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Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study Franc¸ois Letarte, M.D.a,*, Julie Hallet, M.D., F.R.C.S.C.b, Se´bastien Drolet, M.D., F.R.C.S.C.a,c, Cindy Boulanger-Gobeil, M.D.a, Alexandre Bouchard, M.D., F.R.C.S.C.a,c, Roger C. Gre´goire, M.D., F.R.C.S.C.a,c, Jean-Pierre Gagne´, M.D., L.L.M., F.R.C.S.C.a,c, Claude Thibault, M.D., F.R.C.S.C.a,c, Philippe Bouchard, M.D., F.R.C.S.C.a,c a
Department of Surgery, Universite´ Laval, Que´bec, QC, Canada; bDivision of General Surgery, University of Toronto, Toronto, ON, Canada; cDepartment of Surgery, CHU de Que´bec - Hoˆpital SaintFranc¸ois d’Assise, Que´bec Centre for Minimally Invasive Surgery, 10 Rue de l’Espinay, Que´bec, QC, Canada KEYWORDS: Acute complicated diverticulitis; Emergency surgery; Minimally invasive surgery; Acute care surgery
Abstract 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 5 .02), time to oral intake shorter (3 vs 6 days; P , .01), and LOS shorter (5 vs 8 days; P 5 .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. Crown Copyright Ó 2014 Published by Elsevier Inc. All rights reserved.
The authors declare no conflicts of interest. Presented as podium presentation at the SAGES 2013 Annual Meeting and was awarded SAGES 2012 Best International Paper Acknowledgement. * Corresponding author. Tel.: 11-418-525-4160; fax: 11-418-691-5020. E-mail address: [email protected] Manuscript received May 29, 2014; revised manuscript July 13, 2014 0002-9610/$ - see front matter Crown Copyright Ó 2014 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.07.017
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Diverticular disease presents in the emergency setting as complicated diverticular disease (CDD) in 25% of cases, of which 25% require acute surgical management.1,2 The benefits of laparoscopic over open surgery have now been highlighted for the treatment of a variety of diseases, mainly because of decreased pain, blood loss, length of stay (LOS), and perioperative morbidity. It is now considered the preferred approach in most patients for the elective treatment of diverticular disease.3 Surgery for CDD, including intra-abdominal abscesses, intraperitoneal perforation, peritonitis, and acute obstruction, is undertaken in difficult local and systemic conditions. Compared with elective resection, emergent surgery pertains higher mortality and morbidity rates, longer hospital stays, and more frequent use of stoma that often become permanent. Patients treated in the emergency setting could potentially benefit significantly from the advantages of laparoscopic surgery, but this approach is still debated. Concerns remain regarding safety and feasibility of the laparoscopic approach considering technical challenges such as tissue friability, obliteration of dissection plane, distorted anatomy, poor visualization, and difficulty with mobilization of bowel. Few studies have examined the role of laparoscopic surgery for the acute treatment of CDD.4–8 The most recent guidelines of the European Association of Endoscopic Surgeons conclude that presumed acute uncomplicated diverticulitis should not be treated laparoscopically, except for the use of laparoscopic lavage in some selected cases.9 The American Society of Colon and Rectal Surgeons practice parameters on sigmoid diverticulitis do not comment on the use of laparoscopy for emergent colonic resection and qualifies it as ‘‘appropriate for selected patients’’ in the elective setting.10 We sought to review and compare the perioperative outcomes of laparoscopic colon resection (LCR) and open colon resection (OCR) for the treatment of CDD during emergent hospital admission.
classification was based on operative reports. Colon resection during emergent hospital admission included procedures performed at the time of admission through the emergency department or during the same hospital stay after failure of conservative medical treatment. Patients with successful medical treatment of their episode of CDD were excluded. Failure of medical treatment was determined based on worsening, persistence, or recurrence of fever, leukocytosis, abdominal pain, or peritoneal signs.
Patients and Methods We conducted a retrospective cohort study to compare LCR with OCR for the treatment of CDD during emergent hospital admission.
Selection of participants All patients with acute presentation of diverticular disease undergoing surgery from January 2000 to June 2011 in a single academic institution (CHUQ-HSFA, Quebec, Canada) were identified through the hospital administrative database. We included patients with CDD undergoing colon resection with or without primary anastomosis during emergent hospital admission. CDD was defined as an Hinchey I to IV acute diverticulitis and acute presentation of diverticular disease complicated by fistulas, hemorrhage, or colonic strictures.11 Final Hinchey
Outcome measures and data collection Retrospective chart review was performed by a single reviewer not involved in the treatment process, using a standardized data collection form. The primary outcomes were overall 30-day postoperative morbidity (Clavien grade 1 to 4 complications) and mortality.12 Secondary outcomes included operative time, estimated blood loss, 30-day major postoperative morbidity (Clavien grade 3 and 4 complications), time to oral intake, prolonged ileus, and LOS. Prolonged ileus was defined as 5 days without return of flatus, based on previously described definitions.13,14 LOS was calculated from the day of surgery. Data collection included demographics, diagnostic details, operative procedure, intraoperative complications, and postoperative course characteristics. Conversion was defined as intraoperative change in approach from laparoscopic to open (midline laparotomy), excluding limited left lower quadrant or Pfannenstiel extraction incisions. Occurrence of diverticulitis recurrence on longest follow-up was also recorded. Anastomotic leak was defined as peri-anastomotic contrast extravasation or pelvic abscess around the anastomosis on imaging performed based on clinical suspicion.
Technical information Of the 9 academic surgeons proceeding with OCR, 6 performed both LCR and OCR. Among the latter, 5 surgeons completed subspecialized training in colorectal surgery and 4 in minimally invasive surgery. Three surgeons were fellowship trained in both colorectal and minimally invasive surgery. Subspecialty training of the 3 surgeons who performed only OCR was vascular surgery for 2 and bariatric surgery for 1. Decision to perform primary anastomosis was made by the attending surgeon according to intraoperative findings. No institutional guidelines were present at the time of the study. However, according to the philosophy of the group of surgeons, sigmoid resection with distal section at the level of the superior rectum, and primary colorectal anastomosis with or without a temporary loop ileostomy was the procedure of choice, if allowed by local and systemic conditions. Hartmann procedure, with sigmoid resection and terminal colostomy, was reserved for cases where contamination or the patient’s global condition precluded primary anastomosis (high burden of purulent or fecal contamination,
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hemodynamic instability, active immunosuppression). Decision to proceed with open or laparoscopic approach was made by the surgeon when posing the indication and consenting the patient for surgery. Under general anesthesia, patients were placed in the lithotomy position. OCR was performed using a standard lower midline laparotomy. For LCR, open technique for creation of pneumoperitoneum was followed by a 4-trocars technique for resection. Additional 5-mm trocars were used if required. Trendelenburg and reverse Trendelenburg positions were used to facilitate surgical exposure. If anastomosis was performed, the splenic flexure was completely mobilized to ensure tension-free anastomosis. The proximal colon was transected in an area of nonthickened colon without florid diverticular disease. The surgical specimen was extracted through a small left lower quadrant or Pfannenstiel incision. For anastomosis, the anvil was inserted into the proximal colon to proceed with intracorporeal double-stapled anastomosis. Although no formal protocol was in place at the time of the study, postoperative management included early ambulation and start of oral intake, and minimal use of intravenous fluids. The same nursing and residents teams looked after patients in both groups.
Statistical analysis Statistical analyses were conducted using XLSTAT version 2011 (Addinsoft SARL, Paris, France) for Microsoft Excel (Microsoft, Redmond, WA). Continuous data are expressed as means with standard deviation or medians with interquartile range as deemed appropriate and categorical data are reported as proportions. Comparisons between open surgery and laparoscopic surgery groups were performed using 2-sample t test, Fisher’s exact test, or Pearson’s chi-square test when appropriate. Missing data were estimated by the mean for quantitative variables and by the mode for categorical variables. Data were analyzed according to intention to treat principle, with patients converted from LCR to OCR analyzed in the LCR group. Data were considered statistically significant at P value less than or equal to .05.
3 emergent hospital admission were available for analysis: 39 LCR and 86 OCR. Overall, 83 patients were managed with upfront surgery and 42 required surgery after failing initial medical treatment (Fig. 1). Demographic and clinical characteristics are presented in Table 1. Patients in both groups were similar according to baseline demographics, except for a higher proportion of men in the OCR group (P , .01). More patients in the LCR group had one or more prior episode of acute diverticulitis. The most common indication for acute surgical treatment was perforated diverticulitis in both groups (LCR 82.0%, OCR 93.7%; P 5 .17). There was a higher proportion of Hinchey I diseases in the LCR group (P , .01), whereas more Hinchey III diseases were observed in the OCR group (P , .01). Other indications for acute surgical treatment were colonic fistulas (n 5 3), colonic obstruction (n 5 10), and diverticular hemorrhage (n 5 3).
Operative characteristics Operative data are provided in Table 2. Median operative time was 31.8 minutes longer in the LCR group (P , .01) and median estimated blood loss 270 mL higher in the OCR group (P 5 .01). Two (5.1%) patients in the LCR group required conversion. The type of surgical procedure differed significantly between both groups. Sigmoid resection with primary anastomosis was more common in the LCR group (84.6% vs 54.6%; P , .01). Hartmann procedure was used more frequently in the OCR group (5.1% vs 22.1%; P 5 .02). Sigmoid resection with primary anastomosis and a diverting ileostomy was used in 4 patients in the LCR group and 19 patients in the OCR group (10.3% vs 22.1%; P 5 .139). There was no difference in the intraoperative complication rate (15.5% vs 11.7%; P 5 .57).
Postoperative course Data on postoperative course are detailed in Table 3. Overall morbidity (Clavien grades 1 to 4) was significantly lower
Results Patient characteristics We retrieved 182 patients undergoing surgery for diverticular disease at our institution during the study period, of which 57 cases were excluded. Of those 57 patients, 12 were excluded because they had diagnostic laparoscopy followed by medical treatment, 31 were excluded because their diverticulitis did not meet the criteria of complicated diverticulitis, and 14 were excluded because laparoscopy revealed another pathology other than diverticulitis. A total of 125 patients who underwent colon resection for CDD during
Figure 1
Flow diagram of participants.
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4 Table 1
Demographic and clinical characteristics of the included patients
Age (years) Male sex Body mass index ASA score 1 2 3 4 Diabetes Immunosuppression Previous abdominal surgery Clinical presentation Hinchey classification at presentation 1 2 3 4 Colonic fistula Colonic obstruction Diverticular hemorrhage Hemodynamic unstability APACHE score Indication for surgery Upfront surgery Failure of initial medical management
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
61.6 (13.7) 12 (30.8) 26.3 (4.0)
60.9 (12.0) 53 (61.6) 26.7 (4.5)
.22 ,.01 .68
1 30 8 0 3 6 21
(2.6) (76.9) (20.5) (0) (7.7) (15.4) (53.8)
1 61 21 0 11 8 31
(1.2) (70.9) (24.4) (0) (12.8) (9.3) (36.0)
.53 .48 .63 d .55 .32 .06
11 13 7 1 2 5 1 0 11.4
(34.4) (33.3) (21.9) (3.1) (5.1) (12.8) (2.6) (0) (5.0)
9 27 37 5 1 5 2 2 12.1
(11.5) (34.6) (47.4) (6.4) (1.2) (5.8) (2.3) (2.3) (5.8)
.01 .84 ,.01 .66 .23 .28 1.0 d .47
68 (79.1%) 18 (20.9%)
,.01 ,.01
15 (38.5%) 24 (61.5%)
Data are expressed as number (percent) or mean (SD). APACHE 5 Acute Physiology and Chronic Health Evaluation; ASA 5 American Society of Anesthesiology; SD 5 standard deviation.
in the LCR group (25.6% vs 52.3%; P ,.01), but occurrence of major morbidity (Clavien grades 3 and 4) did not differ between groups (7.8% vs 12.8%; P 5 .40). No death was observed in the LCR group compared with 4 deaths in the
Table 2
OCR group because of massive pulmonary embolism on postoperative day 3, heart failure secondary to myocardial infarction on postoperative day 5, and multiple organ failure on postoperative day 6 and 24. Anastomotic leak rates did not
Operative characteristics of the included patients
Conversion to open surgery Operating time Estimated blood loss Surgical procedure Colonic resection and primary anastomosis Colonic resection, primary anastomosis, and covering ileostomy Hartmann procedure Transverse colostomy Intraoperative complications Enterotomy Serotomy Bleeding Ureteral trauma Spleen trauma Bladder trauma Anastomotic leak Data are expressed as number (percent) or mean (SD). NA 5 not applicable; SD 5 standard deviation.
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
2 (5.1) 273.6 (60.3) 170.6 (217.1)
NA 241.8 (65.5) 441.9 (303.3)
d .01 ,.01
33 (84.6) 4 (10.3) 2 0 6 2 2 2 0 0 0 0
(5.1) (0) (15.4) (5.1) (5.1) (5.1) (0) (0) (0) (0)
47 (54.6) 19 (22.1)
,.01 .14
19 1 10 2 2 1 1 1 1 2
.02 d .57 .59 .59 .23 d d d d
(22.1) (1.2) (11.6) (2.3) (2.3) (1.2) (1.2) (1.2) (1.2) (2.3)
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5
differ. Prolonged ileus was less frequent with LCR. Median time to oral intake and LOS were 3 days shorter with LCR compared with OCR. Median follow-up did not differ (332 vs 327 days; P 5 .51). There was no recurrence of diverticulitis on follow-up in either group.
Comments This is one of the first reports comparing LCR with OCR for CDD during emergent hospital admission. Few reports exist on the laparoscopic approach for CDD, with most being small noncomparative prospective case series. Conversion rates ranged from 10.9% to 26% with 17.4% to 44% morbidity among a majority of Hinchey I and II diseases.4–8 One prospective study by the Laparoscopic Colorectal Surgery Study Group reported 18.2% conversion and 30% morbidity with 3.1% mortality for elective and emergent surgery for diverticular disease. Most acute cases consisted of Hinchey I and II diverticulitis.15 In our study, patients having OCR were twice as likely to suffer from any complication compared with patients having LCR. These results are similar to the figures reported in the elective setting, such as results from the Sigma Trial that identified a 15.4% reduction in major morbidity with LCR compared with OCR.16 A recent metaanalysis of elective resection for diverticular disease revealed similar results with a 10.2% reduction in major complications with laparoscopy.17 Reduced surgical stress and lower postoperative pain described with LCR were suggested as the main drivers of this difference. These benefits can likely be transposed to the emergent setting and explain the lower morbidity we observed with LCR. Although mean operative time was 31.8 minutes longer with laparoscopic surgery, this was associated with a significant decrease in estimated blood loss. This is likely the result of the enhanced visualization associated with LCR and the necessity for a more careful and delicate dissection. Reduction in surgical stress also translates into reduced Table 3
time to resume peristalsis, highlighted by shorter time to oral intake and LOS of about 3 days for LCR compared with OCR. Interestingly, this difference appears to be driven by the benefit of LCR over OCR in low-grade complications (Clavien grades I and II), such as surgical site infection (2.6% vs 18.6%; P 5 .01) and prolonged ileus (12.8% vs 32.6%; P 5 .02), which may be less morbid but impact postoperative flow and patient experience. Similar observations reporting benefits of laparoscopic colectomy with regards to surgical site infection and bowel recovery have been made in large population-based studies, for a variety of diseases.18–20 Anastomotic leakage is one of the most feared complications of bowel resection in elective and emergent settings. In our series, 2 patients in each group suffered from anastomotic leak. Three were treated nonoperatively with percutaneous drainage and 1 patient in the LCR group required a laparotomy for creation of a covering ileostomy. No anastomosis was required to be taken down in these patients. We acknowledge the high number of primary anastomosis in both groups (LCR 84.6% and OCR 54.5%). This reflects the practice at our institution where primary anastomosis is the first choice for CDD as it has been reported to be approached in the hemodynamically stable immunocompetent patient without significant peritoneal contamination, with the use of a diverting ileostomy if deemed necessary.21–23 Our results also parallel the population-based trend toward decreased use of Hartmann in the United States.24 We observed only 2 (5.1%) conversions to a laparotomy in the LCR group, despite a high number of patients having had prior abdominal surgery. One patient was because of dense adhesions for which dissection was deemed unsafe, and the other to extensive purulent contamination in an immunocompromised patient. This rate appears low compared with previous data, including the 19.2% conversions reported in the Sigma trial.16 Moreover, we recognize that this result diverges from prior reports on conversion in laparoscopic surgery. Mayo clinic’s experience observed
Postoperative course of the included patients
Median follow-up (days) 30-day overall morbidity 30-day major morbidity* Anastomotic leak Intra-abdominal abscess Superficial surgical site infection Intra-abdominal bleeding or hematoma Prolonged ileus Reoperation rate 30-day postoperative mortality Time to oral intake (days) Length of stay (days)
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
332 10 3 2 2 1 1 5 1 0 3 5
327 45 11 2 7 16 0 28 6 4 6 8
.51* ,.01 .40 .59 .72 .01 d .02 .32 d ,.01 .05
(118–1,134.5) (25.6) (7.8) (5.1) (5.1) (2.6) (2.6) (12.8) (2.6) (0) (3.0–5.0) (4–8.5)
Data are expressed as number (percent) or median (interquartile range). *Clavien grade 3 and 4 complications.
(94.7–870) (52.3) (12.8) (3.0) (8.1) (18.6) (0) (32.6) (7.0) (4.6) (5.0–8.0) (7.0–14.0)
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that prior abdominal surgery was the only independent predictor of conversion for laparoscopic treatment of diverticular disease (odds ratio 3.6; P 5 .006).17 We believe that while the low conversion rate observed in our study may be pinned to selection bias, it most likely explained the vast laparoscopic experience of our institution. Indeed, surgeon’s and hospital’s volume assessments report lower postoperative morbidity after colectomy in elective setting and for CDD, as well as lower conversion rates for highvolume institutions.17 As any retrospective comparative cohort study, our work is subject to potential flaws. Bias selection is the main one and its impact cannot be well addressed statistically on a small sample size. We could not capture the decision process leading to the surgeon’s to choose between LCR and OCR. Sicker patients could have been more likely to get OCR because of instability and thus more likely to experience worse outcomes, which could explain the higher morbidity rate in the OCR group. Measuring and comparing physiological state of a patient before surgery are challenging. We did not identify statistically significant differences between groups according to baseline characteristics including American Society of Anesthesiologists and APACHE scores. However, more OCR patients presented Hinchey III disease, which would favor the LCR group. However, decision to undergo surgery was based on clinical examination and/or response to medical treatment. As previously mentioned, final Hinchey classification was established at the time of surgery, after surgical approach had been decided. Additionally, Hinchey does not take into account important factors of surgical decision making, such as quality of tissues, age, immunocompetence, or hemodynamic stability. Recent studies using multivariate models confirmed that comorbidity is more significant than locoregional disease spread in predicting outcomes after surgical treatment of acute diverticulitis.25 Comorbidities were similar between groups. While recognizing the selection bias, it would not appear to completely account for the observed difference in postoperative morbidity. Also, no definite postoperative protocol was established at the time the surgeries took place. Patients were put on a regular diet and discharged based on the clinical judgment of the attending and its residents. Hence, the benefits observed in the perioperative period in the LCR group cannot be proven and might be the result of a more aggressive approach with patients treated with laparoscopic surgery. Another bias resides in the different backgrounds of the 9 surgeons involved in the study. As mentioned, 3 of them performed only open procedures because of a lack of experience in minimally invasive surgery. As for the 6 surgeons who performed both LCR and OCR, they performed more than 90% of the surgeries and all had extensive experience in minimally invasive surgeries. Hence, it must be assumed that the background of each surgeon did affect his decision to choose between LCR and OCR, creating a potential selection bias. Beyond reports of a single surgical treatment arm’s results, this study provides insight into feasibility of LCR for CDD in the emergency setting but
also benefits over the open approach. It provides data on which to base further efforts to develop the use of the LCR in acute care surgery to provide acute patients with similar benefits than their elective counterpart, and improve process and flow of care for organizations.
Conclusion This study reports the feasibility and safety of LCR compared with OCR for the treatment of CDD during emergent hospital admission. In the patients, in our series, who were selected to undergo minimally invasive surgery, LCR was associated with decreased overall postoperative morbidity, time to resume diet, and LOS compared with OCR. LCR for CDD is a reasonable approach for selected patients in the hands of experienced laparoscopic surgeons. The final decision remains to be tailored to the patient’s condition and surgeon’s expertise.
References 1. Stollman NH, Raskin JB. Diverticular disease of the colon. J Clin Gastroenterol 1999;29:241–52. 2. Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol 2011;25:385–9. 3. Schlachta CM, Mamazza J, Gregoire R, et al. Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures. Can J Surg 2003;46:432–40. 4. Franklin ME, Dorman JP, Jacobs M, et al. Is laparoscopic surgery applicable to complicated colonic diverticular disease? Surg Endosc 1997;11:1021–5. 5. Fine AP. Laparoscopic surgery for inflammatory complications of acute sigmoid diverticulitis. JSLS 2001;5:233–5. 6. Titu LV, Zafar N, Phillips SM, et al. Emergency laparoscopic surgery for complicated diverticular disease. Colorect Dis 2009;11:401–4. 7. Martel G, Bouchard A, Soto CM, et al. Laparoscopic colectomy for complex diverticular disease: a justifiable choice? Surg Endosc 2010;24:2273–80. 8. Zdichavsky M, Granderath FA, Blumenstock G, et al. Acute laparoscopic intervention for diverticular disease (AIDD): a feasible approach. Langenbecks Arch Surg 2010;395:41–8. 9. Sauerland S, Agresta F, Bergamaschi R, et al. Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery. Surg Endosc 2006;20:14–29. 10. Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939–44. 11. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85–109. 12. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. 13. Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, et al. Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg 2008;32:1495–500. 14. Millan M, Biondo S, Fraccalvieri D, et al. Risk factors for prolonged postoperative ileus after colorectal cancer surgery. World J Surg 2012; 36:179–85. 15. Ko¨ckerling F, Schneider C, Reymond MA, et al. Laparoscopic resection of sigmoid diverticulitis. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group. Surg Endosc 1999;13:567–71. 16. Klarenbeek BR, Bergamaschi R, Veenhof AA, et al. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up
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assessment of the randomized control Sigma trial. Surg Endosc 2011; 25:1121–6. Cirocchi R, Farinella E, Trastulli S, et al. Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review. Colorectal Dis 2012;14:671–83. Wilson MZ, Hollenbeak CS, Stewart DB. Laparoscopic colectomy is associated with a lower incidence of postoperative complications compared with open colectomy: a propensity score-matched cohort analysis. Colorect Dis; 2013 [Epub ahead of print]. Cone MM, Herzig DO, Diggs BS, et al. Effect of surgical approach on 30-day mortality and morbidity after elective colectomy: a NSQIP study. J Gastrointest Surg 2012;16:1212–7. Causey MW, Stoddard D, Johnson EK, et al. Laparoscopy impacts outcomes favorably following colectomy for ulcerative colitis: a critical analysis of the ACS-NSQIP database. Surg Endosc 2013;27: 603–9.
7 21. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmannʼs procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012;256:819–27. 22. Constantinides VA, Tekkis PP, Athanasiou T, et al. Primary resection with anastomosis vs. Hartmann’s procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 2006;49:966–81. 23. Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis. Ann Surg 2007;245:94–103. 24. Masoomi H, Buchberg BS, Magno C, et al. Trends in diverticulitis management in the United States from 2002 to 2007. Arch Surg 2011;146:400–6. 25. Hassan I, Cima RR, Larson DW, et al. The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes. Surg Endosc 2007;21:1690–4.
Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study Franc¸ois Letarte, M.D.a,*, Julie Hallet, M.D., F.R.C.S.C.b, Se´bastien Drolet, M.D., F.R.C.S.C.a,c, Cindy Boulanger-Gobeil, M.D.a, Alexandre Bouchard, M.D., F.R.C.S.C.a,c, Roger C. Gre´goire, M.D., F.R.C.S.C.a,c, Jean-Pierre Gagne´, M.D., L.L.M., F.R.C.S.C.a,c, Claude Thibault, M.D., F.R.C.S.C.a,c, Philippe Bouchard, M.D., F.R.C.S.C.a,c a
Department of Surgery, Universite´ Laval, Que´bec, QC, Canada; bDivision of General Surgery, University of Toronto, Toronto, ON, Canada; cDepartment of Surgery, CHU de Que´bec - Hoˆpital SaintFranc¸ois d’Assise, Que´bec Centre for Minimally Invasive Surgery, 10 Rue de l’Espinay, Que´bec, QC, Canada KEYWORDS: Acute complicated diverticulitis; Emergency surgery; Minimally invasive surgery; Acute care surgery
Abstract 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 5 .02), time to oral intake shorter (3 vs 6 days; P , .01), and LOS shorter (5 vs 8 days; P 5 .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. Crown Copyright Ó 2014 Published by Elsevier Inc. All rights reserved.
The authors declare no conflicts of interest. Presented as podium presentation at the SAGES 2013 Annual Meeting and was awarded SAGES 2012 Best International Paper Acknowledgement. * Corresponding author. Tel.: 11-418-525-4160; fax: 11-418-691-5020. E-mail address: [email protected] Manuscript received May 29, 2014; revised manuscript July 13, 2014 0002-9610/$ - see front matter Crown Copyright Ó 2014 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.07.017
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Diverticular disease presents in the emergency setting as complicated diverticular disease (CDD) in 25% of cases, of which 25% require acute surgical management.1,2 The benefits of laparoscopic over open surgery have now been highlighted for the treatment of a variety of diseases, mainly because of decreased pain, blood loss, length of stay (LOS), and perioperative morbidity. It is now considered the preferred approach in most patients for the elective treatment of diverticular disease.3 Surgery for CDD, including intra-abdominal abscesses, intraperitoneal perforation, peritonitis, and acute obstruction, is undertaken in difficult local and systemic conditions. Compared with elective resection, emergent surgery pertains higher mortality and morbidity rates, longer hospital stays, and more frequent use of stoma that often become permanent. Patients treated in the emergency setting could potentially benefit significantly from the advantages of laparoscopic surgery, but this approach is still debated. Concerns remain regarding safety and feasibility of the laparoscopic approach considering technical challenges such as tissue friability, obliteration of dissection plane, distorted anatomy, poor visualization, and difficulty with mobilization of bowel. Few studies have examined the role of laparoscopic surgery for the acute treatment of CDD.4–8 The most recent guidelines of the European Association of Endoscopic Surgeons conclude that presumed acute uncomplicated diverticulitis should not be treated laparoscopically, except for the use of laparoscopic lavage in some selected cases.9 The American Society of Colon and Rectal Surgeons practice parameters on sigmoid diverticulitis do not comment on the use of laparoscopy for emergent colonic resection and qualifies it as ‘‘appropriate for selected patients’’ in the elective setting.10 We sought to review and compare the perioperative outcomes of laparoscopic colon resection (LCR) and open colon resection (OCR) for the treatment of CDD during emergent hospital admission.
classification was based on operative reports. Colon resection during emergent hospital admission included procedures performed at the time of admission through the emergency department or during the same hospital stay after failure of conservative medical treatment. Patients with successful medical treatment of their episode of CDD were excluded. Failure of medical treatment was determined based on worsening, persistence, or recurrence of fever, leukocytosis, abdominal pain, or peritoneal signs.
Patients and Methods We conducted a retrospective cohort study to compare LCR with OCR for the treatment of CDD during emergent hospital admission.
Selection of participants All patients with acute presentation of diverticular disease undergoing surgery from January 2000 to June 2011 in a single academic institution (CHUQ-HSFA, Quebec, Canada) were identified through the hospital administrative database. We included patients with CDD undergoing colon resection with or without primary anastomosis during emergent hospital admission. CDD was defined as an Hinchey I to IV acute diverticulitis and acute presentation of diverticular disease complicated by fistulas, hemorrhage, or colonic strictures.11 Final Hinchey
Outcome measures and data collection Retrospective chart review was performed by a single reviewer not involved in the treatment process, using a standardized data collection form. The primary outcomes were overall 30-day postoperative morbidity (Clavien grade 1 to 4 complications) and mortality.12 Secondary outcomes included operative time, estimated blood loss, 30-day major postoperative morbidity (Clavien grade 3 and 4 complications), time to oral intake, prolonged ileus, and LOS. Prolonged ileus was defined as 5 days without return of flatus, based on previously described definitions.13,14 LOS was calculated from the day of surgery. Data collection included demographics, diagnostic details, operative procedure, intraoperative complications, and postoperative course characteristics. Conversion was defined as intraoperative change in approach from laparoscopic to open (midline laparotomy), excluding limited left lower quadrant or Pfannenstiel extraction incisions. Occurrence of diverticulitis recurrence on longest follow-up was also recorded. Anastomotic leak was defined as peri-anastomotic contrast extravasation or pelvic abscess around the anastomosis on imaging performed based on clinical suspicion.
Technical information Of the 9 academic surgeons proceeding with OCR, 6 performed both LCR and OCR. Among the latter, 5 surgeons completed subspecialized training in colorectal surgery and 4 in minimally invasive surgery. Three surgeons were fellowship trained in both colorectal and minimally invasive surgery. Subspecialty training of the 3 surgeons who performed only OCR was vascular surgery for 2 and bariatric surgery for 1. Decision to perform primary anastomosis was made by the attending surgeon according to intraoperative findings. No institutional guidelines were present at the time of the study. However, according to the philosophy of the group of surgeons, sigmoid resection with distal section at the level of the superior rectum, and primary colorectal anastomosis with or without a temporary loop ileostomy was the procedure of choice, if allowed by local and systemic conditions. Hartmann procedure, with sigmoid resection and terminal colostomy, was reserved for cases where contamination or the patient’s global condition precluded primary anastomosis (high burden of purulent or fecal contamination,
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hemodynamic instability, active immunosuppression). Decision to proceed with open or laparoscopic approach was made by the surgeon when posing the indication and consenting the patient for surgery. Under general anesthesia, patients were placed in the lithotomy position. OCR was performed using a standard lower midline laparotomy. For LCR, open technique for creation of pneumoperitoneum was followed by a 4-trocars technique for resection. Additional 5-mm trocars were used if required. Trendelenburg and reverse Trendelenburg positions were used to facilitate surgical exposure. If anastomosis was performed, the splenic flexure was completely mobilized to ensure tension-free anastomosis. The proximal colon was transected in an area of nonthickened colon without florid diverticular disease. The surgical specimen was extracted through a small left lower quadrant or Pfannenstiel incision. For anastomosis, the anvil was inserted into the proximal colon to proceed with intracorporeal double-stapled anastomosis. Although no formal protocol was in place at the time of the study, postoperative management included early ambulation and start of oral intake, and minimal use of intravenous fluids. The same nursing and residents teams looked after patients in both groups.
Statistical analysis Statistical analyses were conducted using XLSTAT version 2011 (Addinsoft SARL, Paris, France) for Microsoft Excel (Microsoft, Redmond, WA). Continuous data are expressed as means with standard deviation or medians with interquartile range as deemed appropriate and categorical data are reported as proportions. Comparisons between open surgery and laparoscopic surgery groups were performed using 2-sample t test, Fisher’s exact test, or Pearson’s chi-square test when appropriate. Missing data were estimated by the mean for quantitative variables and by the mode for categorical variables. Data were analyzed according to intention to treat principle, with patients converted from LCR to OCR analyzed in the LCR group. Data were considered statistically significant at P value less than or equal to .05.
3 emergent hospital admission were available for analysis: 39 LCR and 86 OCR. Overall, 83 patients were managed with upfront surgery and 42 required surgery after failing initial medical treatment (Fig. 1). Demographic and clinical characteristics are presented in Table 1. Patients in both groups were similar according to baseline demographics, except for a higher proportion of men in the OCR group (P , .01). More patients in the LCR group had one or more prior episode of acute diverticulitis. The most common indication for acute surgical treatment was perforated diverticulitis in both groups (LCR 82.0%, OCR 93.7%; P 5 .17). There was a higher proportion of Hinchey I diseases in the LCR group (P , .01), whereas more Hinchey III diseases were observed in the OCR group (P , .01). Other indications for acute surgical treatment were colonic fistulas (n 5 3), colonic obstruction (n 5 10), and diverticular hemorrhage (n 5 3).
Operative characteristics Operative data are provided in Table 2. Median operative time was 31.8 minutes longer in the LCR group (P , .01) and median estimated blood loss 270 mL higher in the OCR group (P 5 .01). Two (5.1%) patients in the LCR group required conversion. The type of surgical procedure differed significantly between both groups. Sigmoid resection with primary anastomosis was more common in the LCR group (84.6% vs 54.6%; P , .01). Hartmann procedure was used more frequently in the OCR group (5.1% vs 22.1%; P 5 .02). Sigmoid resection with primary anastomosis and a diverting ileostomy was used in 4 patients in the LCR group and 19 patients in the OCR group (10.3% vs 22.1%; P 5 .139). There was no difference in the intraoperative complication rate (15.5% vs 11.7%; P 5 .57).
Postoperative course Data on postoperative course are detailed in Table 3. Overall morbidity (Clavien grades 1 to 4) was significantly lower
Results Patient characteristics We retrieved 182 patients undergoing surgery for diverticular disease at our institution during the study period, of which 57 cases were excluded. Of those 57 patients, 12 were excluded because they had diagnostic laparoscopy followed by medical treatment, 31 were excluded because their diverticulitis did not meet the criteria of complicated diverticulitis, and 14 were excluded because laparoscopy revealed another pathology other than diverticulitis. A total of 125 patients who underwent colon resection for CDD during
Figure 1
Flow diagram of participants.
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4 Table 1
Demographic and clinical characteristics of the included patients
Age (years) Male sex Body mass index ASA score 1 2 3 4 Diabetes Immunosuppression Previous abdominal surgery Clinical presentation Hinchey classification at presentation 1 2 3 4 Colonic fistula Colonic obstruction Diverticular hemorrhage Hemodynamic unstability APACHE score Indication for surgery Upfront surgery Failure of initial medical management
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
61.6 (13.7) 12 (30.8) 26.3 (4.0)
60.9 (12.0) 53 (61.6) 26.7 (4.5)
.22 ,.01 .68
1 30 8 0 3 6 21
(2.6) (76.9) (20.5) (0) (7.7) (15.4) (53.8)
1 61 21 0 11 8 31
(1.2) (70.9) (24.4) (0) (12.8) (9.3) (36.0)
.53 .48 .63 d .55 .32 .06
11 13 7 1 2 5 1 0 11.4
(34.4) (33.3) (21.9) (3.1) (5.1) (12.8) (2.6) (0) (5.0)
9 27 37 5 1 5 2 2 12.1
(11.5) (34.6) (47.4) (6.4) (1.2) (5.8) (2.3) (2.3) (5.8)
.01 .84 ,.01 .66 .23 .28 1.0 d .47
68 (79.1%) 18 (20.9%)
,.01 ,.01
15 (38.5%) 24 (61.5%)
Data are expressed as number (percent) or mean (SD). APACHE 5 Acute Physiology and Chronic Health Evaluation; ASA 5 American Society of Anesthesiology; SD 5 standard deviation.
in the LCR group (25.6% vs 52.3%; P ,.01), but occurrence of major morbidity (Clavien grades 3 and 4) did not differ between groups (7.8% vs 12.8%; P 5 .40). No death was observed in the LCR group compared with 4 deaths in the
Table 2
OCR group because of massive pulmonary embolism on postoperative day 3, heart failure secondary to myocardial infarction on postoperative day 5, and multiple organ failure on postoperative day 6 and 24. Anastomotic leak rates did not
Operative characteristics of the included patients
Conversion to open surgery Operating time Estimated blood loss Surgical procedure Colonic resection and primary anastomosis Colonic resection, primary anastomosis, and covering ileostomy Hartmann procedure Transverse colostomy Intraoperative complications Enterotomy Serotomy Bleeding Ureteral trauma Spleen trauma Bladder trauma Anastomotic leak Data are expressed as number (percent) or mean (SD). NA 5 not applicable; SD 5 standard deviation.
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
2 (5.1) 273.6 (60.3) 170.6 (217.1)
NA 241.8 (65.5) 441.9 (303.3)
d .01 ,.01
33 (84.6) 4 (10.3) 2 0 6 2 2 2 0 0 0 0
(5.1) (0) (15.4) (5.1) (5.1) (5.1) (0) (0) (0) (0)
47 (54.6) 19 (22.1)
,.01 .14
19 1 10 2 2 1 1 1 1 2
.02 d .57 .59 .59 .23 d d d d
(22.1) (1.2) (11.6) (2.3) (2.3) (1.2) (1.2) (1.2) (1.2) (2.3)
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5
differ. Prolonged ileus was less frequent with LCR. Median time to oral intake and LOS were 3 days shorter with LCR compared with OCR. Median follow-up did not differ (332 vs 327 days; P 5 .51). There was no recurrence of diverticulitis on follow-up in either group.
Comments This is one of the first reports comparing LCR with OCR for CDD during emergent hospital admission. Few reports exist on the laparoscopic approach for CDD, with most being small noncomparative prospective case series. Conversion rates ranged from 10.9% to 26% with 17.4% to 44% morbidity among a majority of Hinchey I and II diseases.4–8 One prospective study by the Laparoscopic Colorectal Surgery Study Group reported 18.2% conversion and 30% morbidity with 3.1% mortality for elective and emergent surgery for diverticular disease. Most acute cases consisted of Hinchey I and II diverticulitis.15 In our study, patients having OCR were twice as likely to suffer from any complication compared with patients having LCR. These results are similar to the figures reported in the elective setting, such as results from the Sigma Trial that identified a 15.4% reduction in major morbidity with LCR compared with OCR.16 A recent metaanalysis of elective resection for diverticular disease revealed similar results with a 10.2% reduction in major complications with laparoscopy.17 Reduced surgical stress and lower postoperative pain described with LCR were suggested as the main drivers of this difference. These benefits can likely be transposed to the emergent setting and explain the lower morbidity we observed with LCR. Although mean operative time was 31.8 minutes longer with laparoscopic surgery, this was associated with a significant decrease in estimated blood loss. This is likely the result of the enhanced visualization associated with LCR and the necessity for a more careful and delicate dissection. Reduction in surgical stress also translates into reduced Table 3
time to resume peristalsis, highlighted by shorter time to oral intake and LOS of about 3 days for LCR compared with OCR. Interestingly, this difference appears to be driven by the benefit of LCR over OCR in low-grade complications (Clavien grades I and II), such as surgical site infection (2.6% vs 18.6%; P 5 .01) and prolonged ileus (12.8% vs 32.6%; P 5 .02), which may be less morbid but impact postoperative flow and patient experience. Similar observations reporting benefits of laparoscopic colectomy with regards to surgical site infection and bowel recovery have been made in large population-based studies, for a variety of diseases.18–20 Anastomotic leakage is one of the most feared complications of bowel resection in elective and emergent settings. In our series, 2 patients in each group suffered from anastomotic leak. Three were treated nonoperatively with percutaneous drainage and 1 patient in the LCR group required a laparotomy for creation of a covering ileostomy. No anastomosis was required to be taken down in these patients. We acknowledge the high number of primary anastomosis in both groups (LCR 84.6% and OCR 54.5%). This reflects the practice at our institution where primary anastomosis is the first choice for CDD as it has been reported to be approached in the hemodynamically stable immunocompetent patient without significant peritoneal contamination, with the use of a diverting ileostomy if deemed necessary.21–23 Our results also parallel the population-based trend toward decreased use of Hartmann in the United States.24 We observed only 2 (5.1%) conversions to a laparotomy in the LCR group, despite a high number of patients having had prior abdominal surgery. One patient was because of dense adhesions for which dissection was deemed unsafe, and the other to extensive purulent contamination in an immunocompromised patient. This rate appears low compared with previous data, including the 19.2% conversions reported in the Sigma trial.16 Moreover, we recognize that this result diverges from prior reports on conversion in laparoscopic surgery. Mayo clinic’s experience observed
Postoperative course of the included patients
Median follow-up (days) 30-day overall morbidity 30-day major morbidity* Anastomotic leak Intra-abdominal abscess Superficial surgical site infection Intra-abdominal bleeding or hematoma Prolonged ileus Reoperation rate 30-day postoperative mortality Time to oral intake (days) Length of stay (days)
Laparoscopic surgery (n 5 39)
Open surgery (n 5 86)
P value
332 10 3 2 2 1 1 5 1 0 3 5
327 45 11 2 7 16 0 28 6 4 6 8
.51* ,.01 .40 .59 .72 .01 d .02 .32 d ,.01 .05
(118–1,134.5) (25.6) (7.8) (5.1) (5.1) (2.6) (2.6) (12.8) (2.6) (0) (3.0–5.0) (4–8.5)
Data are expressed as number (percent) or median (interquartile range). *Clavien grade 3 and 4 complications.
(94.7–870) (52.3) (12.8) (3.0) (8.1) (18.6) (0) (32.6) (7.0) (4.6) (5.0–8.0) (7.0–14.0)
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that prior abdominal surgery was the only independent predictor of conversion for laparoscopic treatment of diverticular disease (odds ratio 3.6; P 5 .006).17 We believe that while the low conversion rate observed in our study may be pinned to selection bias, it most likely explained the vast laparoscopic experience of our institution. Indeed, surgeon’s and hospital’s volume assessments report lower postoperative morbidity after colectomy in elective setting and for CDD, as well as lower conversion rates for highvolume institutions.17 As any retrospective comparative cohort study, our work is subject to potential flaws. Bias selection is the main one and its impact cannot be well addressed statistically on a small sample size. We could not capture the decision process leading to the surgeon’s to choose between LCR and OCR. Sicker patients could have been more likely to get OCR because of instability and thus more likely to experience worse outcomes, which could explain the higher morbidity rate in the OCR group. Measuring and comparing physiological state of a patient before surgery are challenging. We did not identify statistically significant differences between groups according to baseline characteristics including American Society of Anesthesiologists and APACHE scores. However, more OCR patients presented Hinchey III disease, which would favor the LCR group. However, decision to undergo surgery was based on clinical examination and/or response to medical treatment. As previously mentioned, final Hinchey classification was established at the time of surgery, after surgical approach had been decided. Additionally, Hinchey does not take into account important factors of surgical decision making, such as quality of tissues, age, immunocompetence, or hemodynamic stability. Recent studies using multivariate models confirmed that comorbidity is more significant than locoregional disease spread in predicting outcomes after surgical treatment of acute diverticulitis.25 Comorbidities were similar between groups. While recognizing the selection bias, it would not appear to completely account for the observed difference in postoperative morbidity. Also, no definite postoperative protocol was established at the time the surgeries took place. Patients were put on a regular diet and discharged based on the clinical judgment of the attending and its residents. Hence, the benefits observed in the perioperative period in the LCR group cannot be proven and might be the result of a more aggressive approach with patients treated with laparoscopic surgery. Another bias resides in the different backgrounds of the 9 surgeons involved in the study. As mentioned, 3 of them performed only open procedures because of a lack of experience in minimally invasive surgery. As for the 6 surgeons who performed both LCR and OCR, they performed more than 90% of the surgeries and all had extensive experience in minimally invasive surgeries. Hence, it must be assumed that the background of each surgeon did affect his decision to choose between LCR and OCR, creating a potential selection bias. Beyond reports of a single surgical treatment arm’s results, this study provides insight into feasibility of LCR for CDD in the emergency setting but
also benefits over the open approach. It provides data on which to base further efforts to develop the use of the LCR in acute care surgery to provide acute patients with similar benefits than their elective counterpart, and improve process and flow of care for organizations.
Conclusion This study reports the feasibility and safety of LCR compared with OCR for the treatment of CDD during emergent hospital admission. In the patients, in our series, who were selected to undergo minimally invasive surgery, LCR was associated with decreased overall postoperative morbidity, time to resume diet, and LOS compared with OCR. LCR for CDD is a reasonable approach for selected patients in the hands of experienced laparoscopic surgeons. The final decision remains to be tailored to the patient’s condition and surgeon’s expertise.
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