INDICATIONS FOR SURGERY IN DIVERTICULAR DISEASE

Document Sample
INDICATIONS FOR SURGERY IN DIVERTICULAR DISEASE Powered By Docstoc
					  INDICATIONS FOR
     SURGERY IN
DIVERTICULAR DISEASE
   Changing Trends
  Professor Alexander Deutsch
SURGICAL INDICATIONS


    ARE INDICATIONS CHANGING?

    IF SO WHY?
     CHANGING TRENDS
            ISSUES TO EXAMINE

   Acute Diverticulitis Simple or Complicated

   Surgical Indications After Diverticulitis

   Post Recurrent Attacks

   Surgical Indications in the Young
HOW DID I BEHAVE DURING MY
      RESIDENCY 1966
        SURGICAL INDICATIONS
    HOW DID I BEHAVE DURING MY RESIDENCY
                     1966

   PURELY CLINICAL INDICATIONS

       ACUTE ABDOMEN
       SEVERE SEPSIS
       LARGE BOWEL OBSTRUCTION
       ACUTE COLONIC BLEEDING
       DEFINITIVE SURGERY LATER
           UNAVAILABLE
          INVESTIGATIONS

   ULTRASOUND
   COMPUTERIZED TOMOGRAPHY
   PERCUTANEOUS DRAINAGE ABSCESSES
   INTENSIVE CARE UNITS
   MONITORING
   TOTAL PARENTERAL NUTRITION
   ANTIBIOTICS LIMITED
    SURGERY PERFORMED

      ACUTE SURGICAL SITUATIONS

   OPERATIVE DRAINAGE

   COLOSTOMIES NEVER ILEOSTOMIES

   NEVER PRIMARY ANASTAMOSES
      SURGICAL OPERATIONS
           AVAILABLE
   OPERATIVE DRAINAGE OF
    ABSCESSES

   COLOSTOMY DEVINE DIVERTING

   HARTMANN OPERATION

   RESECTION FOR BLEEDING

   RESECTION WITH ANASTOMOSIS LATER
NATURAL HISTORY OF DIVERTICULAR
DISEASE OF THE COLON. A REVIEW OF
             521 CASES
           TG PARKS (Belfast BMJ 1969)



 Patients between 1951-1965
 Male to Female Ratio     2:3
 Average Age 65.9 (29-89)

 Over 92% over 50 yrs at presentation

 Previous Severe Attacks 41 patients
NATURAL HISTORY OF DIVERTICULAR
DISEASE OF THE COLON. A REVIEW OF
             521 CASES
          TG PARKS (Belfast BMJ 1969)

 455 patients admitted
 138 had emergency or delayed surgery

 317 treated medically

 20 surgery for recurrent attacks (6.3%)

 138+20=158 of 455 (34.7%) operated
     TG PARKS (Belfast BMJ 1969)

               MORTALITY
 Mortality 4.8% (22 of 455 patients)

 Post op mortality 12.3% (17 of 138 pats)

 15 patients during first admission

 10 patients were over 70 years

 6 patients were over 80 years

 12 died had symptoms less one month
NATURAL HISTORY OF DIVERTICULAR
 DISEASE OF THE COLON. A REVIEW
           OF 521 CASES
             TG PARKS (Belfast BMJ 1969)

    Persistent symptoms 455 patients

   Medical treatment 33%
   Severe symptoms       5%
   After surgical treatment at follow-up
                        33%. mild symptoms
                    3% Severe symptoms
NATURAL HISTORY OF DIVERTICULAR
 DISEASE OF THE COLON. A REVIEW
           OF 521 CASES
            TG PARKS (Belfast BMJ 1969)

          Medically treated               317
   Second attack re-admission 78 (24.6%)
   Third attack re-admission 12(3.8%) 15.3%
   Fourth attack re-admission 5(1.6%) 42%
   Others had attacks and not hospitalized
NATURAL HISTORY OF DIVERTICULAR
 DISEASE OF THE COLON. A REVIEW
           OF 521 CASES
          TG PARKS (Belfast BMJ 1969)

       Course of 78 patients re-admitted

 57 (73.1%) had symptoms 50% mild
 1 of 12 symptom free Bet 2nd & 3rd attack

 36 (46%) admitted within a year

 71 (91%) admitted within 5 years
NATURAL HISTORY OF DIVERTICULAR
 DISEASE OF THE COLON. A REVIEW
           OF 521 CASES
          TG PARKS (Belfast BMJ 1969)

      Outcome of 78 recurrent attacks

 6 of 78 (7.7%) died at second admission.
 Twice as high as first admission

 Over half patients continued symptoms
    NATURAL HISTORY OF DIVERTICULAR
    DISEASE OF THE COLON. A REVIEW OF
        521 CASES TG PARKS (Belfast BMJ 1969)
      Outcome 78 of recurrent attacks
   20 were treated by sigmoidectomy 18 cured

   37 of 43 treated medically had severe recurrence

   10 patients died of recurrent diverticular disease

    Nine did not have sigmoidectomy
NATURAL HISTORY OF DIVERTICULAR
 DISEASE OF THE COLON. A REVIEW
           OF 521 CASES
            TG PARKS (Belfast BMJ 1969)


                Conclusions

 Surgery indicated after two attacks
 of diverticulitis treated medically
COMPUTERIZED TOMOGRAPHY

SIR GODFREY NEWBOLD
 HOUNSFIELD
IDEA 1967. FIRST COMERCIAL
 PROTOTYPE 1972

   ALAN Mc CLEOD CORMACK
    MATHEMATICAL ASPECTS

   NOBEL PRIZE 1979
CT HINCHEY CLASSIFICATION
             1978
 HINCHEY A          HINCHEY B




 HINCHEY C          HINCHEY D
               ULTRASOUND
   Abdominal Masses by Pulsed Ultrasound'
        Prof Ian Donald
           Gynecologist Glasgow


           The Lancet of 7 June
                             1958

      Used for diagnosis in the 1980’s
    PERCUTANEOUS DRAINAGE

               John R. Haaga
                    Cleveland Clinic
    American Journal of Roentgenology 1977
New applications of old radiographic
techniques applied to computed tomography
            Expanded No cases 1980


           Stephen G. Gerzof
          1979 sonographic Guidance

        Tufts University School of Medicine
PERCUTANEOUS DRAINAGE
       THE 5-YEAR NATURAL HISTORY OF
    COMPLICATED DIVERTICULAR DISEASE
       N FARMAKIS, RG TUDOR, MRB KEIGHLEY BJS 1994

    120 PATIENTS FOLLOWED 5 YEARS

   10 DIED FURTHER DIVERTICULAR
    COMPLICATIONS (8.3%)

   29 DIED UNRELATED CAUSES

   13 BLEEDING WITH 2 RESECTIONS

   40 OF 110 PATIENTS SYMPTOMATIC (36.4%)
    39 DEVELOPED SEVERE COMPLICATIONS
       THE 5-YEAR NATURAL HISTORY OF
    COMPLICATED DIVERTICULAR DISEASE
       N FARMAKIS, RG TUDOR, MRB KEIGHLEY BJS 1994


        Follow-up at 5 years 120 patients

   70 patients (58%) were symptom free. 7 with
    colostomy

   50 patients (41.6%) patients were symptomatic

   39 (32.5%) patients developed serious complications

   10 (8.3%) died
      THE 5-YEAR NATURAL HISTORY OF
    COMPLICATED DIVERTICULAR DISEASE
       N FARMAKIS, RG TUDOR, MRB KEIGHLEY BJS 1994



   25% patients died following re-admission

   Surgery not suggested for old and high risk .

   Is death from interval resection lower than
    chance of further attack and death
        THE 5-YEAR NATURAL HISTORY OF
     COMPLICATED DIVERTICULAR DISEASE
        N FARMAKIS, RG TUDOR, MRB KEIGHLEY BJS 1994


                   Conclusions


   Interval sigmoidectomy indicated in fit
    patients after admission with complicated
    diverticulitis

   Elective surgery reduces risk of further
    complicated diverticular attacks
    ASCRS PRACTICE
PARAMETERS FOR SIGMOID
    DIVERTICULITIS




   RAFFERTY J, SHELLITO P, HYMAN NH,
                BUIE WD
     DIS COLON RECTUM JULY 2006
        COMPLICATED CASES


   DEFINED AS:-

     ABSCESS
     FISTULA

     OBSTRUCTION

     FREE PERFORATION
     MEDICAL TREATMENT


   IN ACUTE UNCOMPLICATED CASES
    SUCCEEDS IN 70-100%

   CAN BE MANAGED AT HOME

   ADMIT IF NO IMPROVEMENT
         EMERGENCY SURGERY IN
          ACUTE DIVERTICULITIS

   SIGMOID COLECTOMY IF:- DIFFUSE PERITONITIS, FAILURE OF
    MEDICAL TREATMENT (LEVEL 111 B)

   IMMUNOSUPRESSED CASES SURGERY MORE LIKELY

   ANASTAMOSIS POSSIBLE, DEPENDS ON PATIENT STATUS OR
    CONTAMINATION (HINCHEY)+

   COLONIC LAVAGE OR LOOP ILEOSTOMY PRECISE ROLE
    CONTROVERSIAL

   HARTMANN OFTEN PERFORMED, 2ND STAGE MAY BE DIFFICULT,
    COLOSTOMY MAY BE PERMANENT.
     ELECTIVE SURGERY POST
      ACUTE DIVERTICULITIS
   DECISION CASE BY CASE BASIS (LEVEL 111 B)

   ONE THIRD WLL HAVE 2ND ATTACK

   AFTER 2ND ATTACK 3rd WILL HAVE ATTACKS

   DECISION AFFECTED BY :-
       AGE
       MEDICAL CONDITION
       FREQUENCY OF ATTACKS
       SEVERITY OF ATTACKS

   PERSISTANT SYMPTOMS
           ELECTIVE SURGERY POST
            ACUTE DIVERTICULITIS
   SURGERY MAY NOT PREVENT FURTHER ATTACK

   CT GRADING 1ST ATTACK MAY INDICATE SURGERY

   INABILITY TO EXCLUDE CARCINOMA

   PATIENTS <50Y. NO CLEAR CONCENSUS
       INCREASE RISK OF COMPLICATIONS
       RECURRENT ATTACKS.
       LONGER LIFE SPAN HIGHER CULMULATIVE RISK ?
     COMPICATED DIVERTICULITIS
    TREATED NON OPERATIVELY 111 B

   AFTER PERCUTANEOUS DRAINAGE 41% DEVELOP
    RECURRENT SEPSIS

   RESECT PROXIMAL TO COMPLIANT BOWEL AND
    DISTAL TO UPPER RECTUM (111 B)

   REMOVE SEVERELY AFFECTED SEGMENT,

   NOT ALL DIVERTICULA-BEARING COLON MUST
    BE REMOVED.
 COMPICATED DIVERTICULITIS
TREATED NON OPERATIVELY 111 B


   SAFE IN SELECTED PATIENTS

   COLOSIGMOID ANASTAMOSIS PREDICTOR OF
    RECURRENCE

   LAPAROSCOPY IN SELECTED CASES (111 A)
       LESS PAIN
       SMALLER SCAR
       SHORTER RECOVERY
       ACCEPTABLE IN THE ELDERLY
 INDICATIONS FOR SURGERY
FOLLOWING DIVERTICULITIS


   CLOSURE OF STOMAS-COLOSTOMIES
    WITH RESECTION OF DISEASED COLON

   COLON RESECTION IF ATTACK SEVERE
COMMENT ON PRACTICE PARAMETERS
              MEAGHER AP, & FRIZELLE FA
               DIS COLON RECRUM 2007




   PRACTICE PARAMETERS RECOMMEND SURGERY
    AFTER 2 ATTACKS OF DIVERTICULITIS

   DECISION MADE ON A CASE BY CASE BASIS.

   SHOULD BE FAR MORE CONSERVATIVE IN THE
    LIGHT OF RECENT DATA
       HOSPITALIZATION FOR ACUTE
    DIVERTICULITIS DOES NOT MANDATE
      ROUTINE ELECTIVE COLECTOMY
        BRODERICH-VILLA ET AL ARCH SURG 2005



   3165 AT 12 KAISER PERMANENT HOSPITALS
   FOLLOW-UP 8.9 YEARS
   81% TREATED NON OPERATIVELY
   SINGLE RECURRENCE ONLY 9%
   RE-RECURRENCE 4%
   RECURRENCES NON-OPERATIVE
       HOSPITALIZATION FOR ACUTE
    DIVERDICULITIS DOES NOT MANDATE
      ROUTINE ELECTIVE COLECTOMT
        BRODERICH-VILLA ET AL ARCH SURG 2005


              CONCLUSIONS

   LOW RECURRENCE RATES

   NO ELECTIVE COLECTOMY NECESSARY
   AFTER NON –OPERATIVE MANAGEMENT
    OF ACUTE DIVERTICULITIS
DO MULTIPLE RECURRENCES PREDICT LESS
       FAVOURABLE OUTCOMES
               CHAPMAN LR DOZOIS BG WOLFF BG
                      ANN SURG 2006

     337 DIVERTICULITIS PATIENTS MAYO
                   CLINIC

   Reduced mortality from complicated
    diverticulitis except in perforation

   Complicated diverticulitis first episode
    mostly

   Does elective resection reduce mortality
    The natural history of diverticular disease: is
         there a role for elective colectomy
              Somasekar et al J R COLL SURG EDIN 2002




   108 PATIENT HAD EMERGENCY SURGERY
    (HARTMANN IN 98)

   ONLY 3 HAD PREVIOUS DIVERTICULITIS

   The risk of a Hartmann operation following a previous
    attack is 1 in 2000
COMPLICATED DIVERTICULAR DISEASE OF THE
SIGMOID COLON. AN ANALYSIS OF SHORT TERM
          OUTCOME IN 392 PATIENTS   .
 HAGLUND HELLBERG JOHNSON & HULTEN ANN CHIR
               GYNAECOL 1979


    AFTER FULL RECOVERY

    THE PATIENT RISK OF EPISODES

    NOT SIGNIFICANTLY DIFFERENT

    THAN ANY PATIENT WITH DIVERTICULOSIS.
    SEVERE DIVERTICULITIS AFTER HEART
         LUNG TRANSPLANTATION

      QASABIAN ET AL J HEART LUNG TRANSPLANT 2004

                  CONCLUSION

   IMMUNOCOMPROMISED PATIENTS INCREASED
    RISK OF DIVERTICULITIS

   INCREASED MORBIDITY AND MORTALITY RATES

   PATIENTS WITH PERCUTANEOUS ABSCESS
    DRAINAGE AT INCREASED RISK

   SHOULD BE OFFERED ELECTIVE SURGERY.
     SEVERE DIVERTICULITIS AFTER
    HEART LUNG TRANSPLANTATION

QASABIAN ET AL J HEART LUNG TRANSPLANT 2004

                 CONCLUSION

   ELECTIVE SURGERY RARELY:-

       AFTER A COMPLETE RECOVERY FROM ONE OR
        TWO EPISODES OF DIVERTICULITIS
         MANAGEMENT OF DIVERTICULITIS IN
               YOUNGER PATIENTS
           NELSON & ALDIS COLON RECTUM 2006




   RESECTION AFTER A SINGLE ATTACK:-
       ACCEPTED AS CONVENTIONAL WISDOM
        DUE TO A MORE VIRULENT COURSE.
     MANAGEMENT OF DIVERTICULITIS IN
           YOUNGER PATIENTS
       NELSON & ALDIS COLON RECTUM 2006



   5499 PATIENTS REVIEWED
    RETROSPECTIVELY

   962 PATIENTS LESS THAN 50 YRS

   CT PERFORMED IN 411 PATIENTS

   335 UNCOMPLICATED 76 COMPLICATED
     MANAGEMENT OF DIVERTICULITIS IN
           YOUNGER PATIENTS
        NELSON & ALDIS COLON RECTUM 2006


        UNCOMPLICATED 335 CASES

   101 ELECTIVE OPERATION
   234 FOLLOWED UP
   67 RECURRENT EPISODES
   10 COMPLICATED
   5 EMERGENCY OPERATION + COLOSTOMY
    MANAGEMENT OF DIVERTICULITIS IN
          YOUNGER PATIENTS
       NELSON & ALDIS COLON RECTUM 2006




         COMPLICATED 76 CASES

   23 EMERGENCY OP WITH COLOSTOMY
   38 ELECTIVE OPERATION
   15 NO FURTHER ATTACKS
   7 RECURRENT UNCOMPLICATED ATTACKS.
     MANAGEMENT OF DIVERTICULITIS IN
           YOUNGER PATIENTS
       NELSON & ALDIS COLON RECTUM 2006


              CONCLUSIONS

   YOUNG PATIENTS WITH UNCOMPLICATED
    DIVERTICULITIS ON CT RESPOND WELL TO
    MEDICAL MANAGEMENT

   SELDOM REQUIRE EMERGENCY OPERATION
    WITH COLOSTOMY

   SHOULD BE TREATED BY THE SAME CRITERIA AS
    OLDER PATIENTS
           LAPAROSCOPY
           Re-examination
   DISEASE FREE SURVIVAL

   MORBIDITY


   MORTALITY

   QUALITY OF LIFE
             LAPAROSCOPY


   Has promoted a shift

   From not operating on patients with
    multiple attacks of diverticulitis

   To pre-emptive prophylactic resections to
    prevent complications
     Prospective evaluation of functional
     outcome after laparoscopic sigmoid
                  colectomy
       Forgione A et al Ann Surg Feb 2009

   46 patient studied after laparoscopic
    sigmoidectomy

   Significant improvement in quality of life
    compared to pre-operative scores
Laparoscopic sigmoid resection
for diverticulitis decreases major
 morbidity rates: a randomized
    control trial. (Sigma trial)
        Klarenbeek et al, Ann Surg Jan 2009


   Laparoscopic surgery associated with
    15.4% reduction in major complications
     New indications for laparoscopic
            sigmoidectomy
    Bashankaev B and Stephen Wexler
           Nature Reviews July 2009


   Prospective trials needed

   Laparoscopy data challenges the
    dogma of our current practice
              FINAL ANALYSIS


   Decisions decided on a case by case basis

   confusion in what designates “complicated”

   Surgery for uncontrolled peritonitis and sepsis
           FINAL ANALYSIS



   Stoma still used for severe cases

   Anastomoses in some of these cases
             FINAL ANALYSIS

   No prophylactic surgery for uncomplicated
    cases even after several attacks

   Sigmoidectomy after first or second
    complicated attack

   Sigmoidectomy first attack in immune-
    compromised
              FINAL ANALYSIS


   Treat below 50 as above 50 but live longer,
    more time to develop complications

   Recent trend
     Earlier laparoscopic sigmoidectomy.
     Improves quality of life

     Fewer postoperative complications
THANK YOU FOR YOUR ATTENTION

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:140
posted:7/26/2012
language:
pages:58