Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques

Over 1-Year Followup of Laparoscopic Treatment of Enterovesical Fistula

Background and Objective:

Entero vesical fistulas (EVFs) are an uncommon complication mainly of diverticular disease (70%) and less commonly of Crohn's disease (10%). Only about 10% are caused by malignancies. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with EVF. The aim of this study was to assess the feasibility and safety of laparoscopic surgery in the treatment of EVFs in patients with complicated diverticular and Crohn's disease.

Methods:

All patients with the diagnosis of EVF who underwent laparoscopic surgery were identified from prospective collected data based in two institutions between 2007 and 2017. Patients with malignancy were excluded. Recorded parameters included operative time, conversion to open surgery, the presence of a protective loop ileostomy, perioperative complications, number of units of blood transfused, postoperative course, and histologic findings.

Results:

Seventeen patients were included in the study: 10 patients with a colo-vesical fistula due to diverticular disease, and 7 patients with an ileo-vesical fistula due to Crohn's disease. There were no conversions to open surgery and none of the patients needed a protective ileostomy. The bladder was sutured in 12 patients (70%). No intra-operative complications were met, and no blood transfusions were needed; there were no anastomotic leaks, nor mortality in both groups.

Conclusions:

The laparoscopic approach for benign EVF in selected patients is both feasible and safe in the hands of experienced surgeons with extensive expertise in laparoscopic surgery.

Laparoscopic approaches to complicated diverticulitis

BACKGROUND

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.

PURPOSE

The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.

CONCLUSIONS

New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review

INTRODUCTION

Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.

METHODS

Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.

RESULTS

11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.

DISCUSSION

there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.

CONCLUSION

The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.

Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.

Surgical management of complicated diverticulitis: a comparison of the laparoscopic and open approaches

BACKGROUND

Laparoscopy has become a commonly used method of performing colectomies, but the outcomes associated with laparoscopy in the emergency setting have not been well studied.

STUDY DESIGN

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients with diverticulitis without hemorrhage who underwent a colectomy. Patient data retrieved included demographics and preoperative comorbidities. Each member of the cohort received either a primary anastomosis (PA) or a colostomy. Open and laparoscopic procedures were compared within these subgroups. Multivariate logistic regression analyses were performed to compare the risk-adjusted odds of postoperative morbidity and mortality for laparoscopic and open procedures. The risk-adjusted impact of preoperative comorbidities was also assessed.

RESULTS

A total of 11,981 patients in the database met the study criteria. The majority were female (53%) and Caucasian (82%), and the mean age was 58 (±13) years. Comorbidities of the cardiovascular, pulmonary, or renal systems were present in 47%, 5%, and 1% of the cohort, respectively. On bivariate analysis, patients undergoing laparoscopy experienced lower rates of complications with both PA (14% vs 26%, p < 0.001) and colostomy (30% vs 37%, p = 0.02). The laparoscopic approach was associated with decreased mortality rates for patients undergoing PA (0.24% vs 0.79%, p < 0.001). Multivariate analysis revealed that preoperative cardiovascular and pulmonary comorbidities were each associated with increased postoperative morbidity, and that the laparoscopic approach was associated with lower postoperative morbidity for patients undergoing PA. The reduced risk of death for patients undergoing laparoscopic PA (vs open approach) did not achieve statistical significance (odds ratio 0.68, p = 0.3). A small number of patients underwent laparoscopic colostomy (n = 237, 2.4%), and they did not have a significantly different risk of death.

CONCLUSIONS

The laparoscopic approach is associated with lower complication rates compared with the open approach for the surgical treatment of diverticulitis with a primary anastomosis.

Elective laparoscopic versus open colectomy for diverticulosis: an analysis of ACS-NSQIP database

BACKGROUND

The benefits of laparoscopic (LC) versus open (OC) colectomy for symptomatic colonic diverticulosis as an elective operation remain unclear.

METHODS

Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-user file, patients were identified who underwent elective colon resection for symptomatic colonic diverticulosis, between 2005 and 2008. Demographic, clinical, intraoperative variables, and 30-day morbidity and mortality were collected. Logistic regression analysis was performed to determine the association between the surgical approach (LC vs. OC) and risk-adjusted overall mortality, overall morbidity, serious morbidity, and wound complications.

RESULTS

A total of 7,629 patients were identified who underwent colon resection for symptomatic diverticulosis. They were subdivided into two groups: OC (3,870 (50.7%)) and LC (3,759 (49.3%)). Patients who underwent OC were significantly older (59.0 vs. 55.7 years, P < 0.0001) with more comorbidities compared with those who underwent LC. After risk-adjusted analysis, it was noted that the patients treated with LC were significantly less likely to experience overall morbidity (11.9% vs. 23.2%), serious morbidity (4.6% vs. 10.9%), and wound complications (9.1% vs. 17.5%), but not mortality (0.3% vs. 0.8%). Operative duration was significantly longer with LC (176.64 vs. 166.70 min, P < 0.0001), but the length of stay was significantly shorter (4.77 vs. 7.68 days, P < 0.0001). Using logistic regression analysis, patients with history of peripheral vascular disease, percutaneous coronary interventions, current steroid use, and hypertension requiring medication were at an increased risk of morbidity and mortality at 30 days. Patients with history of chronic obstructive pulmonary disease and smoking experienced more wound complications at 30 days.

CONCLUSIONS

In the elective setting for symptomatic diverticulosis, LC seems to be associated with lower 30-day morbidity and complication rates compared with OC.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.

Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption

PURPOSE

Laparoscopic-assisted sigmoidectomy is an attractive but sometimes challenging operative technique for the treatment of diverticulitis of the sigmoid colon. The aim of this study was to compare, with respect to early postoperative analgesic demand and postoperative pain, laparoscopic-assisted sigmoidectomy with a laparoscopic-facilitated technique. In the laparascopic-facilitated technique, the sigmoid colon is removed conventionally via a cosmetically inconspicuous incision after prior laparoscopic mobilization.

PATIENTS AND METHODS

Patients subjected to elective sigmoidectomy for diverticulitis were randomized to either laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy. All patients had piritramide-based, patient-controlled analgesia. The cumulative postoperative consumption over 96 hours was defined as the primary end point. Postoperative pain, fatigue, pulmonary function, and resumption of bowel function were secondary endpoints.

RESULTS

: Forty-five patients were randomized according to the protocol to laparoscopic-assisted sigmoidectomy (n = 22) or laparoscopic-facilitated sigmoidectomy (n = 23). The analgesic consumption between the two groups was equivalent (61.3 (9-171) mg piritramide/96 hours vs. 64.3 (18-150) mg piritramide/96 hours; P = 0.827). Patients with laparoscopic-assisted sigmoidectomy had lower pain levels on Day one and Day two. Cumulative pain levels over 96 hours and over the whole 7-day observation period, however, were not significantly different, although postoperative fatigue and pulmonary function were significantly different. Duration of surgery was slightly shorter for laparoscopic-assisted sigmoidectomy (127 (47-200) vs. 135 (60-239) minutes; P = 0.28), but recovery of bowel activity was faster after laparoscopic-facilitated surgery. There was no significant difference in morbidity.

CONCLUSION

Overall, the postoperative outcome was roughly equivalent after both techniques of laparoscopic sigmoidectomy. Therefore, laparoscopic-facilitated sigmoidectomy could be considered as an alternative to laparoscopic-assisted sigmoidectomy in technically difficult cases of diverticulitis subjected to laparoscopic surgery.

The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis

Backround

Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.

Method

Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.

It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.

Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.

Discussion

The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.

Ergonomics with the use of curved versus straight laparoscopic graspers during rectosigmoid resection: results of a multiprofile comparative study

BACKGROUND

A detailed ergonomic comparison of motions and muscular activity in the left upper extremity using a laparoscopic straight or curved grasper in rectosigmoid resection is presented.

METHODS

The study had two parts: experimental and clinical. In the experiment part, 30 laparoscopic sigmoid resections were performed under animal organ phantom conditions. The operations were divided into three groups according to instrument and trocar position. Group 1 (n = 10) underwent operations performed with a curved grasper in the excentral trocar position (in relation to the telescope trocar), with the left-hand curved grasper placed in the right flank and the right hand instrument in the right lower quadrant. In group 2 (n = 10), straight forceps were used in the excentral trocar position. Group 3 (n = 10) underwent laparoscopic sigmoid resection performed with a straight grasper in the central position (in relation to the telescope trocar), with the instruments placed at both sides of the lower abdomen. To measure ergonomic aspects during rectosigmoid resection, several overview video cameras, surface electromyography (EMG), an ultrasound tracking system (UTS), and a questionnaire were used. In the clinical part of the study, laparoscopic rectosigmoid resections (n = 5) were performed using a curved instrument in the excentral trocar position. The surgeon's left-hand movement and body posture were recorded for further analysis.

RESULTS

The curved grasper required the fewest contractions (group 1) of the measured muscles. A comparison of the UTS analysis in the experimental part of the study and the video analysis in the clinical part showed economy of movements in group 1. According to subjective estimation, both physical activity and mental stress remain at the lowest level when the excentral trocar position is used (groups 1 and 2).

CONCLUSIONS

The combination of the curved grasper and the excentral trocar position (in relation to the telescope trocar) is, according to our examinations, the best ergonomic adjustment for laparoscopic rectosigmoid surgery.

Laparoscopic treatment of colovesical fistulas: technique and review of the literature

Colovesical fistula is an uncommon complication of diverticulitis. We present our technique of a laparoscopic approach for treatment of vesicosigmoid fistulas and review the available published literature. We believe that a laparoscopic approach is a feasible and advantageous alternative for the treatment of colovesical fistulas, with low morbidity and short hospital stay.

Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease.

METHODS

The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months).

RESULTS

Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again.

CONCLUSIONS

When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.

Diverticular disease

Diverticular disease is a common finding in Western countries with an increasing prevalence with age. Many patients with the disorder remain asymptomatic. However, up to 30% of those affected may show clinical signs including pain, bleeding, obstruction, abscess, fistulae and perforation. The purpose of this chapter is to review the epidemiology, pathogenesis, clinical presentation, diagnostic regimens and treatment options for this disorder.