Perforated diverticulitis: Washout it s happening

Transcription

1 Perforated diverticulitis: Washout it s happening or maybe not! Ori D. Rotstein, M.D. Department of Surgery St. Michael s Hospital University of Toronto

2 62 year old male 24 hour history of LLQ pain Now- diffuse pain and tenderness Clinical and Radiological Diagnosis PERFORATED SIGMOID DIVERTICULITIS

3 Principles of Management Adequate resuscitation Antimicrobial therapy Source Control Surgical/radiological Intervention

4 Operative Management Principles Aspirate /drain/ debride purulent or necrotic material Address underlying pathological process Close and patch resect pathology with or without anastomosis exteriorize prevent residual or recurrent infection Radical peritoneal debridement Continuous postoperative peritoneal lavage Scheduled relaparotomy or open abdomen

5 Management of pathological process: Considerations Organ affected Pathological process local conditions in the abdomen systemic factors

6 Surgical options: After resection of sigmoid Hartmann s Procedure Avoids anastomotic leak Stoma closure - high risk - not definite Anastomosis+ defunctioning Risk of leak- but ileostomy option Stoma closure - Closure more straightforward

7 963 patients in 15 studies for comparison (57% Hartmann s vs 43% primary resection all studies: reduction in mortality with 1 0 resection from 15.1% to 4.9% Hinchey > 2 i.e.real emergencies PRA: 14.1% vs HP: 14.4% DCR 2006 Need for prospective randomized trial

8 A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann s Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis Christian Eugen Oberkofler, MD, Andreas Rickenbacher, MD, Dimitri Aristotle Raptis, MD, MSc, 62 patients randomized to HP or PA plus ileostomy Hinchey III and Hinchey IV 1 0 outcome- postop complication rate Considered two components initial operation (i.e. resection) stoma reversal Oberkofler et al: Annals of Surgery Nov 2012

9 A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann s Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis Christian Eugen Oberkofler, MD, Andreas Rickenbacher, MD, Dimitri Aristotle Raptis, MD, MSc, Outcome for both components i.e resection and reversal Total Complications Serious Complications PA and Reversal HP and Reversal 84% 80% 44% 50% Mortality 9% 13% Oberkofler et al: Annals of Surgery Nov 2012

10 A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann s Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis Christian Eugen Oberkofler, MD, Andreas Rickenbacher, MD, Dimitri Aristotle Raptis, MD, MSc, Consider first part ONLY i.e HP vs PA No difference in outcome No difference in operative time, blood loss Consider second part ONLY i.e. reversal Ileostomy closure had: shorter OR, less complications Higher reversal rate: 90% vs 57% Oberkofler et al: Annals of Surgery Nov 2012

11 92 patients with Hinchey 3 or less had laparoscopy and lavage Morbidity 4% and mortality 3% Small number needed intervention early NONE came to surgery with 36 month followup Br J Surg 2008

12 Laparoscopic lavage: Just a little irrigation and suction! Irrigation Suction

13 Survey Approach to managing acute perforated diverticulitis Total number of respondents : 175 Age : 32% (N = 56) were < 40 years of age 75% of respondents operated on at least 1 patient with acute perforated diverticulitis. A minimum of 292 operations were conducted.

14 What I would have done if I had a patient with perforated diverticulitis. Percent (%) Hartmann s Procedure Resection with primary anastomosis +- defunctioning Laparosopic washout and drain Percent (%) Percent (%) Hartmann s Procedure Resection with primary anastomosis +- defunctioning Laparoscopic washout and drain Hartmann s Procedure Resection with primary anastomosis +- defunctioning Laparosopic washout and drain

15 What I did with my patient with perforated diverticulitis Percent (%) Hartmann s Procedure Resection with anastomosis +- ileostomy Laparoscopic washout N/A Percent (%) Percent (%) Hartmann s Procedure Resection with anastomosis +- ileostomy Laparoscopic washout N/A Hartmann s Procedure Resection with anastomosis +- ileostomy Laparoscopic washout N/A

16 Knowledge of Literature The literature provides evidence showing that laparoscopic lavage is better than Hartman s Procedure or resection and anastomosis. TRUE 29.2% FALSE 22.8% DON T KNOW 48%

17 Review article doi: /j x Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis S. Afshar* and M. A. Kurer *Department of General Surgery, Cumberland Infirmary, Carlisle, UK and Department of General Surgery, Keighley, Airedale Hospital NSH Foundation Trust, UK 12 studies totaling 301 patients All non randomized trials Majority are Hinchey III (but some II and IV) Conversions 4.9% Complications 18.9% Mortality 0.25% Elective Resections 51% Colorectal disease 2012; 14:135

18 STUDY PROTOCOL Open Access The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis A and Hartmann s procedure or resection with primary anastomosis for purulent or faecal peritonitis B in perforated diverticulitis (NTR2037) Swank BMC Surg * 2 3 Clinical/imaging signs of diverticulitis with diffuse peritonitis laparoscopy Purulent peritonitis (LOLA): Lavage or PA or Hartmann s Morbidity and mortality Fecal peritonitis (DIVA): PA or Hartmann s Stoma-free survival-1 yr

19 Summary: Perforated diverticulitis Sigmoid resection with 1 0 anastomosis and ileostomy appears to be preferable surgical approach Local conditions/surgeon experience/patient factors should dictate approach Laparoscopic lavage data are WOBBLY Safe, feasible, requires surgeon expertise Here/now: It s not happening all that much

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21 What goes around, comes around! Lavage, drain, defunction Resection of sigmoid colon A little retro Laparoscopic lavage, drain