ORIGINAL CONTRIBUTION

Nonoperative Management of Perforated Diverticulitis With Extraluminal Air Is Safe and Effective in Selected Patients Ville J. Sallinen, M.D., Ph.D. • Panu J. Mentula, M.D., Ph.D. Ari K. Leppäniemi, M.D., Ph.D. Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland

BACKGROUND:  The optimal treatment for diverticulitis with extraluminal air is controversial. OBJECTIVE:  The purpose of this research was to evaluate the safety and effectiveness of nonoperative treatment of acute diverticulitis with extraluminal air. DESIGN:  This was a retrospective cohort. SETTINGS:  The study was conducted at an academic

teaching hospital functioning as both a tertiary and secondary care referral center. PATIENTS:  All of the patients with CT-diagnosed acute

perforated diverticulitis with extraluminal air from 2006 through 2010 were included in this study. INTERVENTIONS:  Nonoperative treatment composed of intravenous antibiotics, bowel rest, and percutaneous drainage were the included interventions. MAIN OUTCOME MEASURES:  The need for operative management and mortality were measured. RESULTS:  A total of 132 patients underwent

nonoperative treatment, whereas 48 patients were primarily operated on. Patients treated nonoperatively were divided into 3 groups on the basis of identified factors that independently predicted risk for failure: 1) patients with pericolic air (n = 82) without abscess had a 99% success rate with 0% mortality. 2) Patients with distant intraperitoneal air (n = 29) had a 62% success Funding/Support: This study was supported by the Martti I. Turunen Foundation. Financial Disclosure: None reported. Correspondence: Ville Sallinen, M.D., Ph.D., Department of Abdominal Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, 00029 HUS, Finland. E-mail: [email protected] Dis Colon Rectum 2014; 57: 875–881 DOI: 10.1097/DCR.0000000000000083 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 7 (2014)

ratewith 0% mortality. Abundant distant intraperitoneal air and fluid in the fossa Douglas were identified as risk factors for failure. Patients without these risk factors had an 86% success rate with nonoperative management. 3) Patients with distant retroperitoneal air (n = 14) had a 43% success rate with 7% mortality. LIMITATIONS:  Comparison of nonoperative versus operative treatment cannot be made because of the study’s retrospective nature. CONCLUSIONS:  Nonoperative treatment of acute diverticulitis with extraluminal air is safe and effective in patients with a small amount of distant intraperitoneal air or pericolic air without clinical signs of peritonitis.

KEY WORDS:  Antibiotics; CT; Diverticular disease; Free air; Laparoscopic lavage; Percutaneous drainage.

A

cute diverticulitis is a common disease entity requiring surgical consultation. One-fourth of patients present with complicated diverticulitis, including abscess, fistula, stricture, or perforation with extraluminal air.1 The traditional treatment option for acute diverticulitis with extraluminal air has been emergent sigmoid resection.1,2 However, emergency sigmoid resections are associated with high mortality and morbidity, prompting the search for other treatment strategies. Recently, laparoscopic lavage has emerged as a viable alternative in acute diverticulitis with extraluminal air and purulent peritonitis (Hinchey III) with lower mortality and morbidity rates.3–5 However, the advantages of laparoscopic lavage compared with resectional operative treatment have yet to be validated in prospective, randomized controlled trials,6,7 and a few recent studies have reported encouraging results of nonoperative treatment of acute diverticulitis with extraluminal air.8,9 Thus, the optimal treatment of diverticulitis with extraluminal air is controversial, whereas current guidelines recommend emergent surgery in such cases.1,10 875

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Sallinen et al: Nonoperative Treatment of Diverticulitis

At our institution, patients with perforated acute diverticulitis with extraluminal air in CT scan in the absence of generalized peritonitis have been treated nonoperatively. The aims of this study were to assess the safety and efficacy of nonoperative treatment of acute diverticulitis with extraluminal air in CT scan. Our hypothesis was that nonoperative treatment is feasible in selected patients.

as a patient living at home before hospitalization returning to his or her home instead of remaining in long-term institutional care. Statistical analyses with Mann-Whitney U test, Fisher exact test, χ2 test, or logistic regression analysis with forward stepwise selection were performed using SPSS Statistics 21 software (IBM, Armonk, NY) where appropriate.

MATERIALS AND METHODS

RESULTS

This was a retrospective cohort study conducted in an academic teaching hospital that functions both as a tertiary and secondary referral center serving a population of ≈1.5 million. Patients treated at the hospital’s acute wards from 2006 through 2010 were identified from electronic patient records by a search for the International Classification of Diseases 10 code “K57.” The study was approved by the institutional review board. Patient records were analyzed, and data regarding patient characteristics, previous operations and diseases, medications, clinical signs, laboratory exams, CT scan findings, operative procedures and findings, complications, mortalities, and follow-up findings were manually extracted. CT scan reports created by expert abdominal consultant radiologists were retrieved and used for data extraction. In addition, original CT scans were analyzed for measurements of extraluminal air bubble size, distance from the inflamed bowel segment, and abscess size. CT scans were performed using intravenous contrast medium in 549 patients (87%) and oral contrast medium in 574 patients (91%). No patient received rectal contrast medium. Distant intraperitoneal air was defined as air bubbles or larger air collections in the abdominal cavity with a distance >5 cm from the inflamed bowel segment. Distant retroperitoneal air was defined as air bubbles or larger air collections in the retroperitoneum with a distance >5 cm from the inflamed bowel segment. Pericolic air was defined as air bubbles or air collection within 5 cm of the inflamed bowel segment without distant air. Distant intraperitoneal air was classified as a small amount of air if the air bubbles were smaller than 1 × 1 cm in coronal CT sections or 1 × 1 cm in coronal CT sections or >2 cm in any direction. Intraoperative findings were classified using a modified Hinchey classification.11 Nonoperative treatment consisted of intravenous antibiotics (cefuroxime and metronidazole if no contraindications, eg, allergy, were present), intravenous fluid resuscitation, and nil per os until the patient could tolerate per oral fluids. Nonoperative management was considered a failure if the patient deteriorated and had to be operated on or died within the same hospital stay period. Percutaneous drainage was considered part of nonoperative treatment but not a failure. Return to home was defined

A search for the International Classification of Diseases 10 diagnosis code “K57” identified 1236 patients whose records were manually analyzed. A total of 603 patients were excluded. These included 212 patients with diverticular disease but no acute colonic diverticulitis, 8 patients with inaccurate coding, 45 patients living outside the served area, 3 patients with inadequate patient records, and 335 patients with clinically diagnosed acute diverticulitis but no CT scan. Of the remaining 633 patients with acute colonic diverticulitis, 194 showed extraluminal air in the abdominal cavity, retroperitoneum, or pericolically in CT scan and were included in the study. Patients (n = 14) with colonic obstruction or suspected or confirmed cancer were excluded from the cohort. The remaining 180 patients formed the final study cohort. A total of 132 patients (73%) underwent primary nonoperative management, whereas 48 patients (27%) were primarily treated operatively mainly because of clinical generalized peritonitis. Of the 132 patients initially managed nonoperatively, 20 (15%) later required emergency surgery. The indication for surgery was clinical progression of the disease during intravenous antibiotic treatment and/or after percutaneous drainage. Patient characteristics were compared between successful and failed nonoperative treatment, and 3 independent factors were identified in multivariate analysis that affected the success of nonoperative treatment (Table 1). Large amounts of free air in the abdominal cavity and distant retroperitoneal air were associated with failed nonoperative treatment. Pericolic air in the absence of distant air or abscess was associated with successful nonoperative treatment. For further analysis, primarily nonoperatively treated patients with extraluminal air were divided into 3 subgroups: 1) patients with distant intraperitoneal air, 2) patients with distant retroperitoneal air, and 3) patients with pericolic air without abscess. Cases of pericolic air with associated abscess (n = 11) were excluded from further analysis. Distant Intraperitoneal Air

Twenty-nine patients with distant intraperitoneal extraluminal air underwent primary nonoperative treatment. Characteristics of nonoperatively treated patients with distant intraperitoneal air are shown in Table 2. Eighteen patients (62%) were successfully treated nonopera-

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TABLE 1.   Factors affecting success of nonoperative management in patients with acute diverticulitis and extraluminal air on CT scan

Free air in abdominal cavity, retroperitoneum, or pericolic in CT

Successful nonoperative management (N = 112) n (%)

Failed nonoperative management (N = 20) n (%)

Univariate p

Multivariate OR (95% CI)

58 (52) 24 (21) 11 (10)

7 (35) 8 (40) 3 (15)

0.17 0.07 0.49

-

9 (8) 3 (3) 1 (1) 20 (18) 1 (1)

4 (20) 0 (0) 2 (10) 4 (20) 3 (15)

0.10 0.46 0.01 0.82 0.001

NS NS

2 (2) 22 (20) 36 (32)

1 (5) 2 (10) 5 (25)

0.37 0.30 0.53

-

88 (79) 56 (50)

14 (70) 11 (55)

0.40 0.68

-

12 (11) 6 (5) 6 (5) 81 (72) 19 (17) 4 (4) 6 (5)

2 (10) 9 (45) 8 (40) 1 (5) 9 (45) 7 (35) 4 (20)

0.92 38ºC Laboratory findings on admission  WBC >10 × 109/L  CRP >150  mg/L CT findings  Intraperitoneal air, size 1 × 1 cm or 2 cm in 1 dimension  Distant retroperitoneal air  Pericolic air without distant air or abscess  Abscess  Abscess size >4 cm  Intraperitoneal fluid in fossa Douglas

Only variables with statistical significance (p < 0.05) in univariate analysis (χ2) were selected for multivariate analysis (logistic regression analysis with forward stepwise selection). AD = acute diverticulitis; CRP = C-reactive protein; NS = not selected in forward stepwise selection; WBC = white blood cell count. a Organ dysfunction was defined as mean arterial pressure 38ºC Laboratory findings on admission  WBC >10 × 109/L  CRP >150  mg/L CT findings  Intraperitoneal air, size 1 × 1 cm or 2 cm in 1 dimension  Distant retroperitoneal air  Pericolic air without distant air or abscess  Abscess  Abscess size >4 cm  Intraperitoneal fluid in fossa Douglas

Pericolic air without abscess (N = 82) n (%)

AD = acute diverticulitis; CRP = C-reactive protein; WBC = white blood cell count. a Organ dysfunction was defined as mean arterial pressure

Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients.

The optimal treatment for diverticulitis with extraluminal air is controversial...
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