Laparoscopy in diverticular disease: Controversies

Encompassing an Emerging Laparoscopic Surgical Procedure for Hinchey III Diverticulitis Into Acute Surgical Care Practice: Our Experience With a Case Report and Review of Literature

In the past decade, there has been emerging data from the West supporting the use of laparoscopic lavage (LL) as a minimally invasive surgical (MIS) technique to treat Hinchey III perforated diverticulitis, rather than previous standard open surgical resection procedures. However, this can only be used in a select group of patients and also requires adequate knowledge and experience of colorectal and MIS techniques. This approach remains novel and rarely practiced in Asia. In this report, we review the current literature and discuss the considerations, outcomes, and limitations of this technique with an illustration of our case report. We report on a case of Hinchey III diverticulitis in a 51-year-old Asian woman who was successfully treated with LL after initial diagnostic laparoscopy in our institution and was discharged on the fifth postoperative day. LL is a colorectal MIS technique that has been evaluated and appears to be effective and has less morbidity compared with Hartmann procedure or primary resection with anastomosis. This technique should be incorporated into our practice for patients with Hinchey III diverticulitis who are suitable for laparoscopy at presentation. With the management of our case, we hence propose a clinical algorithm for adoption of this MIS technique by advocating routine diagnostic laparoscopy in hemodynamically stable patients presenting with gross peritonitis from perforated diverticulitis. This will promote the adoption of LL as a management option for perforated diverticulitis.

Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Purpose

The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis.

Methods

Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression.

Results

Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044).

Conclusions

In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

Complicated Diverticular Disease

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

Sigmoid resection for diverticular disease - to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta-analysis

AIM

In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta-analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage.

METHOD

A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta-analysis software Review Manager 5.3.

RESULTS

Eight studies met the inclusion criteria and were included in the meta-analysis: two randomized controlled trials (RCTs) and six non-RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26-1.33, I²  = 55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14-2.65, I²  = 0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed.

CONCLUSION

This meta-analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA-preserving technique as mandatory in resection for left-sided colonic diverticular disease.

Management of complicated diverticulitis of the colon

Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0–Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib–II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III–IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case‐by‐case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Laparoscopic treatment of complicated colonic diverticular disease: A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis

BACKGROUND

Volume has been shown to be an important determinant of quality and cost outcomes.

METHODS

We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).

RESULTS

A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.

CONCLUSION

Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies

INTRODUCTION

Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD).

PURPOSE

To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis.

METHODS

Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively.

RESULTS

Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications.

CONCLUSIONS

Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.

Single incision laparoscopic resection for diverticulitis

BACKGROUND

Laparoscopic sigmoidectomy is the standard procedure in elective surgery for recurrent diverticular disease. Recently, Single Incision Laparoscopic Surgery (SILS) have been developed as the next generation technique of minimally invasive surgery. SILS advantages include reduced surgical trauma due to reduction in the number of surgical incisions, faster recovery times, and reduced hospitalization. However, the use of SILS in colorectal surgery is technically demanding and requires expert surgeons, which has hampered the reproducibility and the diffusion of this technique.

METHODS

Between October 2009 and August 2013, 488 consecutive patients were referred to Evangelisches Hochstift Hospital (Worms, Germany) and/or Stadt Klinikum Frankental Hospital (Frankenthal, Germany) for sigmoidectomy for diverticular disease. SILS sigmoidectomy via the umbilicus was performed in 484/488 cases. Clinical outcomes such as the rate of conversion to standard laparoscopy and/or to open surgery, operation time, post-operative complications and hospitalization time were recorded.

RESULTS

SILS sigmoidectomy was successfully completed for 484 out of 488 patients. SILS was converted to standard laparoscopy in 3 patients (0.6%) and to an open procedure in 1 patient (0.2%). Median time for the procedures was 103.26 min (range, 52-156 min). No mortalities or major complications were noted. The average hospitalization period was of 5 days.

CONCLUSION

Our work demonstrates that SILS sigmoidectomy via the umbilicus is effective in the treatment of patients affected by diverticular disease on a routine basis and, moreover, is technically feasible also in patients who have been subjected to previous abdominal surgery, with high Body Mass Index and/or patients with perforation at presentation. Thus this procedure represents a valid alternative to standard laparoscopy.

Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitis

BACKGROUND

Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perforated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach.

METHODS

The study included all patients with perforated sigmoid diverticulitis who underwent emergency laparoscopic peritoneal lavage from January 2000 to December 2013. Factors predicting failure of laparoscopic treatment were analysed from data collected retrospectively.

RESULTS

For patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more, American Society of Anesthesiologists grade III or above, and immunosuppression were associated with reintervention.

CONCLUSION

Elderly patients and those with immunosuppression or severe systemic co-morbidity are at risk of reintervention after laparoscopic lavage.