Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1370_Библиотеки_им_академика_М_И_Перельмана
.pdf
improved outcomes in colon and rectal surgery
23. Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B.
Long-term results and functional outcome after Ripstein
rectopexy. Dis Colon Rectum 2000; 43(1): 35–43.
24. Winde G, Reers B, Nottberg H et al. Clinical and functional results
of abdominal rectopexy with absorbable mesh-graft for treatment
of complete rectal prolapse. Eur J Surg 1993; 159(5): 301–5.
25. Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective
randomized trial of Ivalon sponge versus sutured rectopexy for
full-thickness rectal prolapse. Br J Surg 1994; 81(6): 904–6.
26. Mann CV, Hoffman C. Complete rectal prolapse: the anatomical and functional results of treatment by an extended
abdominal rectopexy. Br J Surg 1988; 75(1): 34–7.
27. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results
of operative treatment of rectal prolapse over an 11-year
period: emphasis on transabdominal approach. Dis Colon
Rectum 1999; 42(5): 655–60.
28. Allen-Mersh TG, Turner MJ, Mann CV. Effect of abdominal
Ivalon rectopexy on bowel habit and rectal wall. Dis Colon
Rectum 1990; 33(7): 550–3.
29. Watts JD, Rothenberger DA, Buls JG, Goldberg SM,
Nivatvongs S. The management of procidentia. 30 years’
experience. Dis Colon Rectum 1985; 28(2): 96–102.
30. Huber FT, Stein H, Siewert JR. Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World J Surg 1995; 19(1): 138–43.
31. Husa A, Sainio P, von Smitten K. Abdominal rectopexy and
sigmoid resection (Frykman-Goldberg operation) for rectal
prolapse. Acta Chir Scand 1988; 154(3): 221–4.
32. Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means
of access affect the incidence of small bowel obstruction and
ventral hernia after bowel resection? Laparoscopy versus
laparotomy. J Am Coll Surg 2003; 197(2): 177–81.
33. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized
clinical trial of laparoscopic versus open abdominal rectopexy
for rectal prolapse. Br J Surg 2002; 89(1): 35–9.
34. Purkayastha S, Tekkis P, Athanasiou T et al. A comparison of
open vs. laparoscopic abdominal rectopexy for full-thickness
rectal prolapse: a meta-analysis. Dis Colon Rectum 2005;
48(10): 1930–40.
35. Zittel TT, Manncke K, Haug S et al. Functional results after
laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg
2000; 4(6): 632–41.
36. Himpens J, Cadiere GB, Bruyns J, Vertruyen M. Laparoscopic
rectopexy according to Wells. Surg Endosc 1999; 13(2): 139–41.
37. Dulucq JL, Wintringer P, Mahajna A. Clinical and functional
outcome of laparoscopic posterior rectopexy (Wells) for fullthickness rectal prolapse. A prospective study. Surg Endosc
2007; 21(12): 2226–30.
38. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JR.
Laparoscopic suture rectopexy without resection is effective
treatment for full-thickness rectal prolapse. Dis Colon Rectum
2000; 43(5): 638–43.
39. Kessler H, Jerby BL, Milsom JW. Successful treatment of
rectal prolapse by laparoscopic suture rectopexy. Surg Endosc
1999; 13(9): 858–61.
40. Bruch HP, Herold A, Schiedeck T, Schwandner O. Laparoscopic
surgery for rectal prolapse and outlet obstruction. Dis Colon
Rectum 1999; 42(9): 1189–94.
41. Kellokumpu IH, Vironen J, Scheinin T. Laparoscopic repair
of rectal prolapse: a prospective study evaluating surgical
outcome and changes in symptoms and bowel function. Surg
Endosc 2000; 14(7): 634–40.
42. Baker R, Senagore AJ, Luchtefeld MA. Laparoscopic-assisted
vs. open resection. Rectopexy offers excellent results. Dis
Colon Rectum 1995; 38(2): 199–201.
43. Benoist S, Taffinder N, Gould S, Chang A, Darzi A. Functional
results two years after laparoscopic rectopexy. Am J Surg
2001; 182(2): 168–73.
44. Kairaluoma MV, Viljakka MT, Kellokumpu IH. Open vs. laparoscopic surgery for rectal prolapse: a case-controlled study
assessing short-term outcome. Dis Colon Rectum 2003; 46(3):
353–60.
45. Steele SR, Goetz LH, Minami S et al. Management of recurrent rectal prolapse: surgical approach influences outcome.
Dis Colon Rectum 2006; 49(4): 440–5.
46. Pikarsky AJ, Joo JS, Wexner SD et al. Recurrent rectal pro-Recurrent rectal prolapse: what is the next good option? Dis Colon Rectum 2000;
43(9): 1273–6.
24
Operative and nonoperative therapy for diverticular disease
R Scott Nelson and Alan G Thorson
Unlike other diseases in this text diverticular disease is a common
problem with multiple presentations.
CHALLENGING CASE #1
A 52-year-old male presents to the Emergency Department
with complaints of left lower quadrant (LLQ) abdominal pain
for the last 16 hours. The patient describes the pain as escalating in nature, unrelieved with a bowel movement. History is
unremarkable except for hypertension, which is treated with a
beta-blocker. The patient denies any similar symptoms previously. Abdominal exam reveals a mildly distended abdomen,
with tenderness to the left lower quadrant, but no guarding or
rigidity. A basic metabolic profile is normal and complete blood
count reveals a leukocytosis at 14,000. CT scan of the abdomen
and pelvis with oral and rectal contrast demonstrates thickening of the sigmoid colon with mesenteric thickening but no
identifiable abscess or perforation.
CASE MANAGEMENT
In a 52-year-old male patient with the aforementioned findings, a
clinical and radiographic diagnosis of acute uncomplicated diverticulitis is confirmed. Treatment should consist of broad spectrum
antibiotics, typically, Ciprofloxacin and Flagyl, IV fluids, and bowel
rest. Admission to the hospital is based on physical examination,
comorbidities, and CT findings. Treatment should be continued
until the patient’s pain has resolved or symptomatic improvement
is noted, and then oral intake may resume. Antibiotics are typically
continued for 7–10 days following resolution of pain.
CHALLENGING CASE #2
A 67-year-old female presents to the ED with a two day history
of escalating LLQ pain and evidence of diverticulosis on colonoscopy 10 years ago. Physical exam reveals a tender LLQ without
peritoneal signs, and fullness to palpation. WBC count is elevated
at 17,000 and a CT scan shows a thickened inflamed sigmoid
colon with a 3 cm abscess on the medial aspect of the colon.
Case #2 Management
Any patient diagnosed with a diverticular abscess, elevated WBC
count, and pain, should be admitted to the hospital and started on
intravenous fluids and antibiotics. The risk of requiring an emergent operation secondary to failure of conservative management is
0–30%. Patients with an abscess >2–3 cm should also be evaluated
for percutaneous drainage. Following these measures the patient
should be followed to assess clinical improvement. Resolution
based on physical exam and bowel activity can dictate further
conservative treatment. Elective surgery should be scheduled in
the near future based on the patient’s overall health and ability to
undergo an operation. Failure of conservative therapy deems that
an operation be completed during that hospitalization.
CHALLENGING CASE # 3
65-year-old male admitted for acute uncomplicated diverticular disease is started on antibiotic therapy. After 3 days of I.V.
antibiotic therapy and IV fluid the patient’s pain resolves. He is
switched over to oral antibiotics and started on a low residue diet.
The patient describes the same pain, increasing in the LLQ over
the next 24 hours. He is once again made NPO and I.V. antibiotics are restarted. This time, attempts to switch the patient to oral
antibiotics are successful and he is discharged home. However 10
days later he returns with LLQ pain again and CT scan continues
to show uncomplicated diverticulitis. He is restarted on oral antibiotics and his pain resolves.
Case #3 Management
Chronic diverticulitis should be treated with an operation. There
are not many studies in the literature dedicated to just chronic
diverticular disease; however, it is a subject that probably does
not need such study. Patients with pain that is clearly attributable to a surgical disease and that persists despite maximal medical therapy are candidates for an operation and should have the
problem dealt with.
CHALLENGING CASE #4
A 72-year-old female presents to her primary care physician for
the 4th time in 6 months with a urinary tract infection (UTI). The
patient has no known history of abdominal pain, and no previous
history of frequent UTI, and now has noticed pneumaturia. The
culture shows multiple organisms, including E. Coli. The last pre-
vious colonoscopy 2 years ago demonstrated diverticula, but was
otherwise normal. Abdominal exam reveals no abnormal findings. What would be the best way to proceed in the diagnosis and
treatment of this individual?
Case #4 Management
This patient should undergo confirmatory testing and CT scan. If
the diagnosis is unsuccessful with barium enema, cystoscopy can
also be attempted. If the patient is a candidate for surgery and the
suspicion remains without confirmation, operative treatment is
indicated. Laparoscopic resection has been shown to be possible
in these types of cases as well.
CHALLENGING CASE #5
A 34-year-old female 2 weeks after a renal transplant for polycystic kidney disease complains of anorexia and vague abdominal tenderness, more on the left side. Bowel movements which
had been normal have now stopped over the last three days.
A palpable kidney in the LLQ is not overly tender, and renal
function does not seem abnormal for the time since operation. No changes have been made in her immunosuppressive
medication.
249
improved outcomes in colon and rectal surgery
Case #5 Management
Prophylactic colectomy for diverticulosis is not recommended
before transplant. However, the incidence of diverticulitis following transplant is higher than the general population, though still
relatively rare in the transplant population overall. Additionally
patients receiving immunosuppressive therapy are at a higher
risk for complicated diverticulitis and, more importantly, delay
in diagnosis significantly increases their morbidity and mortality. Patients with polycystic kidney disease also show higher rates
of diverticulosis and diverticulitis as opposed to other populations. These patients require aggressive diagnostic evaluation
with CT scan and if diverticulitis is confirmed, aggressive surgical
management.
INCIDENCE OF DIVERTICULOSIS AND DIVERTICULITIS
It is estimated that nearly 30% of the U.S. population will have evidence of diverticulosis by age 60. That number increases to 60%
by the time an individual reaches 80 years of age. (1) However,
of these patients, only 10–25% will develop symptomatic diverticulitis and of those who become symptomatic only 10–20%
of individuals will require hospitalization. Of patients who are
hospitalized with symptomatic disease, 20–50% will require an
operation. (2) Overall, <1% of patients with diverticula will ultimately require surgical management. In recent years there has
been a shift in the treatment of patients with diverticulitis as
more are treated as outpatients with oral antibiotics than with
hospitalization. (2) Left sided diverticula predominant among
the more western countries including the United States, Canada,
United Kingdom, Europe and Brazil. While left-sided disease is
still more common, right-sided disease is associated more with
eastern countries such as Japan, China, Korea, and Singapore.(3)
The male to female ratio appears to be about equal.
CLASSIFICATION
In order to determine how best to treat patients presenting with
diverticular disease, classification of the severity of the disease
is necessary. Diagnostic modalities have changed substantially
within the last 40 years and along with it our paradigms of treatment. Park, in the late 60s and early 70s along with fellow contemporaries including Larson, and Haglund (4–6) attempted to
evaluate the natural history of diverticulitis in order to classify the
severity of disease. Many of the guidelines and recommendations
by various societies for the treatment of diverticulitis are based
on this original work. However, their diagnosis of the disease was
based on barium enema, physical examination, and pathology
reports. While all three methods are sufficient to make a diagnosis, the improved sensitivity and specificity of newer technology
has changed the way we diagnosis, classify and treat this disease
today. In recent years, criteria for the classification of diverticulitis
has changed from findings on barium enema, history and physical examination and colonoscopy to findings based on computed
tomography (CT) scanning. These scans now provide practical
and predictive information that assist in the classification and
severity of the disease process. A number of useful classification
systems have been developed to assist the physician in deciding
on a course of treatment.(1, 7, 8) These classification systems can
be based on CT scans findings (Table 24.1 and Figures 24.1, 24.2
Table 24.1 Ambrosetti classification of diverticulitis based on CT
findings.
Ambrosetti CT Classifications
Uncomplicated—colonic wall thickening, pericolic fat stranding, inflammatory
changes
Complicated—Extracolonic air, abscess, perforation
Table 24.2 Intra-operative classification.
Hinchey Classifications
Type I—Diverticulitis with no or local peritonitis
Type II—Diverticulitis with a small pericolic abscess
Type III—Diverticulitis with local purulent or fecal peritonitis
Type IV—Diverticulitis with diffuse purulent or fecal peritonitis
Table 24.3 Definitions of diverticular disease.
Diverticulitis Defined:
I. Diverticulosis
1. Asymptomatic
II. Diverticulitis
1. Noninflammatory
A. Symptoms without inflammation
2. Acute
A. Complicated
Perforation, Abscess, Phlegmon, Fistula, Bleeding
B. Uncomplicated (Simple)
Localized, thickening, fat stranding
3. Chronic
A. Recurring or persistent disease
Symptoms with systemic signs (may be intermittent)
B. Atypical
Symptoms without systemic signs
4. Complex
A. Fistula, Stricture, Obstruction
5. Malignant
A. Severe, fibrosing
and 24.3), intraoperative findings (Table 24.2), or a more global
view of the disease (Table 24.3).
Ambrosetti has done extensive work on CT findings of diverticular disease and developed a classification system based on the
appearance of the inflamed colon. (7) His work is simple and
divides patients into two groups; uncomplicated or complicated.
(Table 24.1) Other studies have looked at the size of the abscess
and amount of mesenteric air to determine if those are predictors
of failure of nonoperative therapy.(8)
Another useful method of evaluating diverticulitis was reported
in 1978 by Hinchey. This is based on findings at the time of surgery and the decision for determining the correct surgical intervention was based on this classification system.(9) This simple
formula divided the intraoperative findings into four categories
based on the amount and type of peritonitis. (Table 24.2)
However not all diverticular disease can be classified by CT
scan or at the time of an operation. In a recent description of the
2
operative and nonoperative therapy for diverticular disease
disease, Thorson and Goldberg described the disease based on
the type of presentation, timing and duration of the disease, and
complexity.(10) (Table 24.3)
Acute Uncomplicated Diverticulitis
Nonoperative Treatment
Multiple reports have cited the successful treatment of uncomplicated diverticulitis in all patients, regardless of age.(11–16)
However, the treatment can be quite variable as cited in a recent
survey among members of the American Society of Colon and
Rectal Surgeons (ASCRS). (12) This survey found that the treatment of patients with uncomplicated diverticulitis varied widely
between type and number of antibiotics used, feeding schedule, and admission to the hospital. Further study into the natural history of the disease, with respect to both the short- and
long-term outcomes of patients with uncomplicated diverticulitis, is overwhelmingly in favor of conservative treatment without operation. (13, 15–18) It is estimated that with conservative
treatment 70–100% of patients will improve. Patients are even
being treated as outpatients with oral antibiotics, sports drinks,
and frequent follow-up in an effort to limit cost related to
uncomplicated disease. (19)
Outcome Measures
Economic and morbidity models have been developed to evaluate the cost and risk/benefit ratio of early versus late operation for
patients with uncomplicated diverticulitis. These studies determined that waiting, until after the 3rd or even 4th attack of documented diverticulitis, was both cost effective and less morbid on a
population based model, than performing an early elective operation. (9, 20) Traditional teaching about diverticulitis suggested
that patients suffering more than two episodes of uncomplicated
diverticulitis should undergo an elective operation. In fact, most
of the consensus data on elective resection after two documented
episodes comes from literature that was published before the use
of CT scanning and modern day antibiotic therapy. Because of
these and other studies, the American Society of Colon and Rectal
Surgeons (ASCRS) has revised its previous recommendations of
resection. The 2006 revised practice parameters now read, “The
decision to recommend surgery should be influenced by the age
and medical condition of the patient, the frequency and severity of the attacks, and whether there are persistent symptoms
after the acute episode.” (1) These new recommendations have
changed the traditional perspective taken on this disease process
and forces those involved in the care of patients with this disease
to reevaluate the literature and possibly modify their practice.
Thus today, surgeons must individualize the recommendation
for operation for each patient. One must take into account the
patient’s history, physical exam and diagnostic radiographic findings, response to medical therapy and other comorbidities before
making recommendations for an operation.
Progression of Disease
One of the most feared complications of diverticular disease is
the need for an emergent operation with possible fecal diversion. The increased morbidity and mortality to patients is not
insignificant when an emergent operation is required. However,
the need for emergent fecal diversion most commonly occurs
with a first episode of diverticulitis and is very rarely associated
with recurrent disease. It has been estimated that only 1 in every
2,000 pt/years of follow-up will require an emergent resection
after resolution of an episode of medically treated diverticulitis.
(17) A recent meta-analysis reviewing the outcomes of medically versus surgically treated uncomplicated diverticulitis demonstrated that recurrent hospitalization was more frequent in
the medically treated group than in a surgically treated one.
Mortality rates for uncomplicated disease were generally low
though, regardless of the treatment chosen, especially in patients
less than 50 years of age. (21)
In addition to the fear of an emergent operation and possible
stoma, elective operation has long been recommended based on
risk of recurrence. In the 1950s it was reported that morbidity
and mortality were higher with recurrent attacks of acute inflammation and early interval resection was a means of avoiding
those problems.(22–24) Recent studies have repeatedly shown
that recommendations for prophylactic operation to prevent the
need for an emergent operation are unfounded. In patients with
uncomplicated diverticulitis, Chautems followed 118 patients
after a first attack of uncomplicated diverticulitis for 9.5 years. Of
these patients, 71% had no recurrent episodes and of those that
did, none required emergent surgery.(25) In a population based
study of over 20,000 patients admitted with nonoperatively managed diverticulitis only 5.5% required an emergent colectomy
or colostomy. Younger patients in this study were found to be at
higher risk than their older counterparts.(18) Other studies have
also demonstrated that the risk of patients requiring an emergent
operation from recurrent disease is much lower than previously
thought. (Table 24.4) The number of patients who would benefit
from prophylactic colectomy to prevent a future emergent operation consistently remains <5%.
A step-wise progression of diverticular disease from diverticulosis to uncomplicated diverticulitis followed by complicated diverticulitis and finally complex disease such as fistula or obstruction is
not the natural progression of this disease. Patients may present at
any stage of the disease ranging from asymptomatic to colovesicular fistula without a history of previous attack. Janes reported that
the idea that patients should undergo elective resection to avoid
a colostomy is incorrect; such a concept can scare patients into
“elective surgery.”(17) Prophylactic sigmoid resection based on the
premise of preventing the possibility of future colostomy does not
appear to be founded on evidence-based principles.
Age
Most studies define “young” patients as those <50 years of age.
Younger patients have been thought to have more virulent disease, with a higher risk for recurrence and emergent operation.
Recent publications have questioned whether or not this is the
case.(7, 15, 29–31) Nelson et al. observed that in 234 patients
>50 years of age, with a mean follow-up of 4 years after a CT
scan diagnosed episode of acute uncomplicated diverticulitis,
only 10 patients (4.2%) returned with a complicated episode; of
these, 5 (2.1%) required an emergent colectomy and colostomy.
(29) Anaya published a review of 25,058 patients hospitalized for
an initial episode of diverticulitis. Of the 20,136 patients treated
251
improved outcomes in colon and rectal surgery
Table 24.4 Number of patients requiring urgent surgery who had a previous history of diverticular disease.
Emergent Operation Emergent Operation
Ref Yr # pts Elective OR All Pts
Alexander (26) 1983 673 13 80 37 (5.4%) 10
Nylamo (27) 1990 113 3 48 2 (1.7%) 10
Lorimer (28) 1997 154 28 126 15 (5%)*
Somasekar (2) 2002 108 0 104 28 (2.7%)* 5
* Patients who had been hospitalized previously with diverticulitis.
Pts with hx of
diverticulosis
Pts Who Would Have Benefited
From Prophylactic Colectomy
Pts with a hx of
diverticulitis
F/U in years
Table 24.5 Natural history studies of uncomplicated diverticular disease as reviewed by Janes.(1)
1st Admit 1st Admit 2nd Admit 2nd Admit
Ref Year # Pts F/U Diagnosis All Operations
Parks (4) 1969 455 1–16 Y BE, Path 138 Most 78 20
Larson (5) 1976 132 9 Y BE, Path 33 NR 29 9
Haglund (6) 1979 392 6 Y BE, Path 97 97 73 0
Ambrosetti (32) 1994 226 25 M CT, CE 66 NR 42 8
Emergent
Operation
Recurrence
Emergent
Operation
8
Ambrosetti (33) 1997 423 46 M CT, CE 112 33 27 NR
Makela (34) 1998 366 10 years CE, path, Scope 101 55 57 19
Biondo (30) 2002 327 24–90 months CE, CT, Path 103 78 52
nonoperatively, 19% developed a recurrence, with those >50 years
of age having a slightly higher recurrence rate (27% vs. 17%, p <
.001). They projected that a policy of routine, elective colectomy
in a younger population after an initial episode would require
13 elective operations to prevent one emergent colectomy. In this
large series, 73% of young patients resolved with medical management and never suffered a recurrence. Only 7% of all patients
<50 ever require an emergent operation. The risk of all patients
of any age requiring an emergency operation was 5.5%.(18)
These recurrence rates are significantly lower than previous
estimations which were >30% for younger patients. Very few
patients requiring an emergent operation had been previously
recurrence, most groups recommend initial conservative treatment. As mentioned before, risk/benefit models recommend
withholding resection until after three or four recurrent documented episodes. There has also been a suggestion that no
surgical treatment should be offered despite the number of
uncomplicated episodes.(8)
Nonoperative therapy for patients with uncomplicated diverticulitis has been shown to be safe and effective in a majority of
this population. The ASCRS practice parameter on diverticular
disease also affirms that there is no clear consensus regarding
whether younger patients treated for diverticulitis are at increased
risk for complications or recurrent attacks.(1)
diagnosed with or suffered from diverticulitis. An estimated 75%
to 96% of patients presenting with peritonitis and requiring an
emergent operation have never been diagnosed with the disease
previously. This supports the notion that operating on patients
with a history of acute diverticulitis to prevent complications of
acute disease is ineffective at achieving that goal.(2, 26–28)
Although it seems intuitive that patients with more years
to live relative to their older counterparts are at a higher risk
of recurrence, there is little evidence available to suggest that
younger patients have a more virulent disease process that warrants aggressive surgical intervention. Despite the split over
Risk of Recurrence
The risk of recurrence following an attack of uncomplicated
diverticulitis is low. The range of recurrent episodes of diverticulitis after one uncomplicated attack is 1.4–18%. (13, 15, 16) Janes
(17) reviewed 94 papers in an effort to review the evidence for recommendations put forth for elective resection after two attacks of
diverticulitis. They concluded that there is inadequate evidence to
suggest that complications are more likely to occur with each successive hospital admission, or that the likelihood of a successful
response to medical treatment decreases (Table 24.5).
4
22
operative and nonoperative therapy for diverticular disease
Acute Complicated Diverticulitis
Outcome Measures
When determining how best to treat patients presenting with
acute diverticulitis two questions need to be answered. First, what
category of diverticulitis is present based on history and physical
examination and CT scan findings. Second, what is the feasibility
and indication for operation versus medical therapy? With the
advent and availability of CT scanning and its wide spread use for
typical symptoms of diverticulitis we are better able to classify the
disease. A patient presenting with an acute complicated episode
of diverticulitis typically will have findings of abscess, phlegmon,
or localized perforation on CT scan. In a recent review of patients
presenting with complicated diverticulitis, 29.5% were found to
have a paracolic abscess, 22.3% an acute phlegmon, 13.4% a fistula, 22.6% an obstruction or stricture and 44% a contained or
free perforation.(35)
Peritonitis, free intraabdominal air, or obstruction unrelieved
by other methods is an indication for operation. Patients with
signs of peritonitis or hemodynamic instability are not candidates for medical management and should be resuscitated and
taken to the operating room. However, many patients presenting with an abscess, localized and contained perforation, or
phlegmon are candidates for conservative therapy. These individuals should be evaluated for possible percutaneous drainage
with radiographic guidance. Once stabilized, patients with complicated diverticulitis should have a complete colon evaluation
and most should be scheduled for an elective operation. The
American Society of Colon and Rectal Surgeons (ASCRS) have
recommended that, “Elective colon resection should typically
be advised if an episode of complicated diverticulitis is treated
nonoperatively.”(1) However, there is a growing body of evidence to suggest that select patients with complicated disease
may be safely managed if they respond to more conservative
measures.
Ambrosetti attempted a prospective trial of surgery versus
observation after the 1st complicated attack of diverticulitis but
abandoned the trial after 19 months as only 4 of the 52 (8%) had
a recurrence.(36)
Faramakis followed 120 patients from 30 centers over 5
years with complicated diverticulitis, defined as abscess, fistula, obstruction, or free perforation. Of these patients, 32%
developed a severe complication and 10 patients died. However,
many of these patients were treated nonoperatively because they
were not felt to be surgical candidates and three times as many
patients died from cardiovascular or pulmonary complications,
compared to those who died from complications of diverticular
disease.(37)
One small study followed 28 patients after identification of
complicated disease on CT scan. Ten patients were percutaneously
drained and the rest were treated conservatively. Two patients ultimately required operation during their initial hospitalization and
18 patients (24%) had recurrence. They concluded that most
patients could be managed without an operation or drainage.
(38) However, until more evidence substantiates a clear path to
follow, operative resection remains the standard for most patients
presenting with complicated disease.
Risk of Recurrence—Indications for surgical treatment
Patients presenting with peritonitis should undergo an urgent
operation after appropriate resuscitation. Patients presenting
with complicated disease without peritonitis should initially be
treated conservatively with IV Fluids, NPO, antibiotics, and percutaneous drainage of any abscess. Evaluation in a recent study
identified 511 patients diagnosed with complicated diverticulitis.
Of these patients, 99 were diagnosed by CT scan with abscess and
16 of these underwent percutaneous drainage. Of those patients
with continued nonoperative treatment, even after percutaneous
drainage, a recurrence rate of 42% was noted with an increased
probability of emergent procedure. Based on these findings it was
recommended that all patients with complicated findings on CT
scan undergo an elective operation.(8)
Salem reviewed all hospitalized patients for the state of
Washington. After evaluating over 25,000 patients, percutaneous
drainage and medical management were found to decrease the
need for emergency operative interventions.(39)
Other studies have shown that complicated disease is not a
result of multiple uncomplicated episodes. Salem, et.al., demonstrated that of 77 patients followed with complicated diverticulitis, only eight had two or more previous episodes. A majority of
patients (79.4%) with fistula, perforation, bleeding, and abscess
had no previous episodes of diverticulitis. They concluded that
simple acute diverticulitis is not a good predictor for the development of further complications from diverticular disease as only a
minority of patients with complications had previous episodes of
diverticulitis.(13)
Chapmen found that only 21% of patients presenting with
free perforation and peritonitis had a previous history of disease.
(40) Somasekar reviewed 108 patients admitted with complicated
diverticulitis. Of these, 104 required emergent surgery but only
28 patients had a previous history of uncomplicated diverticulitis. However, only 3 (2.7%) of these 28 patients had suffered two
previous episodes and would have qualified for an operation
under the standard guidelines (2) Hart performed a case controlled study of patients presenting with perforated diverticulitis
and found that 78% had no previous history.(41)
Timing for Surgical Intervention
Complicated diverticulitis is at this time an indication for operation. Circumstances may arise that would make continued observation a wiser decision based on the age and comorbidities of the
patient, but until further evidence is available operation continues to be the standard of care.
Pain is a valuable indicator for the patient’s recovery, and provides a marker for evaluation. Attempts at initiating PO intake
and switching antibiotic therapy may be confidently made
based on the patient’s symptoms or lack of resolution of those
symptoms.
Once the patient is pain free and has undergone an adequate
preoperative evaluation, surgery can be undertaken. Before any
surgical procedure patients should undergo endoscopic evaluation of the colon in order to rule out other disease processes that
may need to be taken care of at the same time. Optimal timing for
performing an operation after medical treatment of a complicated
253
improved outcomes in colon and rectal surgery
episode of diverticulitis has occurred and has never been studied.
However, it seems prudent to offer an elective operation within
6 to 8 weeks to allow the inflammatory process to settle and provide an opportunity for safest operation. Laparoscopic surgery
will also be easier without the inflammatory component of the
acute setting.
Chronic Diverticulitis
Indications for Medical versus Surgical Treatment
Chronic diverticulitis is typically defined as uncomplicated acute
diverticular disease that resolves with antibiotic therapy only to
flare again once antibiotics are discontinued. It is not a particularly common entity within the spectrum of diverticular disease.
Patients initially respond well to antibiotic therapy but fail to
fully resolve their symptoms, or have frequent recurrences within
weeks of each other. Patients may experience multiple flares of
the disease that resolve spontaneously but continue to plague the
patient for weeks to months.
Indications for surgical treatment
Chronic diverticulitis is an indication for operation. However, the
correct diagnosis of recurrent or chronic diverticulitis must be
secure. Chronic abdominal pain unrelated to diverticular disease
has been described and an operation for pain without confirmatory findings is doomed to failure. Barium enema may be the
colon clearing test of choice in this situation as colonoscopy can
be associated with an increased risk of perforation in the face of
smoldering diverticular disease.
Best Timing for surgical intervention
Ideally, patients should be continued on their antibiotics up to
the time of operation. A bowel prep should be instituted in these
patients and their nutritional status be reassessed depending on
the amount of time they have had a chronic smoldering infection
and been unable to eat. A good starting place is to simply evaluate
the amount of weight lost over the recent past. Patients may be
candidates for either laparoscopic or open surgery, as both have
been shown to be safe and effective in the hands of well practiced
surgeons.
Complex Diverticulitis
Indications for surgical treatment
Complex diverticulitis is defined as patients with colonic fistula, stricture or obstruction. Colovesicular fistulas are the most
common fistula, but colosalpingo, colocutaneous, colo-colo,
colovaginal, and coloenteric fistulas all have been reported as a
complication of diverticular disease. Bleeding divertula is not
typically associated with the inflammatory state of diverticulitis
and thus falls outside the scope of this chapter.
About 1–2% of patients with diverticulitis develop an internal
fistula.(6) Symptoms of fistula depend on the location. Dysuria,
fecaluria, and pneumaturia are the most common presenting
signs for colovesicular fistula. At times, symptoms go unnoticed
and a delay in diagnosis for a prolonged period of time is not
uncommon. Rarely, some patients who present with complex
diverticulitis have never formally been diagnosed with previous
episodes of diverticulitis. This may be because the patient never
sought medical attention despite having some symptoms, or the
symptoms were mistaken for gastroenteritis, or other such ailment. Complications of diverticular disease appear to be related
more to the severity of the attack at a specific location than from
progression from simple to complex disease in an orderly fashion. This inflammatory process may range from uncomplicated
to complex.
Contrast enema has been described as one of the ways to diagnose an abnormal connection between the colon and another
organ. However various reports put the success rate between
34–83%.(42, 43) Vaginography or cystoscopy are two other ways
to confirm the diagnosis. If suspicions are still present with relevant symptoms, and CT scan confirms diverticulitis, operation
can be offered without confirmatory testing.
Whatever the source, patients with complex diverticulitis
should undergo an operation to correct the problem, unless the
patient is not a surgical candidate. These patients who are not
surgical candidates can be managed on suppressive antibiotics.
One important concept to remember is that fistulas do not represent an emergency. If the patient is appropriately draining, and
does not appear to be septic, there is no emergency to the operation. Complex fistulas have been managed with a single operation successfully in as many as 90% of cases, both with open and
laparoscopic techniques.(44–46)
Obstruction from diverticular disease is quite different. Patients
who present completely obstructed from diverticular disease will
require urgent decompression. Depending on the stability of the
patient, multiple options including resection and primary anastomosis with or without proximal diversion, Hartmann procedure,
Turnbull colostomy, or stent placement are available for the surgeon. These patients may carry an extensive history of diverticular
disease. Ruling out other sources of obstruction, specifically colon
cancer, is important. If the patient has not been screened appropriately, one may choose to perform intraoperative colonoscopy
depending on the patient’s condition and state of the bowel. If this
is impossible during the operation, as is frequently the case, then
follow up colonoscopy should be undertaken after the operation.
IMMUNOSUPPRESSED PATIENTS
Risk of developing diverticulitis
Difficulty arises in attempting to diagnosis diverticulitis in an
immunocompromised patient because many fail to manifest
the classical signs and symptoms of the disease. Patients who are
considered to be immunosuppressed include transplant recipients, those with an immunodeficiency syndrome, or those taking
immunosuppressive medications for arthritis, autoimmune diseases, or inflammatory bowel disease. Patients who are especially
problematic are those that are receiving prednisone in dosages
>20 mg/day. They present with fewer symptoms, have a longer
time to operation, and higher mortality (85%) when compared
with patients receiving lower doses (13%).(47) Thus, any patient
taking higher doses of an immunosuppressive medication must be
considered immunosuppressed and evaluated accordingly. These
patients are much more likely to present with a free perforation than
their nonimmunocompromised patients.(48–50) Correlation
24
operative and nonoperative therapy for diverticular disease
between a delay of diagnosis and mortality has also been demonstrated in these patients.
Transplant patients make up an ever growing population that
requires immunosuppressive medication. The incidence of transplant diverticulitis varies by the type of transplant performed;
however, all studies show a low incidence of the disease. One
report reviewed 2,000 patients over a period of 30 years following
renal transplants and reported a 0.5% risk of any colonic problems including diverticulitis.(51)
Many studies have reported an incidence of diverticulitis
among both lung and heart transplant patients that varies from
0.75% to 4%. However the hospital admission rate for diverticulitis in a “normal” population is 25–50 per 100,000 admissions
(0.025–0.053%), which is much less than in a transplant population.(51–53) From 1985 to 1996, a review of six series including
986 of heart and lung transplant patients showed an incidence
of 0.75%. The authors concluded that pretransplant screening of
diverticulosis is not justified in the absence of symptoms.(54)
Other authors have evaluated their experience with complicated diverticulitis in renal transplant patients. Of 1,211 patients,
13 patients had episodes of diverticular disease for a 1.1% incidence. They concluded that the problem is rare but the clinical
presentation is atypical.(55)
One of the major benefits among the transplant population
was the introduction of cyclosporine because of the decreased
steroid requirement. It has been demonstrated that a nearly
50% decrease in the rate of complicated diverticulitis was
accomplished in patients who were treated with cyclosporine;
however, this did not reach statistical significance due to small
sample size.(55)
Prophylactic Sigmoid Resection
Most authors recommend that patients with symptomatic diverticulitis with appropriate confirmation undergo sigmoid resection before transplant. Diverticulosis without symptoms though
does not require further investigation and is not an indication for
prophylactic resection. However, these patients are at a slightly
higher risk than the general population and should be monitored
closely.(55) Postoperative mortality is high in immunocompromised patients who develop acute diverticulitis requiring operative intervention. An increased index of suspicion is necessary in
treating immunocompromised patients. An approach incorporating an aggressive evaluation with medical support and early
surgical exploration is generally warranted.
One specific population deserves mention and those are
patients with polycystic kidney disease. These patients appear to
have a higher incidence of complicated diverticulitis than other
transplant patients, and one study concluded that these individuals warrant more aggressive diagnostic evaluation for any symptoms. Pretransplant screening and prophylactic sigmoid resection
deserve further study.(55)
OPERATIVE MANAGEMENT
What manner of operation is best?
Three operations are typically recommended for patients requiring a sigmoid resection. Open sigmoid resection, laparoscopic
sigmoid resection, or hand assisted laparoscopic resection (HAL).
Despite the recent eruption of literature and discussion about the
benefits of laparoscopic colectomies, only 5–10% of all colectomies are currently performed using a laparoscopic technique.(56)
However, with increased training and utilization, it is anticipated
that this number will continue to increase substantially.
Open colectomy is the gold standard for comparison.
Laparoscopic colectomy has gained increased prominence following the successful application of this technique for other procedures. While it is still in its infancy, it is fast becoming the main
choice for a growing number of patients and surgeons. Many
large studies have been undertaken to assess the safety of laparoscopic colectomy as well as its economic feasibility.
Reported benefits of laparoscopic colectomy include shorter
hospital stay, less postoperative pain, earlier return of bowel function, and quicker return to daily activities. Other reported benefits
include less wound, respiratory, gastrointestinal, and cardiopulmonary complications when compared to open surgery.(57–60)
The downsides of laparoscopic surgery include surgeon specific
initial higher complication rates and conversion rates associated
with a steep learning curve, longer operating room time, and
higher cost for operations.(58) However, a recent study looking
directly at total cost for open sigmoid resection versus laparoscopic sigmoid resection by Senagore (59), revealed that overall
total costs were significantly lower for laparoscopic patients, and
that operating room costs were not different between the two
types of surgery. They concluded that laparoscopic resection was
a cost effective means of managing sigmoid diverticular disease.
A key factor to keeping the costs equivalent between open and
laparoscopic resection was the minimization of conversion and
complication rates. A conversion rate of 6.6% was observed in
this study.
However, many factors go into a study like this including routine postoperative care, and surgeon and patient comfort levels
with earlier discharge. Despite this, slow but steady progress in
training of younger surgeons and greater familiarity with the new
techniques will more than likely make laparoscopic surgery the
standard of care in the future, much as laparoscopic cholecystectomy has become.
Hand Assisted Laparoscopic (HAL) Colectomy has also been
compared against laparoscopic resection and been found to be
equivalent as far as outcome of patients.(56, 61) Benefits of HAL
have been shorter operating times when compared with straight
laparoscopic surgery as well as lower conversion rates. One recent
study identified an advantage to using HAL colectomy with complicated diverticulitis and laparoscopic resection for uncomplicated diverticulitis.(56) The cost of utilizing a hand port was not
significantly different when offset by the faster operating room
time.(61)
Much depends on the ability of the surgeon to complete the case
without conversion. Conversion rates increase the total cost of the
operation as well as the potential morbidity rates for the patient.
In an article by Belizon (60) an analysis was made of patients
undergoing conversion to an open operation. Postoperative morbidity was significantly higher for laparoscopic resection procedures that were converted to open after 30 minutes into the
255
improved outcomes in colon and rectal surgery
operation. Wound complications and greater length of stay in the
hospital were the two most common findings. Obesity, adhesions,
bleeding, and inflammation beyond area of operation were the
most common predictors for conversion.
The best operation for an individual seems to be the operation the surgeon can perform. However, with advancing minimally invasive techniques that can be implemented at a similar
cost structure, it behooves all surgeons to continue to educate and
modify their practices to provide the best care possible to their
patients.
Which Operation is Best?
Three different operations have been proposed for the treatment
of complicated diverticulitis with peritonitis. The first operative
approach described was the three stage procedure encompassing drainage with stoma, followed by resection and anastomosis
with continued diversion, and finally by restoration of continuity. The second approach involved resection and diversion or the
traditional Hartmann procedure (HP). However, this approach is
being challenged by the third approach of resection with primary
anastomosis. Primary resection with anastomosis (PRA) can be
performed with or without a covering stoma, and/or on-table
lavage. The three stage procedure will not be discussed here as it
is not considered standard of care and should be used only in very
infrequent situations.
In 1921, Hartman advocated his two stage resection which was
superior and quickly became the standard of care. However early
in the 1960s there were eight reports with a total of 50 patients
that underwent resection and primary anastomosis for generalized peritonitis with a low mortality of 10%.(63) Not much debate
is raised now with respect to patients presenting with recurrent
or chronic diverticulitis. They are typically managed in an elective
fashion with primary anastomosis. Patients are still traditionally
given a bowel preparation before surgery, at least in the United
States, and probably will for some time though there is a growing
swell within the literature questioning its necessity.
Patients who present with acute symptoms, typically Hinchey
stages III or IV, are taken to the operating room urgently. These
patients constitute approximately 3.2 per 100,000 patients.(63)
These patients present a dilemma, because typically they are
older, have a high number of comorbidities, and suffer a greater
number of complications. In a recent review by Salem reviewing
98 articles on the outcome of complicated diverticulitis based on
the type of operation performed, they identified 1,051 patients
who underwent a Hartmann procedure from 54 studies, and
569 patients having undergone a primary anastomosis from 50
studies. (Tables 24.6 and 24.7) Of the patients undergoing a primary anastomosis, 16% had covering stomas and 10% had ontable lavage. The mortality rates of those in the Hartmann group
(19.6%) were much higher than those undergoing a primary
anastomosis (9.9%). The anastomotic leak rate in patients with
a primary anastomosis ranged from 6.3% to 19.3%. If a diverting
proximal stoma was performed at the time of a primary anastomosis the anastomotic dehiscence rate fall to 6.3%. Wound
infections were also more frequently seen in the Hartman group
(24.2%) versus the primary anastomosis group (9.6%). Again,
patients with covering stomas had the lowest wound infection rate
Table 24.6 Outcomes of primary anastomosis in patients with
complicated diverticulitis—Salem et al.(61)
Primary Primary Primary Primary with
Anastomosis Anastomosis Anastomosis Anastomosis
Overall Alone with Stoma lavage
Mortality 9.9% 8.1% 9.2% 9.6%
# of Studies 48 29 17 3
# of Cases 548 297 109 52
Anastomotic Leak 13.9% 19.3% 6.3% 9.6%
# of Studies 29 14 8 3
# of Cases 353 145 64 52
Wound Infection 9.6% 16.4% 4% 12%
# of Studies 17 6 3 2
# of Cases 219 55 25 50
Table 24.7 Outcomes of Hartmann and Hartmann Reversal.
Salem et al. (61)
# of
Patients
Hartmann 1,051 198 (18.8%) 70 (24.2%) 12 (10.3%) NA
Hartman
Reversal
787 6 (0.8%) 7 (4.9%) NA 20 (4.3%)
Mortality
Wound
Infection
Stoma
Complications
Leaks
at 4%. Patients undergoing a Hartmann procedure also required
a larger second operation than those who had PRA with or without a covering stoma. Complications from a Hartmann reversal
were associated with a mortality of 0.8%, a wound infection rate
of 4.9% and an anastomotic leak rate of 4.3%. These patients also
experienced stoma complications (10.3%) that required medical attention. The conclusion was the primary anastomosis is no
worse than a Hartmann procedure and has several advantages
including higher restoration of continuity rate, less hospitalization, and fewer infectious complications.(64)
Multiple studies have evaluated the morbidity and mortality of the
Hartmann procedure as well as the risks incumbent with takedown.
Most seasoned surgeons realize that at times restoration of continuity can be more of a challenge to both patient and surgeon than the
original operation. This was demonstrated in a recent multicenter
prospective trial involving 415 patients with complicated diverticulitis. Two hundred forty-eight patients underwent resection with primary anastomosis. The other 167 had a Hartmann procedure. The
mortality rate for those undergoing primary anastomosis was 4.0%
while those with resection and diverting colostomy was 23.4%. After
case adjustment, the data suggested that the Hartmann procedure
was associated with a 1.8 fold increase in likelihood of death. This was
not statistically significant. However a 2.1 fold increase in morbidity
was found between the two groups and this was significant. In part
this is due to the fact that surgeons typically reserved a Hartmann
procedure for those older patients with more comorbidities and thus
predisposed to a poorer outcome.(65)
Risks associated with Hartmann Reversal
Reversal of a Hartmann colostomy also carries with it a significant risk that must be entertained when considering this operation for patients who will desire continuity in the future. Failure
2
operative and nonoperative therapy for diverticular disease
Table 24.8 The cr-POSSUM scoring system.
Physiologic Parameters
Age
Cardiac No Failure Treatment for angina or HTN Edema, cardiomyopathy, coumadin Cardiomegaly, Raised JVD
Systolic BP 110–130 131–170
Pulse 50–80 80–100 100–120
Hgb 13–16 11.5–12.9 10–11.4
Urea 7.6–10 10.1–15
Type of Operation Minor Moderate Major Complex Major
Peritoneal Contamination None Cloudy Pus Fecal
Malignancy Status None, T1–2 T 3,4 Mal + Nodes Mal + Mets
Timing of OR Elective Urgent Emergent < 2 hours
to reverse the colostomy has been reported in 20–50% (61) of
patients and leak rates on reversal fall around 2–30% (61, 63)
Mortality has been reported anywhere from 0–10% and wound
infection rates range from 12–50%.
A strong interest in primary anastomosis has been revived in
the literature, with papers describing the successful outcomes of
patients undergoing this type of operation. However, few papers
are prospective, less are randomized, and such a trial is still needed
today to definitively answer the questions of safety and efficacy.
Multiple trials though have shown that the outcomes of primary
anastomosis are indeed as safe as a Hartman and in many cases
better. In a recent review, Constantinides et al. reviewed the outcomes of patients undergoing Hartmann (66), primary resection
with anastomosis (PRA) (135 patients) and primary resection
<61
62–70
Operative Parameters
rate of 7%, and no deaths. Postoperative stay after primary anastomosis and intraoperative lavage was 18.4 days and Hartmann
Procedure was 38 days. They concluded that primary anastomosis with intraoperative lavage and a Hartmann Procedure are
both adequate approaches for generalized peritonitis complicating diverticulitis.(17)
Covering stomas have been recommended by most studies
when primary anastomosis is performed because of the variable
anastomotic leak rate. Both diverting colostomies and ileostomies
have been described with equal success. Most of the poor outcomes noted are not necessarily due to the operation performed,
but the comorbidities and peritonitis associated with the patient
and disease. These risks play more into the outcome of patients
than the type of operation performed.
>71
>170 <90
<50
<10 or >18
>15
with anastomosis and diversion (126 patients). Patients undergoing a Hartmann procedure had a morbidity and mortality
Complications of Operation
of 35% and 20% respectively. Primary anastomosis showed a
slightly higher morbidity and mortality at 55% and 30%, while
those with a primary anastomosis with diverting stoma demonstrated a morbidity and mortality rate of 40% and 25% respectively. Stomas were permanent in 27% of patients undergoing a
Hartmann procedure and 8% of those having a primary anastomosis with diversion. They concluded that primary anastomosis
with defunctioning stoma may be an optimal strategy for selected
patients. Hartmann procedure should be reserved for patients
with an extremely high risk of perioperative complications and
only after consideration of long-term implications.(63)
Patients undergoing on-table lavage have been analyzed as well,
which showed similar outcomes to those who did not undergo
on-table lavage. Regenet, described 60 patients, all Hinchey III or
greater, in whom 27 underwent primary anastomosis with intraoperative lavage and 33 who had a Hartmann procedure. In this
prospective observational study they found that the Hartmann
procedure took much less time to perform, but that the mortality and morbidity for both groups were equal. Three patients in
the intraoperative lavage group had an anastomotic leak (11%).
A Hartmann reversal occurred in 69% of the patients. The reversal had its own associated morbidity of 24%, an anastomotic leak
Predictors of Morbidity and Mortality—Scoring Systems
Multiple scoring systems have been evaluated in attempts to predict outcome and risk in patients undergoing both elective and
emergent colon resection for diverticulitis. With an increasing
interest in outcomes by doctors, patients, and payers, predictive
scoring systems may be one of the many ways surgeons, hospitals,
and systems are evaluated.
Developed by Copeland in 1991, the Physiological and
Operative Severity Score for the enumeration of Mortality and
Morbidity (POSSUM) was developed as a tool to compare morbidity and mortality in a wide range of general surgical procedures. This was to facilitate surgical audit and the comparison
of hospital performance. It has been further adapted for patients
undergoing colon and rectal surgery and named cr-POSSUM
(Table 24.8). The idea was to adjust risk of a surgical procedure
based on the patient’s physiological condition and therefore
allow a more accurate comparison of a unit (or individual’s)
performance.
Oomen has been one of the physiological and operative severity score (POSSUM) score’s biggest proponents and has done
a number of studies attempting to validate the system. When
257
Соседние файлы в папке Библиотека им академика М.И. Перельмана