Diverticular Disease Dr. Charles H. Knowles (PhD FRCS)

Transcription

1 Diverticular Disease Academic Surgical Unit Barts and the London School of Medicine and Dentistry Queen Mary University of London 1 Overview - diverticular disease Definitions Spectrum of disease Epidemiology Aetiology Management Societal impact 2 Diverticular disease A common condition of uncertain aetiology in which serosa-covered out-pouchings (diverticula) of mucosa occur through gaps in the muscularis propria Pseudo (false) diverticula Mucosa and serosa only Rarely true diverticula Solitary caecal All 3 layers Definitions (1) 3 1

2 Definitions (2) Taxonomy Noun singular: diverticulum Noun plural: diverticula (not ae) Adjective: diverticular The presence (symptomatic or asymptomatic) of diverticula is termed: diverticulosis: syn. diverticular disease 4 Spectrum of disease (1) Uncomplicated Classification of diverticulitis 1 Asymptomatic (incidental) I. Symptomatic uncomplicated disease Symptomatic II. Recurrent symptomatic disease Complicated III. Complicated disease Septic complications Diverticulitis Perforation Abscess Mass Fistula Peritonitis (purulent or faecal) Bleeding Obstruction 1. Kohler et al., EAES Consensus statement; Surg Endosc 1999; 13: Spectrum of disease (2) Diverticulosis Diverticulitis 6 2

3 Spectrum of disease (3) Hinchey classification of perforated disease 1 Pericolic abscess or phlegmon Pelvic, intra-abdominal or retroperitoneal abscess Diverticulitis with purulent peritonitis Diverticulitis with faecal peritonitis Stage I II III IV Modified Hinchey classification 2 Distant abscess amenable to drainage Complex abscess +/- fistula IIa IIb 1. Hinchey EJ et al., Adv Surg 1978; 12: Sher et al., Surg Endosc 1997; 1: Spectrum of disease (4) Hinchey IIb 8 Spectrum of disease (5) Hinchey IIb + fistulae Hinchey III 9 3

4 History First pathological description ascribed to Cruveilhier First clinical description First textbook description First population studies Epidemiology (1) Projecting from sides of the colon, in intervals of the septa, were small coecal pouches, in each was situated one of the concretions referred to; The number of pouches and concretions amounted to nearly thirty (Sir Erasmus Wilson, Lancet 1840) 1925: 10% adults barium enema (UK) : 6% adults barium enema (USA) 5 NB: Alexis Littre 1719 = ileal (Meckels) 1. Cruveilhier J. Traite d Antomie Pathologique; Balliere et Cie 1849; 1: Telling & Gunner; Br J Surg 1917; 4: Telling WHM; Proc R Soc Med 1920; 13: Sprigs & Marxer; Q J Med 1925; 19: Mayo WJ 1930; Ann Surg Med 1930; 92: Epidemiology (2) DD: increasing incidence Radiological Trend towards increasing prevalence Over-estimateestimate High risk populations (age, symptomatic) Autopsy studies Mostly unselected (asymptomatic?) Hospital admissions for complications 11 Epidemiology (3) Changing incidence of diverticular disease on barium enema Author Year Population N % Sprigs & Marxer 1925 UK (adults) Rankin & Brown 1930 USA Edwards 1934 UK (over 40 years) Landing 1935 Sweden Oschner & Burgen 1935 USA Willard & Bockus 1936 USA Median 11 Eggers 1941 USA Allen 1953 USA Edwards 1953 UK (over 35 years) Smith & Christensen 1959 USA Manousos et al UK (over 60 years) Median

5 Epidemiology (4) Autopsy incidence Left sided: 1917: Drummond: 4.4% (n = 500) 1930: Rankin & Brown: 5.6% (n =1925) 1968: Parks: 37% (n = 300) 1969: Hughes: 45% (n = 200) Right sided: 1986: Lee (Singapore): 19% (n = 1014) 1993: Munakata et al., (Japan): 23% 13 Epidemiology (5) Age incidence Slack (1962) unselected autopsies 60 e % incidence Slack WW. Br J Surg 1962; 50: Epidemiology (6) Changing sex ratio of diverticular disease Author Year Male: female Telling & Gunner : 1.0 Sprigs & Marxer : 1.0 Mayo : 1.0 Oschner & Burgen : 1.0 Boles & Jordan : 1.2 Brown & Toomey : 1.5 Brown & Toomey : 1.3 Manousos et al : 1.8 Manousos et al : 1.4 Parks : 1.5 Botsford et al : 1.3 Male predominant Female predominant 15 5

6 Epidemiology (7) Geography Pre-1960s Post-1960s 16 Epidemiology (8) Right-sided diverticular disease 1-2% Western cases Majority of Japan, South East Asian Caecum 79%, 1/3 rd = solitary Some true (full thickness)? developmental Present younger (30-40 years) Increasing incidence (Lee 1986; Munakata et al., 1993; Miura et al., 2000) Presentations: acute appendicitis or bleeding 17 Epidemiology (9) Complicated diverticular disease Increase burden well-documented by admission and death rates Age M F M F Admission rates in Scotland per 100,000 population Kyle & Davidson. Br J Surg 1975; 62:

7 Epidemiology (10) Admission rate / 100,000 pop n % of admissions with surgery 1989/ /2000 % change M F M F M F Case fatality rate Kang et al., APT 2003; 17: Epidemiology (11) Humes et al., Gastroenterology 2009; 136: Increasing incidence even with age adjustment Epidemiology (12) Etzioni et al., Ann Surg 2009; 249:

8 Aetiology (1) Ageing Lower dietary fibre Congenital pre-disposition Colonic thickening & segmentation Weakening of the colonic wall High intraluminal pressures Diverticular disease 22 Aetiology (2) 23 Aetiology (3) Dietary fibre: epidemiological evidence DD incidence parallels inc refined sugar & decreased fibre (roller milling from 1880s) 1 Changing incidence in mobile populations e.g. Japan to Hawaii 2 and Negro Americans 3 reflect dietary reductions in fibre Decreased incidence in vegetarians 4 Increased in low SES populations with poor diet 5 Case control 6 and cohort 7 studies of fibre intake 1. Burkitt DP. Lancet 1970; 2: Stemmerman GN. Arch Envirn Health 1969; 20: Cleave TL et al., Gear et al., Lancet 1979; 1: Eastwood et al., Gut 1978; 19: Brodribb & Humphries. Br Med J 1976; 1: Aldoori et al., J Nutr 1998; 128:

9 Aetiology (4) Dietary fibre: experimental evidence - Pulsion theory of diverticular disease (Buie 1939; Painter et al., 1965) Sigmoid has highest regional pressures in colon Wall thickening in DD (Morson et al., 1963) Pressures inc. in DD (Parks & Connell, 1969; Christopher et al., 2000) Longitudinal animal studies e.g. rodents (Fischer et al., 1985) Surgery of the Anus, Rectum & Colon; WB Saunders Co. Ltd, London 1993, Vol 2, p Aetiology (5) Effect of obesity: cohort studies: BMI > 30 Study Population N F.up RR/hazard ratio Humes et al., UK general y 1.39 (perforated) 2009 Rosemar et al., Sweden, male y 4.4 (hospitalised) 2008 Strate et al., USA, Health y 1.78 (diverticulitis) 2009 Professionals 3.19 (D. bleeding) Etzioni et al., Ann Surg 2009; 249: Aetiology (6) Abnormal neuromuscular function Changes in neurochemical coding of enteric neurones Motor: unlikely to contribute to aetiology Sensory: post-inflammatory visceral hypersensitivity Changes in ICC Probably secondary PGP 9.5 (Simpson et al., 2009) Milner et al., 1990; Golder et al., 2003; Bassotti et al., 2005; Guagnini et al., 2006; Simpson et al., 2009 CD 117 (Bassotti et al., 2005) 27 9

10 Aetiology (7) Abnormal extracellular matrix Rare connective tissue (collagen) disorders are associated with early-onset diverticular disease Ehlers Danlos inc. tenascin mutations Several studies demonstrate ECM (collagen & elastin) changes in thickened colonic wall (Whiteway & Morson, 1985; Wess ) Abnormal cross linking of collagen III 28 Management (1) Symptomatic complicated Outline Diverticulitis Asymptomatic Symptomatic uncomplicated Hinchey I/II Hinchey III/IV Special cases Preventative strategy Dietary advice Weight loss Exercise Pharmacological based on symptoms Dietary advice Anti-spasmodics Laxatives Anti-diarrhoeals IV antibiotics Resuscitation Bowel rest (level II/III) Hydration IV antibiotics Analgesia Bowel rest + Analgesia CT scan + +/- Laparotomy Percutaneous or laparoscopic drainage washout of abscess +/- Elective resection As specific complication e.g. GI bleeding Obstruction 29 Management (2) Diagnosis Elective DCBE preferable to colonoscopy Emergency revolutionised by widespread availability of helical CT (and interventional radiology) Septic patient with abdominal signs and known diverticulosis 30 10

11 Management (3) Principles of surgery Sigmoid colectomy Sigmoid colectomy & defunct. loop ileostomy Hartmann s Procedure +/- mucous fistula Defunctioning loop colostomy Elective Hinchey I Emergency Hinchey IV 31 Management (4) Medical therapy for symptomatic uncomplicated disease Case series: fibre (bran): excellent results ( ) Early controlled studies mixed results Devroede et al., no advantage Taylor & Duthie, all improved Brodribb most improved Hodgson no advantage Ornstein et al., reduced straining only Leahy et al., reduction in complications and symptoms No recent RCTs 32 Management (5) Surgical therapy for symptomatic uncomplicated disease Sigmoid myotomy (and variations): no longer practiced Elective resection: rarely recommended Morbidity higher than cancer surgery Patients often unfit and elderly High complication rates (esp. anastomotic leaks) High permanent stoma rates Poor symptomatic control Failure to consistently prevent complicated disease Surgery of the Anus, Rectum & Colon; WB Saunders Co. Ltd, London 1993, Vol 2, p

12 Management (6) Management of diverticulitis: Hinchey I/II Clinical assessment IV fluid resuscitation Analgesia Broad spectrum antibiotics Low residue diet or bowel rest CT +/- abscess drainage Confirmation of the diagnosis after resolution (DCBE or colonoscopy) Laparotomy if failure (low threshold in immunocompromised) 34 Management (7) Management of diverticulitis - Hinchey I/II: indications for elective surgery Controversial Evidence limited to audit data (Farmakis et al., 1994) and eminence-based opinion General indications: 2 episodes diverticulitis (single episode in immuno-compromised) Fistula (colovaginal or colovesical) Mass in which cancer cannot be excluded endoscopically Problems of high complication rates persist even in specialist centres 35 Sigmoid diverticulitis : the Dutch experience Elective n = 149 Acute n = 114 Age 64 (M 61; F 66) 67 (M 62; F 70) Female/male 98/51 67/47 Possum score completeness >95% >95% Predicted possum mortality 4.9% 23.4% Mortality 4.7% (M 7.8%; F 3.1%) 17% (M 15%; F18%) Complication 53.7% 71.1% Reoperation at first admission 12.1% 15.8 Operations after discharge 15.4% 61.4% Surgery Resection and anastomosis 88% 8% Hartmann 5% 71% Other 8% 21% AF Engel, JLT Oomen, Zaans Medical Centre,

13 Management (8) Elective surgery: notes The surgery is nearly always more difficult than for cancer Consent must realistically explain: Potential outcomes (anastomosis, loop ileostomy, Hartmann s) Complications (anastomotic leak) Low threshold for ureteric stenting Anatomical above and below approach inc. splenic flexure Low threshold for defunctioning stoma (mark both sides) 37 Management (9) Management of diverticulitis: Hinchey III/IV Resuscitation Level II/III care Fluids, pressors & invasive monitoring +/- other organ support IV antibiotics, analgesia Laparotomy almost always indicated Frank discussion with patient & carers Mortality > 20% High likelihood of stoma (mark both sides) 38 Mortality after acute surgery for complications of diverticular disease of the sigmoid colon First author Year No. of patients Overall (%) Mortality Hinchey I/II (%) Hinchey III/IV (%) Rodkey (183) 35.3 (17) Rodkey (218) 21.6 (51) Krukowski Krukowski (11) 30.0 (10) Greg Kronborg (62) Tudor (117) 32.8 (58) Wedell (31) 28.0 (25) Oomen JLT et al. Colorectal Disease 2006; 8: Hoemke (103) 10.0 (10) Zeitoun (99) Gooszen (35) (10) Schilling (55) Blair (24) 22.2 (9) Biondo (28) (55) Present study (67) 21.3 (47) Number in parentheses is number of patients per Hinchey group Median 22% 39 13

14 Management (10) Surgery for diverticulitis: Hinchey III/IV Contentious (no good quality evidence) Hinchey III Fit patients without profound contamination or sepsis Resection and anastomosis possible +/- defunct. loop ileostomy +/- OT bowel wash out Avoids morbidity of reversal of Hartmann s Hinchey IV Always Hartmann s procedure +/- mucous fistula Defunct loop colostomies are suboptimal (use limited to genuine cases of damage limitation) Anastomosis is madness! 40 Management (11) Avoiding laparotomy and resection in Hinchey III Hinchey II, n = 25 Hinchey III, n = 67 Myers E et al., Br J Surg 2008; 95: /- elective surgery 41 Management (12) Role of laparoscopy in elective resection No RCTS Meta-analysis of non-randomised studies Decrease LOS Decrease complications Laparoscopic vs. Open resection for diverticular disease Length of stay Purkayastha S et al., DCR 2006; 49: Favors laparoscopic Favors open 42 14

15 Societal impact (1) DD is common US 2004 national audit data 312,000 admissions 1.5 million inpatient days $2.6 billion UK 2005 NHS data 217,000 bed days (more than UC and CD combined!) Epidemiological data show clearly increasing incidence (age independent) Increasingly aged and obese population 43 Societal impact (2) DD is highly morbid Patients are frequently unfit Elective and emergency surgery are hazardous Complication rates are high Mortality rates are high Stoma rates are high 60-70% never reversed (Navara et al., 1995; Belmonte et al., 1996) Frequently suboptimal quality 44 Societal impact (3) DD is an orphan disease Governments obsessed with cancer initiatives Of all system specific areas, oral/gi has the poorest ratio of investment in research to burden of disease with the exception of respiratory (3 years) MeSH core clinical journals 208 vs for colon cancer Only 1 study of pathophysiology/aetiology Only 1 RCT (c.f. 13 in IBS) No non-human studies (c.f. 38 in IBS) 1. UK Clinical Research Collaboration 2006 data 45 15

16 Summary Diverticular disease Increasing incidence of asymptomatic and complicated forms Aetiology: low fibre, aging and obesity (complications) Medical management limited, surgical management complex and hazardous High societal cost but little research investment 46 Thank you The old (1742) and the new (2010)