Is laparoscopic surgery applicable to complicated colonic diverticular disease?

The role of emergency laparoscopic surgery for complicated diverticular disease: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery develops rapidly in both elective and emergency settings. The study aimed to determine the role of different laparoscopic methods for the emergency treatment of complicated diverticulitis.

METHODS

MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to November 2019 to identify all published articles related to the topic. Statistical analysis was performed using Stata 15.

RESULTS

Fourteen publications were included in the analysis. Laparoscopic surgery was applied in 425 patients, and 493 patients underwent open colon resection (OCR). Postoperative mortality, morbidity, severe complications, and reoperation rates were not significantly different between the laparoscopic and open surgery groups. Subgroup analysis was performed based on the different laparoscopic methods (laparoscopic colon resection [LCR] and laparoscopic lavage and drainage [LLD]). Subgroup analysis indicated that LCR was superior to OCR in terms of morbidity, while OCR was superior to LLD in terms of severe complications.

CONCLUSIONS

The safety of laparoscopic surgery for the emergency treatment of complicated diverticulitis is related to different surgical methods. LCR is suggested to be a better choice according to the postoperative outcomes. More definite conclusions can be drawn in future randomized controlled trials.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Diverting Ostomy: For Whom, When, What, Where, and Why

Fecal diversion is an important tool in the surgical armamentarium. There is much controversy regarding which clinical scenarios warrant diversion. Throughout this article, we have analyzed the most recent literature and discussed the most common applications for the use of a diverting stoma. These include construction of diverting ileostomy or colostomy, ostomy for low colorectal/coloanal anastomosis, inflammatory bowel disease, diverticular disease, and obstructing colorectal cancer. We conclude the following: diverting loop ileostomy is preferred to loop colostomy, an ostomy should be used for a pelvic anastomosis < 5 to 6 cm including coloanal anastomosis and ileo-anal-pouch anastomosis, severe perianal Crohn's disease frequently requires diversion, a primary anastomosis with diverting ileostomy in the setting of diverticular perforation is safe, and a diverting stoma can be used as a bridge to primary resection in the setting of an obstructing malignancy.

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy

Introduction

Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS.

Methods

All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011–2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study.

Results

There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m² (SD ± 3.33). Thirteen cases (38%) were Wasvary’s modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann’s procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann’s procedures.

Conclusion

DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

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.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis

Background

Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial.

Methods

Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results.

Results

Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P &lt; 0·001); however, the Cleveland Global Quality of Life score did not differ between groups.

Conclusion

The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 (http://www.clinicaltrials.gov).

Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described.

METHOD

MEDLINE, Embase and the Cochrane Database of Systematic Reviews (up to July 2014) were searched. Two authors independently reviewed citations using predefined inclusion and exclusion criteria.

RESULTS

The search strategy yielded 3233 citations; 54 were eligible, comprising 18 983 patients. Twenty-six studies were prospective [17 of these being randomized controlled trials (RCTs)] and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3% (95% CI 8.4-12.5) and 10.2% (95% CI 5.6-17.8) for non-RCTs and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for RCTs. The used definition of PPOI, the type of surgery and access (laparoscopic, open) and the duration of surgery lead to significant variability of reported PPOI incidence between studies. The incidence of PPOI is lower after laparoscopic colonic resection.

CONCLUSION

There is a large variation in the reported incidence of PPOI. A uniform definition of PPOI is needed to allow meaningful inter-study comparisons and to evaluate strategies to prevent PPOI.

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.

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.

Safety of nonoperative management after acute diverticulitis

Purpose

The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery.

Methods

We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode.

Results

Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated with elective surgery had a higher rate of stoma than patients treated non-operatively (7.2% vs. 1.4%; P = 0.028); this difference was not observed in the subgroup of patients with CAD (15.3% vs. 6.8%; P = 0.458).

Conclusion

After an episode of AD, nonoperative management is safe because fewer than 5% of patients will need an emergent procedure in a subsequent attack of AD. A first episode of CAD is the only risk factor for emergency surgery in patients managed conservatively.

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.

Laparoscopic resection of chronic sigmoid diverticulitis with fistula

BACKGROUND AND OBJECTIVES

A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula.

METHODS

A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period.

RESULTS

Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence.

CONCLUSIONS

Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.

[Laparoscopic repair of enterovesical fistula in patient affected by left megaureter]

INTRODUCTION

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. We present the case of EVF secondary to diverticular disease in a male with congenital megaureter. A laparoscopic repair of the colon vesical fistula was performed with colon resection.

MATERIALS AND METHODS

With the patient in the Trendelenburg position -30° degrees on the right side, 5 trocars are positioned trans-peritoneally. The exploration of the abdominal cavity shows the sigmoid diverticular disease adhering tenaciously to the posterior wall of the bladder. The intestinal loops are medialized. The inferior mesenteric vein is isolated, clipped and divided. The mesosigma is isolated and the inferior mesenteric artery is closed 2 cm from its emergence from the aorta with EndoGIA™ 45 stapler. The left colon is isolated from its splenic flexure to the mesorectum. The peritoneum between the bladder and sigmoid colon at the site of the tenacious adhesions is incised. The left megaureter is isolated from the diverticular disease and the bladder is opened on the site of the fistula, to permit a wide resection of the fistula. The posterior wall of the bladder is then closed with double running sutures. Section of the rectum with EndoGIA™ 45 stapler. Extraction of 20 cm of sigma comprising diverticular disease by a 5 cm suprapubic laparotomy. The sigma is cut and the proximal head of the circular stapler is inserted and closed with a running suture. The left colon is put back in place into the peritoneal cavity. The laparotomy is closed and the surgery is reconverted into laparoscopy. A colorectal end-to-end anastomosis according to Knight Griffen is performed with ILS 29 circular stapler. The anastomosis is tested for leakage with hydropneumatic test: no evidence of spillage. A laminar drainage is placed close to the anastomosis and the incisions are closed.

RESULTS

The operative time was 240 minutes. There were no intra- or post-operative complications. The bladder catheter was removed on day 7 after cystography. The patient was discharged asymptomatic on the 8th post-operative day.

CONCLUSIONS

Laparoscopic treatment of enterovesical fistulas for benign disease is a safe and standardized procedure. It remains a difficult procedure with a conversion rate higher than laparoscopy for uncomplicated diverticulitis or malignancy. The procedure in a single session with intracorporeal bowel anastomosis is the standard.

Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease

PURPOSE

Laparoscopic-assisted sigmoidectomy is a widely applied technique in the operative treatment of diverticular disease. Treatment guidelines recommend operation of complicated diverticulitis and after recurrent attacks of uncomplicated diverticulitis. These guidelines have become subject to controversy. The objective of this study was to assess disease-related quality of life after laparoscopic sigmoidectomy.

METHODS

Data were collected retrospectively. Patients filled in a form describing their quality of life. All patients undergoing elective operation for diverticular disease between 1999 and 2006 at the Department of Surgery of the Uster Hospital, a regional medical center in Switzerland were included. The measurement tool we used is the Gastrointestinal Quality of Life Index (GIQLI). Wilcoxon-Mann-Whitney test or unpaired t-tests were applied to determine statistical significance of differences observed.

RESULTS

A total of 130 patients were included and 120 questionnaires were available for analysis. Mean follow-up was 40 months. Of the total, 48% reported a GIQLI >100 before the operation, which rose to 83% after the operation (p < 0.0001). Mean GIQLI was 95 before and 114 after the operation (p < 0.0001). Female patients reported lower GIQLI rates. Overall, 96% were satisfied with the operation.

CONCLUSIONS

The results in this study population show that in a majority of patients who underwent elective laparoscopic-assisted sigmoidectomy for recurrent diverticulitis gastrointestinal quality of life improved with the operation.

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann's procedure

BACKGROUND

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

METHODS

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study.

RESULTS

A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %.

CONCLUSIONS

Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

Laparoscopic management of diverticular disease

Despite its potential advantages, laparoscopic management of diverticular disease is currently performed by a minority of surgeons on a small group of patients. However, the role for laparoscopy in diverticular disease continues to develop. At present, adequate evidence exists for the routine use of laparoscopy for uncomplicated diverticular disease. Complicated disease, including fistulizing disease and free perforation requires additional expertise and study. As the experience grows among individual surgeons and institutions, it can be expected that the complication and conversion rates will continue to decline allowing even further evolution of laparoscopy for the treatment of this challenging disease process.

Laparoscopic sigmoidectomy for diverticulitis: a prospective study

Results of this study suggest that laparoscopic surgery for diverticular disease is a safe, feasible, and effective management strategy.

Background:

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.

Method:

All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications.

Results:

During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%).

Conclusions:

Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage

PURPOSE

This study was designed to review the results of laparoscopic lavage for the management of perforated sigmoid diverticulitis.

METHODS

A 10-year retrospective review was conducted of 78 consecutive cases of sigmoid diverticulitis warranting emergency surgical intervention (1999-2008).

RESULTS

Hinchey grades were I (12 patients), II (31 patients), III (29 patients), and IV (6 patients). The patients' mean age was 72 years. Procedures performed were laparoscopic washout (35), Hartmann procedure (31), percutaneous drainage of abscess (4), and resection and primary anastomosis (8). Overall mortality was 5 of 78 (7%); all of these patients were in the Hartmann group. Washout was successful in 27 of 35 cases, meaning recovery from the initial episode of peritonitis without resection. The short-term failures of washout in 8 patients were because of perforated cancer (1), fecal fistula formation (2), and inadequate washout and ongoing sepsis (5). In long-term follow-up, 8 patients in the washout group developed symptoms of recurrent complicated diverticulitis, including painful phlegmon (3), stricture (1), fistulas (3), and repeat perforation (1); all 8 patients underwent delayed resection. Eight patients underwent early planned resection without experiencing further symptoms. Eleven patients were observed without further symptoms with a mean follow-up of 20 months (range, 6-60 mo).

CONCLUSIONS

Laparoscopic washout is an emerging technique that is particularly applicable to the management of Hinchey III perforated peritonitis. Short- and long-term problems exist with the technique that may be overcome with further improvement in technique and case selection. Resection and radiological drainage remain widely used in managing perforated sigmoid diverticulitis.

Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review

AIM

This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis.

METHOD

We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included.

RESULTS

Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy.

CONCLUSION

There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.

Nonoperative management of complicated diverticular disease

The complications of diverticular disease of the colon can be divided into those related to inflammatory conditions (diverticular abscess, fistula, and perforation) and those related to noninflammatory conditions (lower gastrointestinal hemorrhage and noninflammatory stricture or obstruction). Nonoperative management of uncomplicated diverticulitis includes bowel rest and antibiotics. For abscesses, percutaneous drainage by radiologic guidance often turns complicated diverticulitis to an uncomplicated condition. In very select instances, fistulas or even perforation may be managed without operation. Strictures may be dilated or stented. Diverticular hemorrhage may be controlled with colonoscopic and angiographic techniques. For colonoscopy, these include cautery, epinephrine injection, and endoclips. For angiography, these include arterial infusion of vasopressin and selective embolization of bleeding vessels. For both diverticulitis and diverticular bleeding, these nonoperative therapeutic modalities may be utilized as a bridge to surgery, or in select instances as a definitive therapy obviating the need for surgery.

Laparoscopic management of diverticular disease

Laparoscopy surgery has achieved wide acceptance for the treatment of benign disease of the colon. A review of the literature regarding the indications, surgical technique, and outcomes of laparoscopic surgery for diverticular disease is presented.

Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis--a proof of concept

PURPOSE

Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.), and second look to restore intestinal continuity was developed.

METHODS

This algorithm allowed for three surgical procedures: primary anastomosis +/- VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III) RESULTS: All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n = 6). Nine patients in group II (n = 15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n = 7), the rate of anastomosis in surviving patients was 70%.

CONCLUSIONS

Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.

Review article: the current and evolving treatment of colonic diverticular disease

BACKGROUND

Formation of colonic diverticula, via herniation of the colonic wall, is responsible for the development of diverticulosis and consequently diverticular disease. Diverticular disease can be associated with numerous debilitating abdominal and gastrointestinal symptoms (including pain, bloating, nausea, constipation and diarrhoea).

AIMS

To review the state of treatment for diverticular disease and its complications, and briefly discuss potential future therapies.

METHODS

PubMed and recent conference abstracts were searched for articles describing the treatment of diverticular disease.

RESULTS

Many physicians will recommend alterations to lifestyle and increasing fibre consumption. Empirical antibiotics remain the mainstay of therapy for patients with diverticular disease and rifaximin seems to be the best choice. In severe or relapsing disease, surgical intervention is often the only remaining treatment option. Although novel treatment options are yet to become available, the addition of therapies based on mesalazine (mesalamine) and probiotics may enhance treatment efficacy.

CONCLUSIONS

Data suggest that diverticular disease may share many of the hallmarks of other, better-characterized inflammatory bowel diseases; however, treatment options for patients with diverticular disease are scarce, revolving around antibiotic treatment and surgery. There is a need for a better understanding of the fundamental mechanisms of diverticular disease to design treatment regimens accordingly.

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.

Emergency laparoscopic surgery for complicated diverticular disease

OBJECTIVE

The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease.

METHOD

A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease.

RESULTS

Sixty-six patients (28 men), median age 69 years (23-95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis--Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6(1/2)-year period: 43 high anterior resections, 17 Hartmann's resections and seven low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo-fallopian (4), entero-colic (3). The median operation time was 110 min (45-195 min). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient-controlled analgesia in 24 (36%), oral Paracetamol and Oramorph (12%) and epidural opioid infusion (1.5%). The median time to normal diet was 24 h (4 h-6 days) and median hospital stay 5 days (2-30). There were two deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection eight (12%), anastomotic leak four (8%), port-site hernia one and one case of Clostridium difficile colitis requiring colectomy. There were five (7.5%) returns to theatre and two readmissions (3%).

CONCLUSION

Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictable operation that allows for early hospital discharge and, in our opinion, improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection.

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.

Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis

BACKGROUND

The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary.

METHOD AND MATERIALS

Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed.

RESULTS

Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention.

CONCLUSION

Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.

[Results of sigma resection in acute complicated diverticulitis : method and time of surgical intervention]

BACKGROUND

The aim of this study was to check the results of laparoscopic sigmoid resection for sigmoid diverticular disease with respect to stage of inflammation and time of surgical intervention.

PATIENTS AND METHODS

All patients were divided into four groups: uncomplicated (Group 1) vs complicated diverticular disease (Group 2), and depending on surgical intervention in early elective (4-8 days, Group A) vs late elective sigmoid resection (4-6 weeks, Group B).

RESULTS

At total of 244 patients underwent laparoscopically-assisted resection during the examination period. Differences in favor of Group 1 were found in duration of surgery (153 min vs 167 min), postoperative wound infections (3.55% vs 15.5%), and postoperative hospitalization period (12.2 days vs 14.6 days). Group A had more conversions (7.8% vs 0.9%), more minor complications (25.9% vs 12.9%), and more wound infections (16.4% vs 4.6%) than Group B.

CONCLUSIONS

Laparoscopic sigmoid resection can be performed in cases of complicated diverticulitis without significantly increasing their overall morbidity. Because of the lower complication rate, we recommend that patients with acute sigmoid diverticulitis receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection.

Emergent and elective surgery for diverticulitis

The scientific evidence and basis for standardized treatment for diverticulitis has been questioned. For years, medical and surgical management of acute diverticulitis included the theory that more than 2 significant attacks of diverticulitis would lead to the recommendations of surgical resection. This should be questioned and further investigated with prospective randomized trials. Only a small number of well-published articles support the surgical management with good scientific data. Although our ability to take a history and skill of physical examination has not changed, the use of improved technology such as high-speed computerized axial tomography has afforded us the ability to make earlier and more accurate diagnoses. This may further allow us to standardize treatment and study outcomes. It is possible that only the most critical situations may necessitate an operation. The age group less than 40 years, the immunocompromised, steroid-dependent, diabetic, and transplant patients, seem to be at greater risk with increased morbidity if not treated early and aggressively. Those individuals who present with perforation or compromised obstruction most likely will continue to need emergent intervention. But we need to reevaluate who needs surgical intervention while remaining within the confines of excellent and cost-effective care.

Operative treatment of recurrent or complicated diverticulitis

Sigmoid diverticulosis remains a common disease in developed Western countries, and surgeons are frequently asked to manage diverticulitis and its complications. When to offer elective surgery to patients with uncomplicated, but recurrent, diverticulitis should be individualized, and practice recommendations by national societies continues to be debated. Complicated diverticulitis remains a surgically treated disease, and new technology such as colonic stents (for obstruction) and computed-tomography-guided percutaneous drainage (for abscess) have become bridging techniques to avoid two-stage operations in selected patients. Minimally invasive surgery for elective sigmoid resection has been shown to be safe and feasible and confers many patient-related short-term over traditional open surgery.

Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures

BACKGROUND

Classic emergency surgical management of complicated perforated sigmoid diverticulitis is based on the principle of a two-stage operation, with colon resection and temporary stoma (Hartmann's procedure). But the later second-stage operation can be technically difficult and can be associated with a significant morbidity rate. We argue that laparoscopy may be beneficial in such patients with peritonitis in terms of operative results and could facilitate later surgical management.

STUDY DESIGN

We studied all consecutive patients with perforated sigmoid diverticulitis requiring emergency surgery between January 2000 and December 2004.

RESULTS

Twenty-four patients underwent emergency laparoscopic management for perforated sigmoid diverticulitis. Nineteen patients (80%) were found to have a purulent or fecal diffuse peritonitis. No conversion and colostomy were necessary. The overall morbidity rate was 8%; 2 patients with pelvic abscesses required radiologic drainage. The median hospital stay was 12 days (range 7 to 35 days). Prophylactic sigmoid resection was performed by laparoscopy in all patients, with a conversion rate of 16%.

CONCLUSIONS

Laparoscopic treatment of generalized peritonitis secondary to diverticulitis is feasible and safe and may be a promising alternative to more radical surgery in selected patients, avoiding fecal diversion and allowing a delayed elective laparoscopic sigmoid resection.

Polybacterial pyomyositis following laparoscopic colectomy for complicated diverticulosis

We report a case of diffuse subacute muscle infection caused by enteric bacteria, diagnosed two months after laparoscopic colectomy for a sigmoid abscess and successfully treated with antibiotics alone.

Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis

PURPOSE

Purulent or fecal peritonitis is one of the most serious complications of acute diverticulitis. Up to one-fourth of patients hospitalized for acute diverticulitis require an emergent operation for a complication, including abscess, peritonitis, or stenosis. Open Hartmann's procedure has been the operation of choice for these patients. The advantages of laparoscopy could be combined with those of the primary resection in selected patients with peritonitis complicating acute diverticulitis. However, because of technical difficulties and the theoretic risk of poorly controlled sepsis, laparoscopic Hartmann's procedure has been seldom reported for such patients.

METHODS

Data were prospectively collected from 2003 to 2005 in a single referral center specialized in abdominal emergencies. Laparoscopic Hartmann's procedure (Stage 1) was performed in selected patients with peritonitis complicating acute diverticulitis. Secondarily, Hartmann's reversal (Stage 2) also was performed laparoscopically.

RESULTS

Thirty-one patients were studied. The median Mannheim Peritonitis Index score was 21 (+/-5; range, 12-32). The conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively. There was no perioperative uncontrolled sepsis. Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively. Stoma reversal was possible in 90 percent of patients.

CONCLUSIONS

The results of this small series demonstrated that the indications of laparoscopy in diverticulitis could be extrapolated to selected patients with peritonitis. The technical feasibility and safety of laparoscopic Hartmann's procedure in selected patients seem acceptable. However, larger-scale, controlled studies are needed to define more accurately the role of laparoscopy in complicated diverticulitis.

The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes

BACKGROUND

The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease.

METHODS

Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture.

RESULTS

The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70).

CONCLUSIONS

A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure.