Transcript Practice Parameters for Sigmoid Diverticulitis

Practice Parameters for
Sigmoid
Diverticulitis
Janice F. Rafferty, M.D.
Professor, University of Cincinnati
Department of Surgery
Chief, Division of Colon and Rectal Surgery
Cincinnati, Ohio, USA
Practice Parameters for Sigmoid
Diverticulitis
 Paul Shellito, M.D.
 Neil H. Hyman, M.D.
 W. Donald Buie, M.D.
 Standards Committee of The American
Society of Colon and Rectal Surgeons
Dis Colon Rectum 2006; 49: 939–944
Practice Parameters for Sigmoid
Diverticulitis
 Published literature from January 2000 to
August 2005 was retrieved and reviewed.
 Searches of MEDLINE were performed by
using keywords: diverticulitis,
diverticulosis, peridiverticulitis, and fistula.
Levels of Evidence
 I
Meta-analysis of multiple well-designed, controlled studies,
randomized trials with low-false positive and low-false negative errors
(high power)
 II At least one well-designed experimental study; randomized trials
with high false-positive or high false-negative errors or both (low
power)
 III Well-designed, quasi experimental studies, such as
nonrandomized, controlled, single-group, preoperative-postoperative
comparison, cohort, time, or matched case-control series
 IV Well-designed, nonexperimental studies, such as comparative
and correlational descriptive and case studies
 V
Case reports and clinical examples
Adapted from Cook DJ, Guyatt GH, Laupacis A,
Sackett DL. Rules of evidence and clinical
recommendations on theuse of antithrombotic
agents. Chest 1992;102(4 Suppl):305S–11S
Grade of Recommendation
 A Evidence of type I or consistent findings from
multiple studies of Type II, III, or IV
 B Evidence of Type II, III, or IV and generally
consistent findings
 C Evidence of Type II, III, or IV but inconsistent
findings
 D Little or no systematic empirical evidence
Statement of the Problem
 Acquired colonic diverticular disease affects the sigmoid
colon in 95 percent of cases.
 Thirty-five percent of patients with sigmoid diverticulosis
also have more proximal diverticuli
 Diverticula are rare below the pelvic peritoneal reflection.
 Prevalence correlates with age:
* 30 percent by age 60 years
* 60 percent of those 80 years and older
 10-25 % of those with diverticulosis -> diverticulitis
Diverticular Disease
 2.2 million cases
(2 billion dollars)
Sandler Gastroenterology
2002
 Health care costs$1.7 trillion
www.cms.hhs.gov/statistics
(accessed 4/1/2005)
Diverticular Disease-Etiology
 Deficiency of dietary fiber (Burkitt and Painter Lancet
1972, Backo BJS 2001:88:1595, Aldoori AM J Clin Nutr 1994)
 Segmentation and high intra-colonic
pressures
 Aging (decreased tensile strength of
collagen and muscle fibers)
 Hereditary disorders (Marfan’s and Ehler’s
Danlos syndrome)
Initial Diagnosis
 History and physical exam
 Helpful tests: KUB, CBC, urinalysis (V,D)
 Alternative diagnoses:

*irritable bowel syndrome * gastroenteritis
* bowel obstruction
* appendicitis
* colorectal cancer
*kidney stone
* IBD
*ischemic colitis
*urinary tract infection
*gynecologic disorder
Acute Diverticulitis
Making the Diagnosis
Signs and Symptoms
Fever
Leukocytosis
left lower quadrant pain with
or without mass
Initial Diagnosis: CT Scan
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Accuracy enhanced by enteral contrast
Highly sensitive and specific
High PPV for inflammation and wall thickness
Can identify complications
“Severity staging” possible
III, A
CT Scan: Severity Staging
 More severe inflammation predictive of
* Failure of medical management
* Future complications
Detry R, James J, Kartheuser A, et al.
Acute localized diverticulitis: optimum management requires accurate staging.
Int J Colorectal Dis 1992;7:38–42
Chautems RC, Ambrosetti P, Ludwig A, Mermillod B,Morel P, Soravia C.
Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery
mandatory? A prospective study of 118 patients.
Dis Colon Rectum 2002;45:962–6
CT Criteria to assess severity of
Diverticulitis
Mild
 Localized sigmoid
wall thickening (>5
mm)
 Inflammation of
pericolic fat
Severe
 Abscess
 Extraluminal air
 Extraluminal contrast
Ambrosetti et al Dis Colon Rectum
2000:43:1363-7
Acute Diverticulitis
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Hinchey Classification
Stage I Pericolic Abscess
Stage II Pelvic,
Retroperitoneal or intraabdominal abscess
Stage III Purulent
Peritonitis
Stage IV Fecal Peritonitis
Hinchey et al Adv Surg
1978:12:85-105.
Phlegmon
Phlegmon
Free Air
Diagnosis: Other modalities
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Ultrasound
Barium enema
Flexible sigmoidoscopy
Cystoscopy
III, B
Acute Diverticulitis
Contrast enema findings
 “Deformed diverticula”
 Extravasation of contrast
 Intramural fistulization
 Spasm
 Stricture
 Diverticulosis
Fistula
Medical treatment of acute
diverticulitis
 Nonoperative treatment typically includes dietary
modification and oral or intravenous antibiotics (III, B)
 Successful in 70-100 % of patients.
 OUTPATIENT MANAGEMENT: appropriate IF NO
* fever
* excessive vomiting
* marked peritonitis
 Must have opportunity for follow-up
 Patient should be able to take liquids and antibiotics PO
CT guided drainage
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15% will have pelvic or mesenteric abscess
>2cm abscess: in patient care plus drainage
<2cm: may resolve without drainage
May allow multi-staged approach
Stoma avoidance
III, B
Role of Percutaneous Drainage
 Well Defined Abscess
 “Radiologic Window”
 Contraindicated in patients
with generalized
peritonitis or
pneumoperitoneum
 Generally NOT necessary
for patients with small
pericolic abscesses
Emergency surgery for acute
diverticulitis (III, B)
 Severe or diffuse peritonitis (Hinchey 3,4)
 Failure of medical management
 Surgical options:
* Hartman’s procedure
* primary anastomosis (Hinchey 2-3)
* anastomosis with proximal diversion
Hartmann Resection
Elective surgery after
uncomplicated diverticulitis
 Evaluate on case by case basis
 1/3 will have episode within one year
 Additional 1/3 will have a third attack
 Elective resection may not decrease
likelihood of complications
 Worst episode=first episode
 III, B
Elective surgery after
uncomplicated diverticulitis
 CT graded severity predictive of natural
history: more sever= worse outcome
 Inability to exclude carcinoma
 Immunosuppression
Natural history of diverticulitis
Age/Severity on CT n
<50/Mild
<50/Severe
>50/Mild
>50/Severe
14
14
74
16
Poor Outcome
6
9
16
7
Probability
at 5 yrs
36
54%
19
44%
Chautems et al Dis Colon Rectum 2002;45:962-966
Diverticulitis and Renal Disease
 184 renal failure patients
• 59 PKD
• 125 ESRD
 12 pts with PKD had acute diverticulitis versus 4
of non-PKD (20% v. 3%)
 50% required surgery
 Suggested diverticular disease may be an
extrarenal manifestation of PKD
Lederman AM Surg 2000;66:200-3
Young patients with
diverticulitis
 Virulence appears to be no different
 Male predominance
 Longer life=increased cumulative risk?
 Younger patients more likely to present
with severe disease
Diverticulitis in Young Patients
 40 patients - < 50 years old
 25% - surgery on first admission
 Two- thirds did not require surgery during
the follow-up period of 4-9 years
Vignati et al Dis Colon Rectum 1995;38:627-629.
Diverticulitis in Young Patients:
retrospecive review: 5,499 patients
 962 <50 years; 411 had CT with 1st episode of disease
 335 (81%) uncomplicated diverticultitis- 234 were followed nonoperatively.
28% recurrent uncomplicated episode,
4% recurrent complicated episode
2% required emergent operation and colostomy.
 76 (19%) complicated diverticultitis
23 emergent surgery, 38 elective surgery, 15 non-operative management
 7/15 recurrent uncomplicated episode
 None required emergent operation or colostomy.
Nelson RS, Velasco A, Mukesh BN.
Dis Colon Rectum. 2006 Sep;49(9):1341-5
Young patients with
diverticulitis
< 40 years
Severe
72%
Emergent Op 40%
>40 years
35%
13%
p<.02
p<.04
*Pautrat K, Bretagnol F, Huten N, de Calan L.
Department of Digestive Surgery, Trousseau Hospital, Tours, France.
Dis Colon Rectum. 2007 Apr;50(4):472-7
Complicated diverticulitis
 Abscess
 Stricture
 Fistula
 Bleeding
Stricture
Diverticular fistulas
Complicated diverticulitis
 41% will develop severe recurrent sepsis
 Elective resection following abscess
drainage recommended
 III, B
Kaiser AM, Jiang JK, Lake JP, Atrinvan A, Gonzalez-Ruiz C, Beart RW Jr.
Am J Gastroenterol. 2005 Apr;100(4):910-7
Non-operative management of
Complicated diverticulitis
 Retrospective study- 256 patients with complicated
diverticulitis on CT; 99 managed non-operatively
 Patient outcomes were reviewed.
 46% had a recurrent episode
 20 underwent a sigmoid colon resection, 1 required stoma
 No recurrence resulted in emergency resection
Nelson RS, Ewing BM, Wengert TJ, Thorson AG.
Am J Surg. 2008 Dec;196(6):969-72
Extent of resection
 Proximal margin: pliable colon without
hypertrophy or inflammation
 Distal margin: splay of taenia
 Risk of recurrence higher with colosigmoid
anastomosis
 III, B
Level of Anastomosis and
Recurrent Diverticulitis
Anastomosis
Number
Colocolostomy
Coloproctostomy
321
180
Recurrence
# (%)
40(12.5)
12(6.7)
501
52
Total
Benn et al Am J Surg 1986;151:269-71
Laparoscopy for diverticulitis
 Appropriate in selected patients
 No increase in complications
 Cost and outcomes comparable
 III, A
Conclusions
 Timing and need for surgical treatment of sigmoid
diverticular disease remains a topic of controversy.
 Elective surgery for diverticulitis can be avoided in
patients with uncomplicated disease, regardless of the
number of recurrent episodes.
 Age of the patient should not influence need for elective
surgery
 Clinical exam, and radiologic severity index, help
determine which patients need operation
Thank you
Janice Rafferty, MD
University of Cincinnati
Division of Colorectal
Surgery
2123 Auburn Avenue
Suite 524
Cincinnati, Ohio 45219
(513) 929-0104