Acute laparoscopic intervention for diverticular disease (AIDD): a feasible approach

Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial)

OBJECTIVE

The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints.

SUMMARY OF BACKGROUND DATA

The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up.

METHODS

From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome.

RESULTS

At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients.

CONCLUSION

Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.

The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis

BACKGROUND

Nowadays sigmoidectomy is recommended as "gold standard" treatment for generalized purulent or faecal peritonitis from sigmoid perforated diverticulitis. This systematic review and meta-analysis aimed to assess effectiveness and safety of laparoscopic access versus open sigmoidectomy in acute setting.

METHODS

A systematic literature search was performed for randomized controlled trials (RCTs) and non-RCTs published in PubMed, SCOPUS and Web of Science.

RESULTS

The search yielded four non-RCTs encompassing 436 patients undergoing either laparoscopic (181 patients, 41.51%) versus open sigmoid resection (255 patients, 58.49%). All studies reported ASA scores, but only four studies reported other severity scoring systems (Mannheim Peritonitis Index, P-POSSUM). Level of surgical expertise was reported in only one study. Laparoscopy improves slightly the rates of overall post-operative complications and post-operative hospital stay, respectively (RR 0.62, 95% CI 0.49 to 0.80 and MD -6.53, 95% CI -16.05 to 2.99). Laparoscopy did not seem to improve the other clinical outcomes: rate of Hartmann's vs anastomosis, operating time, reoperation rate and postoperative 30-day mortality.

CONCLUSION

In this review four prospective studies were included, over 20 + year period, including overall 400 + patients. This meta-analysis revealed significant advantages associated with a laparoscopic over open approach to emergency sigmoidectomy in acute diverticulitis in terms of postoperative complication rates, although no differences were found in other outcomes. The lack of hemodynamic data and reasons for operative approach hamper interpretation of the data suggesting that patients undergoing open surgery were sicker and these results must be considered with extreme caution and this hypothesis requires confirmation by future prospective randomised controlled trials.

Appendiceal diverticulitis shortly after a performed laparoscopic sigma resection

Diverticulosis of the vermiform appendix is rare and usually asymptomatic or associated with mild, chronic or intermittent abdominal pain. A 52-year-old patient was admitted to our department due to lower abdominal pain. Assuming the second episode of diverticulitis of the sigmoid, a computed tomography (CT) was performed, and complicated sigmoid diverticulitis and an accentuated appendix without inflammatory signs were diagnosed. Laparoscopic sigmoid resection was performed with an intraoperative macroscopic inconspicuous appendix. Two months later, right-sided abdominal pain returned. CT scan showed increasing signs of thickened appendix. Because of a gallbladder polyp, a combined laparoscopic appendectomy and cholecystectomy with one additional laparoscopic access was performed. Pathology detected a small diverticulum of the appendix and a small tubular adenoma with low-grade intraepithelial neoplasia in the gallbladder. Although diverticulitis of the appendix is very rare, it should be considered in patients with right lower abdominal pain, and appendectomy should be performed even in macroscopic unsuspicious cases.

Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease

AIM

Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA).

METHODS

This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors.

RESULTS

The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04).

CONCLUSION

Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study

BACKGROUND

We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission.

METHODS

Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality.

RESULTS

From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs. 32.6%; P = .02), time to oral intake shorter (3 vs. 6 days; P < .01), and LOS shorter (5 vs. 8 days; P = .05) for LCR.

CONCLUSIONS

In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Laparoscopic emergency surgery for diverticular disease that failed medical treatment: a valuable option? Results of a retrospective comparative cohort study

BACKGROUND

Laparoscopic surgery has become the standard of treatment for elective management of diverticular disease. However, its use in the acute setting remains controversial.

OBJECTIVE

The aim of this study is to compare the outcomes of laparoscopic surgery with open surgery in the acute management of complicated diverticular disease that failed initial medical treatment.

SETTINGS

This is a single-center comparative retrospective cohort study.

PATIENTS

Patients undergoing surgery for complicated diverticular disease after an attempt at medical treatment from 2000 to 2011 were selected.

INTERVENTION

Laparoscopic versus open surgery was compared.

OUTCOME MEASURES

The primary outcomes were overall 30-day morbidity and mortality. Secondary outcomes were length of stay, time to resume diet, and need for a permanent stoma.

RESULTS

Forty-two patients were identified by using medical records: 24 laparoscopic surgery and 18 open surgery. Baseline demographics, ASA classification, Acute Physiology and Chronic Health Evaluation scores, Hinchey classification, and Charlson Comorbidity Index did not differ between groups. The mean operative time was 36 minutes longer (p = 0.05) and blood loss was 460 mL less (p < 0.001) for laparoscopic surgery. Two patients (8.3%) in the laparoscopic surgery group required conversion to open surgery. There was no mortality. Overall morbidity was lower favoring laparoscopic surgery (16.7% vs 55.6%; p = 0.01). Two patients in the laparoscopic surgery group experienced an anastomotic leak compared with none in the open surgery group. Mean time to resume diet (3 vs 6.5 days; p < 0.01) and length of stay (5 vs 8 days; p = 0.04) were shorter for the laparoscopic surgery group. Rate of permanent stoma at last follow-up (median, 332 days) did not differ significantly between groups.

LIMITATIONS

This study is limited by selection bias.

CONCLUSIONS

Compared with open surgery, laparoscopic surgery for patients in whom medical treatment for complicated diverticular disease failed is associated with favorable outcomes, including a reduced rate of morbidity and a shorter length of stay. When applied to selected patients, this approach appears to be a safe procedure with a low rate of conversion.

Systematic review of emergency laparoscopic colorectal resection

BACKGROUND

Laparoscopic surgery (LS) has become standard practice for a range of elective general surgical operations. Its role in emergency general surgery is gaining momentum. This study aimed to assess the outcomes of LS compared with open surgery (OS) for colorectal resections in the emergency setting.

METHODS

A systematic review was performed of studies reporting outcomes of laparoscopic colorectal resections in the acute or emergency setting in patients aged over 18 years, between January 1966 and January 2013.

RESULTS

Twenty-two studies were included, providing outcomes for 5557 patients: 932 laparoscopic and 4625 open emergency resections. Median (range) operating time was 184 (63-444) min for LS versus 148 (61-231) min for OS. Median (range) length of stay was 10 (3-23) and 15 (6-33) days in the LS and OS groups respectively. The overall median (range) complication rate was 27.8 (0-33.3) and 48.3 (9-72) per cent respectively. There were insufficient data to detect differences in reoperation and readmission rates.

CONCLUSION

Emergency laparoscopic colorectal resection, where technically feasible, has better short-term outcomes than open resection.

Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome

BACKGROUND

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

METHODS

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

RESULTS

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

CONCLUSIONS

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Peritonitis from perforated peptic ulcer and immune response

BACKGROUND

Elevated intra-abdominal pressure during the laparoscopy may promote bacteremia, endotoxemia, and systemic inflammatory response. In patients with generalized peritonitis from perforated peptic ulcer (PPU), we sought to compare acute phase response, immunologic status, and bacterial translocation from laparoscopic and open approach.

STUDY DESIGN

From July 2005 to September 2011, 115 consecutive patients underwent peptic ulcer repair for PPU: 58 cases laparoscopic peptic ulcer repair (LR) and 57 cases open peptic ulcer repair (OR). Bacteremia, endotoxemia, white blood cells population, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-1 and 6 (IL-1 and IL-6), and C-reactive protein (CRP) were investigated.

RESULTS

Patients characteristics and grade of peritoneal contamination were similar in the two groups. One hour after intervention, bacteremia was significantly higher in the "open" group than in the laparoscopic group (p < .001). A significantly higher concentration of systemic endotoxin was detected intraoperatively in the "open" group of patients in comparison to the laparoscopic group (p < .0001). Laparotomy caused a significant increase in neutrophil concentration, neutrophil-elastase, IL-1 and IL-6, CRP, and decrease of HLA-DR. We recorded six cases (10.3%) of intra-abdominal abscess in the "open" group and one (1.7%) in laparoscopic group (p < .001).

CONCLUSIONS

OR, in case of peritonitis after PPU, increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with LR. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense after laparotomy (decrease of HLA-DR), leading to enhanced sepsis in these patients.

Surgical treatment of acute recurrent diverticulitis: early elective or late elective surgery. An analysis of 237 patients

BACKGROUND

The optimal timing of elective surgery in diverticulitis remains unclear. We attempted to investigate early elective versus late elective laparoscopic surgery in acute recurrent diverticulitis in a retrospective study.

METHOD

Data of patients undergoing elective laparoscopic surgery for diverticulitis were retrospectively gathered, including Hinchey stages I-II a/b. the primary endpoint was in-hospital complications according to the Clavien-Dindo classification. Secondary endpoints were surgical complications, operative time, conversion rate, and length of hospital stay.

RESULTS

Of 237 patients, 81 (34%) underwent early elective operation (group A) and 156 (66%) underwent late elective operation (group B). In-hospital complications developed in 32% in group A and in 34% in group B (risk difference 2%, 95% Confidence Interval (95% CI): -11%, 14%). Higher age (p = 0.048) and borderline higher American Society of Anesthesiologists score (p = 0.056) were risk factors for in-hospital complications. Severe surgical complications occurred in 9% of patients in group A and 10% in group B (risk difference 2%, 95% CI: -6%, 9%). Conversion rate was 9% in group A and 3% in group B (p = 0.070). Severity of disease did not seem to have an impact on complications or length of hospital stay. The median postoperative hospital stay was 8 days in both groups (interquartile range 6-10). Mean operative time was 220 min (SD 64) in group A and 202 min (SD 48) in group B.

CONCLUSIONS

This is the first study comparing early versus late elective surgery for diverticulitis in terms of the postoperative outcome using a validated classification. Although the retrospective setting and large confidence intervals don't allow definitive recommendations, these results are of utmost importance for the design of future prospective, randomized controlled trials.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Early-elective single-incision laparoscopic sigmoidectomy for perforated diverticulitis using a totally reusable single-port device

BACKGROUND

Single-port access (SPA) is an emerging concept in minimally invasive colorectal surgery. The authors report their experience using SPA sigmoidectomy as an early-elective approach to complicated diverticulitis with paracolic abscess.

METHODS

Between September 2009 und April 2010, 4 patients underwent SPA sigmoidectomy for Hinchey-I diverticulitis using the reusable X-Cone device.

RESULTS

After a median time of antibiotic treatment of 8 days, SPA sigmoidectomy was performed successfully in all patients. The median operative time was 200 minutes (range, 187-221 minutes). No intraoperative or postoperative complications were recorded; the median postoperative hospital stay was 7 days (range, 5-7 days). No incisional hernias were observed at midterm follow-up (median, 11.5 months; range, 8-14 months).

CONCLUSIONS

When performed by an experienced laparoscopic surgeon, early-elective SPA sigmoidectomy is a feasible and safe approach to complicated diverticulitis. The reusability of the X-Cone device ensures that the costs of the procedure are not high.

Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future

BACKGROUND

The supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear.

METHODS/RESULTS

The first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle?

CONCLUSIONS

This paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.

DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative treatment. A multicenter randomised clinical trial

Background

Persisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.

Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.

We, therefore, constructed a randomised clinical trial comparing these two treatment strategies.

Methods/design

The DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.

The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years.

Discussion

Considering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.

Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation.

Trial Registration

(Trial register number: NTR1478)

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.