologic rather than pathologic phenomenon. Most patients will not have further episodes of diverticulitis.

Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study

PURPOSE

This study was designed to compare postoperative outcomes of laparoscopic peritoneal lavage and open primary anastomosis with defunctioning stoma in the management of Hinchey 3 diverticulitis.

METHODS

From 1994 to 2006, 35 patients underwent laparoscopic peritoneal lavage for Hinchey 3 diverticulitis in three institutions. Data prospectively collected were compared with those of a retrospective series of 24 patients matched for Hinchey's classification and who underwent primary anastomosis with defunctioning stoma.

RESULTS

There was no postoperative death. Postoperative morbidity was not different between the two groups. One patient in the laparoscopic peritoneal lavage group required a Hartmann's procedure because of a colonic fistula. One patient in the primary anastomosis with defunctioning stoma group underwent a reoperation for incisional dehiscence. The median hospital stay was lower in patients treated by laparoscopic peritoneal lavage (8 vs. 17 days, P < 0.0001). Twenty-five patients in the laparoscopic peritoneal lavage group underwent elective laparoscopic resection. One of them required conversion to laparotomy. All patients in the primary anastomosis with defunctioning stoma group have had their ileostomy closed. Cumulative surgical morbidity (16 vs. 37.5 percent, P = 0.0507) and hospital stay (14 vs. 23 days, P < 0.0001) were lower in the laparoscopic peritoneal lavage group.

CONCLUSION

In the management of Hinchey 3 diverticulitis, laparoscopic peritoneal lavage does not result in excess morbidity or mortality, it reduces the length of hospital stay and avoids a stoma in most patients, and it is, therefore, a reasonable alternative to primary anastomosis with defunctioning stoma.

Laparoscopic Hartmann's procedure: a viable option for treatment of acutely perforated diverticultis

BACKGROUND

A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann's procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy.

METHODS

A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann's procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated.

RESULTS

Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann's takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis.

CONCLUSIONS

Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

Trauma and the acute care surgery model--should it embrace or replace general surgery?

The specialties dealing with emergency medicine and emergency surgery are in need for a new roadmap. While the medical and surgical management of emergency conditions very often go hand-in-hand, issues relating to emergency and trauma surgery have particular concerns, which are global in magnitude. Obviously, choosing a career dealing (solely) with emergencies and trauma is associated with concerns related to lifestyle issues and, for surgeons, maintenance of adequate operative experience with the increased non-operative management. Also, dealing with patients' whose outcome may be dismal with high associated morbidity and mortality is often not viewed as rewarding. The global flux of medical students away from general surgical training and trauma surgery in particular is an example of how recruitment to specialties dealing with uncomfortable, unpredictable, and "out-of-office-hours" work may be in dire straits. How surgeons around the world will deal with this challenge will likely be diverse and tailored according to the needs of any given region, be it North America, Europe, or Scandinavia. However, refurnishing the training in General Surgery in order to ensure proper care for acute surgical illness and trauma appears mandated in order to keep in line with the centennial words of Halstead that "every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise".

Elective resection for diverticular disease: an evidence-based review

Controversy exists as to the most appropriate management of patients following two episodes of diverticulitis. Despite a growing body of new evidence challenging the concept of elective sigmoid resection after a patient experiences two attacks of diverticulitis, we continue to base our practice on outdated studies carried out more than 30 years ago. The recommendation that patients undergo elective sigmoid resection after two attacks of acute diverticulitis should be re-evaluated as it is generally inappropriate and is not cost effective. Elective resection for uncomplicated diverticulitis does not alter outcome, nor does it decrease mortality or prevent complications of the disease. In fact, based on current literature, 18 patients would have to undergo elective operation to prevent one emergency surgery. This article aims to review the current evidence for elective resection following episodes of diverticular disease and addresses emerging controversies in the management of this disease.

[Pylephlebitis in the course of diverticulitis]

Pylephlebitis or septic portal thrombophlebitis is a rare but serious condition which may occur following intra-abdominal sepsis from any source. Sigmoid diverticulitis is one of the most common sources. Modern imaging modalities, particularly CT, have increased the recognition of this condition. Standard treatment consists of anticoagulation plus antibiotic therapy to cover anaerobic and gram negative organisms. The duration of anticoagulation therapy remains controversial. Sigmoid colectomy may be required in cases of perforated diverticulitis or failure of medical therapy.

Incidence of perforated diverticulitis and risk factors for death in a UK population

Background

Perforated diverticulitis (PD) remains a serious acute abdominal condition. The aims of this study were to measure its incidence in a large UK population and to identify factors affecting outcomes.

Methods

Computerized searches of hospital coding databases for PD were performed in five hospitals in East Anglia, UK. Data were collected from hospital records over 5 years (1995–2000). Incidence was calculated using population data, and factors associated with mortality and morbidity were identified using univariable and multivariable testing.

Results

Some 202 patients with PD were identified, of whom 93·1 per cent underwent surgery and 24·3 per cent died. The age-adjusted adult incidence of perforation was 3·5 per 100 000 per annum, with a standardized female to male ratio of 1·3 (95 per cent confidence interval (c.i.) 1·1 to 1·5) to 1. Risk factors for death were increased age (odds ratio (OR) 3·5 (95 per cent c.i. 1·9 to 6·1)), pre-existing renal disease (OR 18·7 (1·6 to 211·4)) and pre-existing use of non-steroidal anti-inflammatory drugs (NSAIDs) (OR 3·1 (1·3 to 7·3)).

Conclusion

PD is uncommon, with the highest incidence in women over 65 years old. Mortality rates are high, particularly in those taking NSAIDs or with pre-existing renal impairment.