Original Paper Received: November 25, 2014 Accepted after revision: January 25, 2015 Published online: March 5, 2015
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis Nir Horesh Andrew P. Zbar Avinoam Nevler Nadav Haim Mordechai Gutman Oded Zmora Department of Surgery and Transplantation, Chaim Sheba Medical Center, Sackler Medical School and Tel Aviv University, Ramat Gan, Israel
Abstract Background: Contemporary surgical management of complicated diverticulitis is controversial. Traditionally, the gold standard has been resection and colostomy, but recently peritoneal lavage and drainage without resection in cases of purulent peritonitis have been suggested. This study aims to review our initial experience with laparoscopic peritoneal lavage for complicated diverticulitis. Methods: Retrospective review of all patients who underwent emergent peritoneal lavage and drainage for acute complicated diverticulitis. Results: Five-hundred-thirty-eight patients admitted for acute diverticulitis between 2007 and 2012 were recorded in the database. Thirty seven underwent emergent surgery of which 10 had peritoneal lavage and drainage without colonic resection for complicated diverticulitis causing peritonitis. Peritoneal lavage and drainage resulted in the resolution of acute symptoms in all cases. In long-term follow-up, 3 (30%) patients required elective resection owing to symptomatic disease, two of these due to recurrent diverticulitis, and one owing to complicated fistula following the procedure. Conclusion: Peritoneal lavage is a feasible option for complicated diverticulitis with purulent non-fecal peritonitis, but a significant portion of the patients may require elec-
© 2015 S. Karger AG, Basel 0253–4886/15/0322–0108$39.50/0 E-Mail [email protected] www.karger.com/dsu
tive resection. Comparative studies with emergent resection are needed to determine the role of peritoneal lavage in complicated diverticulitis. © 2015 S. Karger AG, Basel
Introduction
The surgical treatment of acute diverticulitis is dramatically changing in recent years. It has changed from a three-step procedure to the two-stage Hartmann’s procedure, to a one-stage resection and primary anastomosis, mainly in elective patients. Since the late 1990s, there is increasing evidence that peritoneal lavage and drainage may be a viable option in selected patients, avoiding the resection of the perforated diseased sigmoid colon. Minimally invasive procedure without resection may potentially decrease postoperative complications including wound infection and anastomotic leaks, and it overcomes patient’s difficulties coping with the stoma [1]. The first series of laparoscopic peritoneal lavage and drainage, reported in 1996 by O’Sullivan et al. [2], included 8 patients with excellent results. Further prospective studies indicated that although peritoneal lavage is a viable option,
Podium Presentation – Jagelman/Turnball Colorectal convention – February 2014, Cleveland clinic – Fort Lauderdale, Florida, USA.
Nir Horesh Yoni Netanyahu 18 Givat Shmuel, 54424 (Israel) E-Mail nir_horesh @ hotmail.com, nir.horesh @ sheba.health.gov.il
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
Key Words Diverticulitis · Colonic perforation · Emergency surgery · Peritoneal lavage
this surgical technique may not resolve all the aspects involving surgical management of acute complicated diverticulitis. Currently, there are no firm and widely accepted guidelines for the selection of patients for either laparoscopic peritoneal lavage and drainage, or resection with or without anastomosis. The aim of this study is to review our initial experience with peritoneal lavage over the last few years.
Table 1. Patient demographics
Age ASA BMI M:F
Range
Median
38–73 1–3 24.6–39.6 8:2
46.3 1.8 27.2
Table 2. Patient Hinchey classification
Methods Hinchey score Definition 2 3 4
Patients
Diverticulitis with pelvic/ 2 retroperitoneal abscess Diverticulitis with purulent peritonitis 7 Diverticulitis with fecal peritonitis 1
Retrospective data analysis from a collective database of admissions for acute diverticulitis from January 2007 to June 2013 yielded 538 admissions. Ninety patients underwent surgery, of which 37 patients were treated with emergency surgery. Nineteen out of 37 patients were treated with the Hartmann’s procedure. Eight patients out of 37 underwent a segmental resection with primary
anastomosis, 7 in the left colon and one in the right colon. Overall, 10 patients out of 37 underwent diagnostic laparoscopy with peritoneal lavage between March 2008 to June 2013, with a median age of 46.3 years, of which 8 were males and 2 females. All patients gave their informed consent to the lavage and drainage procedure should the operative findings fit bases on attending surgeon’s judgment. Patients’ demographics are outlined in table 1. Interestingly, none of the patients had history of diverticulitis or diverticular disease prior to admission, and all of these patients were operated owing to perforation on their first episode of diverticulitis. Patients were classified according to the Hinchey score [3] in according to intraoperative findings as detailed in table 2. All patients demonstrated large amounts of free air in imaging studies with clinical signs of peritonitis, and therefore, emergent surgical intervention was decided. In retrospective, intra-operative findings demonstrated that 2 patients presented with a Hinchey Class 2 perforation, which can be treated in most cases only with a percutaneous drainage, but the severity of symptoms along with the radiological findings led to the decision of them being operated by the attending surgeon on call. Eight out of 10 patients had complicated diverticulitis of the left colon, mainly at the sigmoid colon. Two patients had perforated ascending colonic diverticula. Nine were taken to the operating room within the first 24 h from arrival to the emergency department and one patient diagnosed with sealed perforated diverticulitis was first treated conservatory and deteriorated 5 days later and was taken urgently to surgery. Length of hospital stay varied from 5 to 22 days with an average of 11 days. Patients resumed regular
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
Results
109
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
Retrospective analysis of patients who underwent intraperitoneal lavage and drainage as the surgical treatment for complicated acute diverticulitis was performed based on a database of admissions for diverticulitis from January 2007 to June 2013. Data relative to the clinical presentation, surgical procedure, hospital admission and follow-up were recorded. All patients in this series presented with clinical signs of peritonitis along with radiological evidence of intra-abdominal free air in either CT scans or plain abdominal radiography due to complicated diverticular disease. Nine out of 10 patients underwent a CT scan upon arrival to the ER due to clinical signs of peritonitis with evidence of free intraperitoneal air and contrast leakage from the colon due to complicated diverticular perforation. One patient was initially diagnosed using a CT scan with a sealed colonic perforation due to complicated diverticulitis and after 5 days of treatment with intravenous antibiotics, the patient demonstrated worsening abdominal pain with an increase in white blood cells count. An abdominal plain radiograph was performed demonstrating free air and the patient was taken to the OR. All patients were taken to surgery after initial treatment with intravenous fluid resuscitation and broad spectrum antibiotics. The surgical procedure included laparoscopic evaluation, minimal mobilization to allow adequate exploration, abscess drainage and intra-abdominal warm saline irrigation until the liquid clarified. Care was taken to avoid unsealing of the perforation site, avoiding dissection of adhered bowel loops and omentum off the diseased sigmoid colon. A Jackson-Pratt closed suction drain was left in the peritoneal cavity and adjacent to the diseased bowel loop. Intra-operative assessment of the Hinchey score recorded along with intra operative findings. All patients were treated with antibiotics in the postoperative period for at least a week. The JP drainage tube was removed during the postoperative period. Patients were followed for a period varying from 2 months to 30 months (median 9 months).
Discussion
The prevalence of acute diverticulitis gradually increases due to various factors including dietary habits and aging population. Diverticular disease is estimated to be found in over 60% of the population over the age of 65 [4]. The increase in life expectancy around the world has a direct effect on the increasing number of hospital admissions for acute diverticular disease. A nationwide inpatient study of hospitalizations in the United States showed an increase of 26 percent in admissions for acute diverticulitis from 1998 to 2005 [5]. Complicated diverticulitis, that accounts for 15–25% of all cases that manifest clinically and can present with a wide range of symptoms. Colonic perforation due to acute diverticulitis is often the first manifestation of the disease [6], usually resulting with acute peritonitis. Cases of complicated diverticulitis usually require surgical intervention, and are associated with high morbidity and a significant mortality rate that may range from 5 to 25% [6–9]. 110
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
The surgical management of complicated acute diverticulitis has changed significantly in the past decades. Until the 1980s, a three-stage procedure was recommended for complicated diverticulitis. This included a diverting colostomy with drainage as an initial step, elective resection of the involved segment and finally a closure of the colostomy [10]. With improved operative perioperative care, the Hartmann’s procedure became the gold standard [11] due to improved surgical outcome with fewer comorbidities when compared with other surgical techniques [12]. Recently, several authors have suggested the use of laparoscopic lavage and drainage in complicated diverticulitis. The first major study was published by Myers et al. [1] in 2008. This study of 92 patients suggested that peritoneal lavage and drainage is a low-risk surgical option for complicated diverticulitis. Several other non comparative studies that were conducted later showed similar results [13–18]. Despite being a relatively small series, our initial experience suggests that despite a high rate of initial success, a significant portion of patients undergoing laparoscopic peritoneal lavage and drainage may suffer from persistent symptoms requiring further surgery with segmental resection. In most cases, this resection may be done in the elective setting, avoiding the need for a temporary stoma. Indeed, several systemic reviews and meta-analyses [19–23] concluded that further investigation is needed in order to define the role of laparoscopic peritoneal lavage and drainage in the treatment of acute diverticulitis. The LADIES trial, a Dutch multicenter prospective trial [24] that compared peritoneal lavage, Hartmann procedure and resection with primary anastomosis has been prematurely terminated at interim analysis owing to high complication rates in the lavage and drainage group. A Scandinavian prospective multicenter trial is currently accruing, but results are pending. Several studies demonstrated that peritoneal lavage and drainage offer better patient outcome when dealing with a Hinchey class 2 and 3 perforation. White et al. [16] concluded that peritoneal lavage is preferable in patients with a Hinchey class 3 perforation, and Gentile et al. [25] demonstrated that peritoneal lavage offers several advantages, including decreased need for ICU admission and shorter length of stay when compared to the Hartmann’s procedure in Hinchey class 2 and 3 perforations, but both studies have a relatively small group of patients , and the latter includes the Hinchey class 2 patients, who could also be treated with percutaneous drainage alone. The meta-analysis conducted by Cirocchi et al. [23] concluded that further investigation is needed to determine the role of peritoneal lavage when compared with primary Horesh/Zbar/Nevler/Haim/Gutman/ Zmora
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
diet on average on the 5th postoperative day based on clinical course. Three out of 10 patients developed intra or early postoperative complications. One patient developed postoperative sepsis due to abdominal abscess most probably due to inadequate peritoneal irrigation during surgery. These patients were treated successfully with a CT-guided percutaneous drainage. One suffered from bleeding from epigastric vessel requiring transfusion. The third suffered from continuous sacral pain and agonizing pain on defecation requiring readmission. Magnetic resonance demonstrated a complicated fistula originating from the sigmoid colon, branching to 3 different directions at the pelvis and around the rectum. This patient was planned for an elective sigmoidectomy and take down of the fistulas, but extensive pelvic fibrosis led to more extensive resection with anterior resection and protective ileostomy. The stoma was reversed several months later with complete resolution of the symptoms. On follow-up after hospital discharge, a total of 4 (40%) required surgery. In addition to the aforementioned patient, 2 patients underwent laparoscopic or robotic sigmoidectomy due to the recurrence of diverticulitis, presenting with abdominal pain, fever and leukocytosis at an average of 9 months. A fourth patient underwent robotic proctectomy one year following the lavage and drainage procedure due to incidental finding of rectal cancer in postoperative colonoscopy.
anastomosis and the Hartmann’s procedure in Hinchey class 3 and 4 perforations. Finally, a study conducted by Liang et al. [26] demonstrated that although laparoscopic lavage and drainage shows better results as a damage control acute surgery, it does not remove the pathogenic source and therefore requires additional elective surgery in Hinchey class 3 and 4 perforations. These studies and others lead to the conclusion that though several surgical options exist today for treating acute complicated diverticular perforation, the therapeutic approach should be tailored to the patient according to the clinical scenario and according to the therapeutic goal [27]. The accurate diagnosis of diverticular disease as a cause for perforation is an additional concern of the laparoscopic lavage and drainage. Despite modern imaging techniques, perforated cancer of the left or sigmoid colon and upper rectum may result in similar clinical presentation. Laparoscopic lavage without resection may leave perforated tumors undetected, emphasizing the impor-
tance of colonoscopy in the follow-up of these patients. Indeed, in one patient in our series, rectal cancer was diagnosed in colonoscopy, requiring further resection.
Conclusion
Our initial experience suggests that peritoneal lavage is a feasible option for the emergent treatment of complicated acute diverticulitis. Laparoscopic peritoneal lavage and drainage treated the acute symptoms in all patients in our series, and prevented further decline toward a lifethreatening clinical emergency. However, a significant portion of the patients required additional surgery, with 30% of the patients requiring additional surgery for diverticular disease. Further, large-scale comparative studies are needed to define the role of laparoscopic peritoneal lavage and drainage and establish guidelines for patients’ selection in complicated diverticulitis.
1 Myers E, et al: Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95: 97– 101. 2 O’Sullivan GC, et al: Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996;171: 432–434. 3 Hinchey EJ, Schaal PG, Richards GK: Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85–109. 4 Painter NS, Burkitt DP: Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol 1975;4:3–21. 5 Etzioni DA, et al: Diverticulitis in the United States: 1998–2005: changing patterns of disease and treatment. Ann Surg 2009;249:210– 217. 6 Morris CR, et al: Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008;95:876–881. 7 Salem L, Flum DR: Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004;47:1953–1964. 8 Constantinides VA, Tekkis PP, Senapati A: Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 2006; 93: 1503–1513. 9 Vermeulen J, et al: [Hospital mortality after emergency surgery for perforated diverticulitis]. Ned Tijdschr Geneeskd 2009; 153: 1209– 1214. 10 Large JM: Treatment of perforated diverticulitis. Lancet 1964;1:413–414.
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis
11 Krukowski ZH, Matheson NA: Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71:921–927. 12 Zeitoun G, et al: Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg 2000;87:1366–1374. 13 Franklin ME Jr, et al: Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 2008;32:1507–1511. 14 Favuzza J, et al: Benefits of laparoscopic peritoneal lavage for complicated sigmoid diverticulitis. Int J Colorectal Dis 2009; 24: 797– 801. 15 Lam HD, et al: Laparoscopic treatment in acute complicated diverticulitis: a review of 11 cases. Acta Chir Belg 2009;109:56–60. 16 White SI, Frenkiel B, Martin PJ: A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage. Dis Colon Rectum 2010; 53: 1537– 1541. 17 Rogers AC, et al: Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum 2012;55:932–938. 18 Edeiken SM, et al: Preliminary experience with laparoscopic peritoneal lavage for complicated diverticulitis: a new algorithm for treatment? Am Surg 2013;79:819–825. 19 Alamili M, Gögenur I, Rosenberg J: Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 2009; 52: 1345–1349.
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
20 Toorenvliet BR, et al: Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010; 12: 862–867. 21 Afshar S, Kurer MA: Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis. Colorectal Dis 2012;14:135–142. 22 Martin ST, Stocchi L: New and emerging treatments for the prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011; 4: 203–212. 23 Cirocchi R, et al: Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2013; 28: 447–457. 24 Swank HA, et al: The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 2010;10:29. 25 Gentile V, et al: Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann’s procedure vs. laparoscopic lavage and drainage in the elderly. Int J Surg 2014;12(suppl 2):S86–S89. 26 Liang S, Russek K, Franklin ME Jr: Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure. Surg Endosc 2012;26:2835–2842. 27 Santaniello M, Bergamaschi R: Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis 2007;9:494–495.
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References
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis Nir Horesh Andrew P. Zbar Avinoam Nevler Nadav Haim Mordechai Gutman Oded Zmora Department of Surgery and Transplantation, Chaim Sheba Medical Center, Sackler Medical School and Tel Aviv University, Ramat Gan, Israel
Abstract Background: Contemporary surgical management of complicated diverticulitis is controversial. Traditionally, the gold standard has been resection and colostomy, but recently peritoneal lavage and drainage without resection in cases of purulent peritonitis have been suggested. This study aims to review our initial experience with laparoscopic peritoneal lavage for complicated diverticulitis. Methods: Retrospective review of all patients who underwent emergent peritoneal lavage and drainage for acute complicated diverticulitis. Results: Five-hundred-thirty-eight patients admitted for acute diverticulitis between 2007 and 2012 were recorded in the database. Thirty seven underwent emergent surgery of which 10 had peritoneal lavage and drainage without colonic resection for complicated diverticulitis causing peritonitis. Peritoneal lavage and drainage resulted in the resolution of acute symptoms in all cases. In long-term follow-up, 3 (30%) patients required elective resection owing to symptomatic disease, two of these due to recurrent diverticulitis, and one owing to complicated fistula following the procedure. Conclusion: Peritoneal lavage is a feasible option for complicated diverticulitis with purulent non-fecal peritonitis, but a significant portion of the patients may require elec-
© 2015 S. Karger AG, Basel 0253–4886/15/0322–0108$39.50/0 E-Mail [email protected] www.karger.com/dsu
tive resection. Comparative studies with emergent resection are needed to determine the role of peritoneal lavage in complicated diverticulitis. © 2015 S. Karger AG, Basel
Introduction
The surgical treatment of acute diverticulitis is dramatically changing in recent years. It has changed from a three-step procedure to the two-stage Hartmann’s procedure, to a one-stage resection and primary anastomosis, mainly in elective patients. Since the late 1990s, there is increasing evidence that peritoneal lavage and drainage may be a viable option in selected patients, avoiding the resection of the perforated diseased sigmoid colon. Minimally invasive procedure without resection may potentially decrease postoperative complications including wound infection and anastomotic leaks, and it overcomes patient’s difficulties coping with the stoma [1]. The first series of laparoscopic peritoneal lavage and drainage, reported in 1996 by O’Sullivan et al. [2], included 8 patients with excellent results. Further prospective studies indicated that although peritoneal lavage is a viable option,
Podium Presentation – Jagelman/Turnball Colorectal convention – February 2014, Cleveland clinic – Fort Lauderdale, Florida, USA.
Nir Horesh Yoni Netanyahu 18 Givat Shmuel, 54424 (Israel) E-Mail nir_horesh @ hotmail.com, nir.horesh @ sheba.health.gov.il
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
Key Words Diverticulitis · Colonic perforation · Emergency surgery · Peritoneal lavage
this surgical technique may not resolve all the aspects involving surgical management of acute complicated diverticulitis. Currently, there are no firm and widely accepted guidelines for the selection of patients for either laparoscopic peritoneal lavage and drainage, or resection with or without anastomosis. The aim of this study is to review our initial experience with peritoneal lavage over the last few years.
Table 1. Patient demographics
Age ASA BMI M:F
Range
Median
38–73 1–3 24.6–39.6 8:2
46.3 1.8 27.2
Table 2. Patient Hinchey classification
Methods Hinchey score Definition 2 3 4
Patients
Diverticulitis with pelvic/ 2 retroperitoneal abscess Diverticulitis with purulent peritonitis 7 Diverticulitis with fecal peritonitis 1
Retrospective data analysis from a collective database of admissions for acute diverticulitis from January 2007 to June 2013 yielded 538 admissions. Ninety patients underwent surgery, of which 37 patients were treated with emergency surgery. Nineteen out of 37 patients were treated with the Hartmann’s procedure. Eight patients out of 37 underwent a segmental resection with primary
anastomosis, 7 in the left colon and one in the right colon. Overall, 10 patients out of 37 underwent diagnostic laparoscopy with peritoneal lavage between March 2008 to June 2013, with a median age of 46.3 years, of which 8 were males and 2 females. All patients gave their informed consent to the lavage and drainage procedure should the operative findings fit bases on attending surgeon’s judgment. Patients’ demographics are outlined in table 1. Interestingly, none of the patients had history of diverticulitis or diverticular disease prior to admission, and all of these patients were operated owing to perforation on their first episode of diverticulitis. Patients were classified according to the Hinchey score [3] in according to intraoperative findings as detailed in table 2. All patients demonstrated large amounts of free air in imaging studies with clinical signs of peritonitis, and therefore, emergent surgical intervention was decided. In retrospective, intra-operative findings demonstrated that 2 patients presented with a Hinchey Class 2 perforation, which can be treated in most cases only with a percutaneous drainage, but the severity of symptoms along with the radiological findings led to the decision of them being operated by the attending surgeon on call. Eight out of 10 patients had complicated diverticulitis of the left colon, mainly at the sigmoid colon. Two patients had perforated ascending colonic diverticula. Nine were taken to the operating room within the first 24 h from arrival to the emergency department and one patient diagnosed with sealed perforated diverticulitis was first treated conservatory and deteriorated 5 days later and was taken urgently to surgery. Length of hospital stay varied from 5 to 22 days with an average of 11 days. Patients resumed regular
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
Results
109
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
Retrospective analysis of patients who underwent intraperitoneal lavage and drainage as the surgical treatment for complicated acute diverticulitis was performed based on a database of admissions for diverticulitis from January 2007 to June 2013. Data relative to the clinical presentation, surgical procedure, hospital admission and follow-up were recorded. All patients in this series presented with clinical signs of peritonitis along with radiological evidence of intra-abdominal free air in either CT scans or plain abdominal radiography due to complicated diverticular disease. Nine out of 10 patients underwent a CT scan upon arrival to the ER due to clinical signs of peritonitis with evidence of free intraperitoneal air and contrast leakage from the colon due to complicated diverticular perforation. One patient was initially diagnosed using a CT scan with a sealed colonic perforation due to complicated diverticulitis and after 5 days of treatment with intravenous antibiotics, the patient demonstrated worsening abdominal pain with an increase in white blood cells count. An abdominal plain radiograph was performed demonstrating free air and the patient was taken to the OR. All patients were taken to surgery after initial treatment with intravenous fluid resuscitation and broad spectrum antibiotics. The surgical procedure included laparoscopic evaluation, minimal mobilization to allow adequate exploration, abscess drainage and intra-abdominal warm saline irrigation until the liquid clarified. Care was taken to avoid unsealing of the perforation site, avoiding dissection of adhered bowel loops and omentum off the diseased sigmoid colon. A Jackson-Pratt closed suction drain was left in the peritoneal cavity and adjacent to the diseased bowel loop. Intra-operative assessment of the Hinchey score recorded along with intra operative findings. All patients were treated with antibiotics in the postoperative period for at least a week. The JP drainage tube was removed during the postoperative period. Patients were followed for a period varying from 2 months to 30 months (median 9 months).
Discussion
The prevalence of acute diverticulitis gradually increases due to various factors including dietary habits and aging population. Diverticular disease is estimated to be found in over 60% of the population over the age of 65 [4]. The increase in life expectancy around the world has a direct effect on the increasing number of hospital admissions for acute diverticular disease. A nationwide inpatient study of hospitalizations in the United States showed an increase of 26 percent in admissions for acute diverticulitis from 1998 to 2005 [5]. Complicated diverticulitis, that accounts for 15–25% of all cases that manifest clinically and can present with a wide range of symptoms. Colonic perforation due to acute diverticulitis is often the first manifestation of the disease [6], usually resulting with acute peritonitis. Cases of complicated diverticulitis usually require surgical intervention, and are associated with high morbidity and a significant mortality rate that may range from 5 to 25% [6–9]. 110
Dig Surg 2015;32:108–111 DOI: 10.1159/000375539
The surgical management of complicated acute diverticulitis has changed significantly in the past decades. Until the 1980s, a three-stage procedure was recommended for complicated diverticulitis. This included a diverting colostomy with drainage as an initial step, elective resection of the involved segment and finally a closure of the colostomy [10]. With improved operative perioperative care, the Hartmann’s procedure became the gold standard [11] due to improved surgical outcome with fewer comorbidities when compared with other surgical techniques [12]. Recently, several authors have suggested the use of laparoscopic lavage and drainage in complicated diverticulitis. The first major study was published by Myers et al. [1] in 2008. This study of 92 patients suggested that peritoneal lavage and drainage is a low-risk surgical option for complicated diverticulitis. Several other non comparative studies that were conducted later showed similar results [13–18]. Despite being a relatively small series, our initial experience suggests that despite a high rate of initial success, a significant portion of patients undergoing laparoscopic peritoneal lavage and drainage may suffer from persistent symptoms requiring further surgery with segmental resection. In most cases, this resection may be done in the elective setting, avoiding the need for a temporary stoma. Indeed, several systemic reviews and meta-analyses [19–23] concluded that further investigation is needed in order to define the role of laparoscopic peritoneal lavage and drainage in the treatment of acute diverticulitis. The LADIES trial, a Dutch multicenter prospective trial [24] that compared peritoneal lavage, Hartmann procedure and resection with primary anastomosis has been prematurely terminated at interim analysis owing to high complication rates in the lavage and drainage group. A Scandinavian prospective multicenter trial is currently accruing, but results are pending. Several studies demonstrated that peritoneal lavage and drainage offer better patient outcome when dealing with a Hinchey class 2 and 3 perforation. White et al. [16] concluded that peritoneal lavage is preferable in patients with a Hinchey class 3 perforation, and Gentile et al. [25] demonstrated that peritoneal lavage offers several advantages, including decreased need for ICU admission and shorter length of stay when compared to the Hartmann’s procedure in Hinchey class 2 and 3 perforations, but both studies have a relatively small group of patients , and the latter includes the Hinchey class 2 patients, who could also be treated with percutaneous drainage alone. The meta-analysis conducted by Cirocchi et al. [23] concluded that further investigation is needed to determine the role of peritoneal lavage when compared with primary Horesh/Zbar/Nevler/Haim/Gutman/ Zmora
Downloaded by: NYU Medical Center Library 128.122.253.228 - 4/19/2015 11:03:17 PM
diet on average on the 5th postoperative day based on clinical course. Three out of 10 patients developed intra or early postoperative complications. One patient developed postoperative sepsis due to abdominal abscess most probably due to inadequate peritoneal irrigation during surgery. These patients were treated successfully with a CT-guided percutaneous drainage. One suffered from bleeding from epigastric vessel requiring transfusion. The third suffered from continuous sacral pain and agonizing pain on defecation requiring readmission. Magnetic resonance demonstrated a complicated fistula originating from the sigmoid colon, branching to 3 different directions at the pelvis and around the rectum. This patient was planned for an elective sigmoidectomy and take down of the fistulas, but extensive pelvic fibrosis led to more extensive resection with anterior resection and protective ileostomy. The stoma was reversed several months later with complete resolution of the symptoms. On follow-up after hospital discharge, a total of 4 (40%) required surgery. In addition to the aforementioned patient, 2 patients underwent laparoscopic or robotic sigmoidectomy due to the recurrence of diverticulitis, presenting with abdominal pain, fever and leukocytosis at an average of 9 months. A fourth patient underwent robotic proctectomy one year following the lavage and drainage procedure due to incidental finding of rectal cancer in postoperative colonoscopy.
anastomosis and the Hartmann’s procedure in Hinchey class 3 and 4 perforations. Finally, a study conducted by Liang et al. [26] demonstrated that although laparoscopic lavage and drainage shows better results as a damage control acute surgery, it does not remove the pathogenic source and therefore requires additional elective surgery in Hinchey class 3 and 4 perforations. These studies and others lead to the conclusion that though several surgical options exist today for treating acute complicated diverticular perforation, the therapeutic approach should be tailored to the patient according to the clinical scenario and according to the therapeutic goal [27]. The accurate diagnosis of diverticular disease as a cause for perforation is an additional concern of the laparoscopic lavage and drainage. Despite modern imaging techniques, perforated cancer of the left or sigmoid colon and upper rectum may result in similar clinical presentation. Laparoscopic lavage without resection may leave perforated tumors undetected, emphasizing the impor-
tance of colonoscopy in the follow-up of these patients. Indeed, in one patient in our series, rectal cancer was diagnosed in colonoscopy, requiring further resection.
Conclusion
Our initial experience suggests that peritoneal lavage is a feasible option for the emergent treatment of complicated acute diverticulitis. Laparoscopic peritoneal lavage and drainage treated the acute symptoms in all patients in our series, and prevented further decline toward a lifethreatening clinical emergency. However, a significant portion of the patients required additional surgery, with 30% of the patients requiring additional surgery for diverticular disease. Further, large-scale comparative studies are needed to define the role of laparoscopic peritoneal lavage and drainage and establish guidelines for patients’ selection in complicated diverticulitis.
1 Myers E, et al: Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95: 97– 101. 2 O’Sullivan GC, et al: Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996;171: 432–434. 3 Hinchey EJ, Schaal PG, Richards GK: Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85–109. 4 Painter NS, Burkitt DP: Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol 1975;4:3–21. 5 Etzioni DA, et al: Diverticulitis in the United States: 1998–2005: changing patterns of disease and treatment. Ann Surg 2009;249:210– 217. 6 Morris CR, et al: Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008;95:876–881. 7 Salem L, Flum DR: Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004;47:1953–1964. 8 Constantinides VA, Tekkis PP, Senapati A: Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 2006; 93: 1503–1513. 9 Vermeulen J, et al: [Hospital mortality after emergency surgery for perforated diverticulitis]. Ned Tijdschr Geneeskd 2009; 153: 1209– 1214. 10 Large JM: Treatment of perforated diverticulitis. Lancet 1964;1:413–414.
Early Experience with Laparoscopic Lavage in Acute Complicated Diverticulitis
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