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288
A Personal View of the Data
The need for colectomy after successful PD of a diverticular abscess has not been
well studied. The majority of studies describing the use of PD of diverticular abscess
did so to demonstrate its feasibility and safety with imaging guidance, as well as a
temporizing measure to decrease the perioperative morbidity of interval colectomy.
Many agree with the decision to not operate on patients with prohibitive operative
risk after successful PD, but what about the otherwise healthy individual? The cur-
rent literature would favor interval colectomy with low (7 %) morbidity as com-
pared to the risk of recurrent diverticulitis (35 %). Although limited, the current
literature would also support that recurrent diverticulitis after successful PD does
not typically require an emergency operation nor is it associated with an increased
risk of stoma with operative treatment. Recurrent or persistent disease after PD
alone typically presents with abdominal symptoms, CT-evidence of diverticulitis
without abscess or perforation, or a persistent colo-cutaneous fistula. Could patients
be followed closely for recurrent symptoms and managed accordingly without the
pre-emptive decision of performing interval colectomy? We believe that, ultimately,
the decision of whether to undergo colectomy after successful PD also depends
upon other factors including the number of episodes before abscess occurrence,
disease- free intervals, ready access to health care, and patient preference.
Our current practice is to recommend interval elective colectomy after successful
PD of a diverticular abscess in those patients with persistent abdominal symptoms
or complications such as fistula, those with a pattern of recurrent symptomatic
diverticulitis, and immunosuppressed patients who do not have prohibitive opera-
tive risk.
References
1. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the
United States. Gastroenterology. 2002;122:1500–11.
2. Kozak LJ, DeFrances CJ, Hall MJ. National hospital discharge survey: 2004. Vital Health Stat.
2006;13:1–209.
1. Elective colectomy should typically be considered in patients with appro-
priate operative risk, after an acute episode of diverticular abscess has
resolved with PD. Grade of Recommendation: weak recommendation
based on low-quality evidence, 2C.
2. Percutaneous drainage of colonic diverticular abscess without subsequent
colectomy appears to be a safe, low-risk, and reasonable management
option in selective patients with prohibitive operative risk or in healthy
patients who prefer to avoid surgery. Grade of Recommendation: weak
recommendation based on low-quality evidence, 2C.
W.B. Gaertner and R.D. Madoff
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3. Chapman J, Davies M, Wolff B, et al. Complicated diverticulitis: is it time to rethink the rules?
Ann Surg. 2005;242:576–81.
4. Kumar RR, Kim JT, Haukoos JS, et al. Factors affecting the successful management of intra-
abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis Colon
Rectum. 2006;49:183–9.
5. Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA. Percutaneous Ct scan-guided
drainage vs. antibiotherapy alone for hinchey II diverticulitis: a case–control study. Dis Colon
Rectum. 2006;49:1533–8.
6. Rafferty J, Shellito P, Hyman NH, Buie WD. Standards Committee of American Society of
Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum.
2006;49:939–44.
7. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parame-
ters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57:284–94.
8. Saini S, Mueller PR, Wittenberg J, Butch RJ, Rodkey GV, Welch CE. Percutaneous drainage
of diverticular abscess: an adjunct to surgical therapy. Arch Surg. 1986;121:475–8.
9. Mueller PR, Saini S, Wittenburg J, et al. Sigmoid diverticular abscesses: percutaneous drain-
age as an adjunct to surgical resection in 24 cases. Radiology. 1987;164:321–5.
10. Neff CC, van Sonnenberg E, Casola G. Diverticular abscesses: percutaneous drainage.
Radiology. 1987;163:15–8.
11. Stabile BE, Puccio E, van Sonnenberg E, Neff CC. Preoperative percutaneous drainage of
diverticular abscesses. Am J Surg. 1990;159:99–104.
12. Hachigian MP, Honickman S, Eisenstat TE, Rubin RJ, Salvati EP. Computed tomography in
the initial management of acute left-sided diverticulitis. Dis Colon Rectum. 1992;35:1123–9.
13. Ambrosetti P, Robert J, Witzig JA, et al. Incidence, outcome, and proposed management of
isolated abscesses complicating acute left-sided colonic diverticulitis: a prospective study of
140 patients. Dis Colon Rectum. 1992;35:1072–6.
14. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of
complicated diverticular disease. Am J Surg. 2003;186:696–701.
15. Macias LH, Haukoos JS, Dixon MR, et al. Diverticulitis: truly minimally invasive manage-
ment. Am Surg. 2004;70:932–5.
16. Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of meso-
colic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis
Colon Rectum. 2005;48:787–91.
17. Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role
of computed tomography. Am J Gastroenterol. 2005;100:910–7.
18. Siewert B, Tye G, Kruskal J, et al. ImpactofCT-guided drainage in the treatment of diverticular
abscesses: size matters. AJR Am J Roentgenol. 2006;186:680–6.
19. Durmishi Y, Gervaz P, Brandt D, et al. Results from percutaneous drainage of hinchey stage II
diverticulitis guided by computed tomography scan. Surg Endosc. 2006;20:1129–33.
20. Singh B, May K, Coltart I, Moore NR, Cunningham C. The long-term results of percutaneous
drainage of diverticular abscess. Ann R Coll Surg Engl. 2008;90:297–301.
21. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. The efficacy of nonopera-
tive management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54:663–71.
22. van de Wall BJ, Draaisma WA, Consten EC, et al. Does the presence of abscesses in diverticu-
lar disease prelude surgery? J Gastrointest Surg. 2013;17:540–7.
23. Gaertner WB, Willis DJ, Madoff RD, et al. Percutaneous drainage of colonic diverticular
abscess: is colon resection necessary? Dis Colon Rectum. 2013;56:622–6.
24. Felder SI, Barmparas G, Lynn J, Murrell Z, Margulies DR, Fleshner P. Can the need for colec-
tomy after computed tomography-guided percutaneous drainage for diverticular abscess be
predicted? Am Surg. 2013;79:1013–6.
25. Subhas G, Rana G, Bhullar J, Essad K, Mohey L, Mittal VK. Percutaneous drainage of a diver-
ticular abscess should be limited to two attempts for a resilient diverticular abscess. Am Surg.
2014;80:635–9.
26 Do We Need to Operate on Patients After Successful Percutaneous Drainage
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26. Elagili F, Stocchi L, Ozuner G, Dietz DW, Kiran RP. Outcomes of percutaneous drainage
without surgery for patients with diverticular abscess. Dis Colon Rectum. 2014;57:331–6.
27. Knapp C, Brand M, Orkin B. Management of diverticular abscesses with nonsurgical drain-
age: Is there a need for interval resection? Dis Colon Rectum. 2015;58:e153–4.
28. Alvarez JA, Baldonedo RF, Bear IG, et al. Presentation, management and outcome of acute
sigmoid diverticulitis requiring hospitalization. Dig Surg. 2007;24:471–6.
W.B. Gaertner and R.D. Madoff
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291© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_27
Chapter 27
The Role of Laparoscopic Peritoneal Lavage
in the Operative Management of Hinchey III
Diverticulitis
Lisa Marie Cannon
Introduction
The 2014 American Society of Colon and Rectal Surgeons practice parameters for
the treatment of sigmoid diverticulitis recommend urgent sigmoid colectomy for
patients presenting with diffuse peritonitis or for those in whose initial nonoperative
management fails [1]. While open Hartmann’s procedure has been long considered
the ‘gold standard’ in these situations, primary anastomosis with proximal diversion
is increasingly supported in recent literature [2, 3]. Laparoscopic sigmoidectomy in
the emergency setting is safe, with decreased morbidity compared to open sigmoid-
ectomy [4].
In the only recent randomized clinical trial (RCT)comparing primary anastomo-
sis with diversion to Hartmann’s procedure in the emergency setting, Oberkofler [3]
reported similar outcomes with the initial colectomy, but superior overall results in
the primary anastomosis group owing to the higher rate of stoma closure and rela-
tive safety/efficiency of ileostomy closure as opposed to Hartmann takedown. The
trial has been criticized for the influence of surgeon discretion on the choice of
technique, as well as calculation of the sample size [5, 6]. A similar RCT [7] was
prematurely terminated due to slow accrual.
Stoma avoidance altogether in the emergency setting is also described in limited
and somewhat dated series; intraoperative colonic lavage is often employed in these
studies to prepare the colon for primary anastomosis, with acceptable morbidity and
anastomotic leak rates [8, 9]. Two recent retrospective analysis also concluded that
primary anastomosis without diversion is an appropriate option in the urgent setting,
L.M. Cannon, MD
Section of Colon and Rectal Surgery, Department of General Surgery, University of Chicago
Medicine, 5841 S. Maryland Avenue, MC 5094, Chicago, IL 60637, USA
e-mail: lcannon@surgery.bsd.uchicago.edu
292
including patients with Hinchey III (purulent) and Hinchey IV (feculent) peritonitis;
careful patient selection is advised [10, 11].
The broad body of literature does not stratify outcomes based on intraoperative
Hinchey classification, though authors recognize that patients with Hinchey IV dis-
ease are likely to have increased perioperative morbidity and mortality as compared
to those with Hinchey III disease. Pending further meta-analysis or randomized
trials, choice of operation in the emergency setting is still predicated on surgeon
experience and preference.
Attempts at nonoperative management in patients presenting with complicated
diverticulitis including extra-digestive air and free fluid is supported by single-
institution series. In one series including 136 patients, ~88 % of patients with extra-
digestive air >2 cm, non-loculated fluid, or abscess >4 cm were able to be successfully
treated without surgery [12]. Another study reported similar results, with an 86 %
success rate in 132 patients with nonoperative management in the absence of diffuse
peritonitis or free pelvic fluid [13]. One study including 39 patients, ¾ of whom
presented with signs of peritonitis, described a 92 % success rate with nonoperative
management [14].
Elective sigmoidectomy after episodes of acute uncomplicated diverticulitis is an
individualized, case by case decision based on patient specific factors. In contrast,
patients with complicated diverticulitis who are successfully managed nonopera-
tively are still generally offered elective resection owing to high recurrence rates [1].
The technique of laparoscopic peritoneal lavage, first described and largely pop-
ularized in European centers [15], challenges both the notion that sigmoidectomy is
necessary in patients requiring emergency operative intervention, and that elective
resection is really required in patients that do successfully navigate an initial nonre-
sectional approach. This chapter aims to examine the evidence for or against lapa-
roscopic peritoneal lavage.
Search Strategy
Using the PICO format, laparoscopic peritoneal lavage (hereafter also referred to as
simply ‘lavage’) was compared to any technique of sigmoidectomy—laparoscopic
or open Hartmann’s procedure or primary anastomosis with or without diversion—
in patients presenting with Hinchey III diverticulitis requiring operative intervention
due to generalized peritonitis or failure of medical management (Table 27.1). The
outcomes evaluated were morbidity and mortality, non-resolution requiring reinter-
vention and sigmoidectomy, rate of disease recurrence requiring sigmoidectomy,
Table 27.1 PICO table
P (patients) I (intervention) C (comparator) O (outcomes)
Hinchey III
diverticulitis
Sigmoidectomy (Hartmann’s or
primary resection and anastomosis
with or without diversion)
Laparoscopic
peritoneal lavage
(washout)
Resolution
recurrence
L.M. Cannon
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293
and the number of patients who are symptom free with no episodes of recurrence
(definitive lavage), or those who were successfully able to undergo elective sigmoid-
ectomy prior to a recurrent episode (lavage as a bridge to elective resection).
A systematic literature search was performed of MEDLINE and PubMed to iden-
tify English language publications related to utilization of laparoscopic peritoneal
lavage in perforated diverticulitis, published from January 1990 through December
2015. Combinations of key words were constructed and applied to these databases.
The search strategy used in MEDLINE included both MeSH subject headings when
possible and/or keyword mapping alias operator commands for the terms ‘diverticu-
litis’ or ‘diverticulum’, AND ‘laparoscopy’ or ‘laparoscopic’, AND ‘peritoneal
lavage’, ‘lavage’, or ‘therapeutic irrigation’. Similar combinations were then applied
to PubMed. The biographies of all the original articles were then explored for any
additional germane publications. Studies that did not include more than one laparo-
scopic peritoneal lavage or therapeutic irrigation patient were excluded. Case
reports, letters, systematic reviews, and duplicate articles were also excluded.
Results
Twenty-two English language studies were identified. Several studies represented
extended series including previously reported patients [15–22]. One database analy-
sis out of Ireland [23] may include the patients reported by Myers et al. [24].
Results of Low and Very-Low Quality Studies
Using the GRADE system approach to developing practice guidelines, 19 of 22
studies were rated either low or very low quality; reasons for this included small
sample size, lack of institutional comparator, allocation concealment, surgeon bias,
failure to adhere to the intention-to-treat principle, and lack of reporting on salient
outcome metrics such as non-resolution or recurrence requiring resection. Most of
the excluded studies had more than one of these limitations. These studies are sum-
marized in Table 27.2.
There are a total of 946 patients represented by low or very low quality studies
undergoing laparoscopic peritoneal lavage and at least 758 are presumed unique
patients across a 22-year period (1991–2013). Of studies clearly reporting intraop-
erative Hinchey classification, 76 % of patients (311 of 416) had Hinchey III diver-
ticulitis, defined as free purulent contamination of the peritoneal cavity. Some
studies allowed patients who had failed an initial trial of medical management with
or without percutaneous drainage of accessible abscess cavities; others only
included patients determined to be urgent surgical candidates on presentation. Four
studies included an intraoperative decision point to proceed with lavage, recogniz-
ing the inherent surgeon bias in this approach.
27 Role of Lavage in Hinchey III Diverticulitis
294
Table 27.2 Low and very low quality evidence on laparoscopic peritoneal lavage
Study
Study
period
Unique
lavage
patients H3 Lavage population
Morbidity
(%)
Death
(%)
Non-
resolution
requiring
resection
(%)
Recurrence
requiring
resection (%)
Elective
resection
without
recurrence
(%)
Symptom
free, no
resection (%)
O’Sullivan
et al. [16]
‘91–‘94 8 8
CD and GP
intra-op; (H3 only)
2 (25) 0 0 0 0 6 (75)
Faranda et al.
[24]
‘94-‘98 18 16 CD and GP on
presentation
3 (17) 0 0 NR 15 (83)
~4 m
NR
Mutter et al.
[29]
’96–‘03 10 10
CD, (−) PCD,
intra-op with (−)
GP, (−) visible
perforation, (−) H4
0 0 1 (10) 0 6 (60)
~2–3 m
NR
Taylor et al.
[20]
’02–‘05 14 10 CD with
perforation
0 (major) 0 3 (21) 0
2–15 m
8 (57)
~6w later
2 (14)
2–15 m
Bretagnol
et al. [18]
’00–‘04 24 18 CD and GP or
FoMM or septic
shock
2 (8) 0 0 0
~4 m; 2–6 m
24 (100 %)
~4 m;
2–6 m
0
Franklin et al.
[22]
’91–‘06 40 32 CD and GP 8 (20) 0 0 0
96 m;
1–168 m
24
a
(60) 16 (40)
96 m;
1–168 m
Myers et al.
[26]
’00–‘07 92 67 CD and GP; (+)
free air, (−) H4
(4) 3 (3.2) 1 (2) 0
36 m;
12–84 m
0
36 m;
12–84 m
88 (96)
36 m;
12–84 m
Favuzza et al.
[30]
NR 7 NR CD and peritonitis;
Imaging (+) fluid
(−) discrete
abscess
NR 0 1 (14) 1 (14)
3 m
5 (71) 0
L.M. Cannon
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295
Karoui et al.
[23]
’94–‘06 35 35 CD and GP on
presentation (H3
only)
9 (26) 0 1 (3) 0 25 (71)
4 m; 2–7
8 (23)
21 m; 7–48 m
White et al.
[19]
’99–‘08 35 11 CD and GP, or (+)
free air or 2QP (+)
>3 cm collection
with FoMM
19 (54) 0 8 (23) 8 (23)
6 m; 2–12 m
8 (23)
2–3 m later
11 (31)
20 m; 6–60 m
Liang et al.
[21]
’91–‘10 47 36 CD and GP with
(+) free air and (+)
contrast
extravasation
2 (4) 0 3 (6.4) 0 18
a
(38) 26 (55)
Rogers et al.
[25]
’95–‘08 427 NR NR 60 (14) 17 (4) NR NR NR NR
Edieken et al.
[31]
’09–‘12 10 8 CD with FoMM or
(+) free air; (+)
HDS
NR 0 3 (30) 3 (30) 0 NR
Swank et al.
[32]
’08–‘10 38 33 CD with
perforation; (+)
free air or H3
17 (45) 4 (11) 5 (13) 3 (8)
6–12 m
0 30 (79)
3 m
Gentile et al.
[33]
’09–‘12 14 3 CD with
perforation (H2-3
only)
3 (21) 1 (7) NR NR NR NR
Rade et al.
[17]
’00–‘13 71 47 CD with GP; (−)
shock (−)
distention (−)
previous surg (−)
H4
20 (28) 4 (6) 11 (15) NR 55 (77)
3 m; 1–9 m
NR
(continued)
27 Role of Lavage in Hinchey III Diverticulitis
296
Table 27.2 (continued)
Rossi et al.
[34]
’06–‘13 46 46 CD with GP;
intra-op H3 only,
(+) HDS
11 (24) 0 5 (11) NR NR NR
Horesh et al.
[35]
’07–‘12 10 7 CD and peritonitis
with (+) free air, or
FoMM
3 (30 %) 0 1 (10 %) 2 (20 %)
~9 m
NR 6 (60 %)
Sorrentino
et al. [36]
’01–‘13 63 54
CD and intra-op;
(−) fecal peritonitis
>1 quadrant
9 (14) 1 (2) 6 (10) 4 (7)
~5y
0 53 (84)
~5y
Shaded studies are those whose patients are represented within more current studies in the table
CD complicated diverticulitis, FoMM failure of medical management, GP generalized or 4-quadrant peritonitis, H Hinchey, HDS Hemodynamic stability, NR
Not recorded, PCD percutaneous drainage, 2QP 2-quadrant peritonitis
a
Value inferred from text
Study
Study
period
Unique
lavage
patients H3 Lavage population
Morbidity
(%)
Death
(%)
Non-
resolution
requiring
resection
(%)
Recurrence
requiring
resection (%)
Elective
resection
without
recurrence
(%)
Symptom
free, no
resection (%)
L.M. Cannon
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297
Lavage technique varied, including decision to disrupt inflammatory adhesions,
use of pelvic drains, decision to patch, suture, or apply fibrin glue to visible perfora-
tions, volume of warm saline used, addition of agents to the irrigant (betadine or
heparin) and duration of postoperative antibiotics. It is not known whether any one
lavage technique positively or negatively influenced outcome.
Of unique studies reporting appropriate outcomes, the morbidity of lavage was
~19 %, with ~3 % mortality. Approximately 10 % of patients experienced non-
resolution after lavage requiring return to the operating room and sigmoidectomy
(~2/3 of studies reporting on this outcome); ~ 6 % of patients experienced a recur-
rence requiring sigmoid resection over a time frame ranging from 2 months to 14
years, ~28 % of patients underwent elective resection within 2–9 months after peri-
toneal lavage, and ~68 % of patients are symptom-free without any further interven-
tion over an unknown time interval (~1/2 of studies reporting on the aforementioned
three outcomes). The decision to proceed with elective resection was an institu-
tional tenet defining lavage as a strategy to bridge patients through an emergency
presentation so that they could undergo surgery in the elective setting. Other studies
highlighted lavage as a potentially definitive procedure.
If we are to define success of peritoneal lavage as those patients who are either
symptom-free with no recurrences or further intervention, or were able to undergo
elective resection prior to any recurrent episode, then lavage was known to be suc-
cessful in ~46 % of the total unique patient population represented by these studies,
with approximately half of studies not reporting on these outcomes.
Several authors suggested criteria to identify those who are likely to fail lavage,
including patients with elevated American Society of Anesthesia (ASA) classifica-
tion, immune suppression, or advanced age [17], those with Hinchey IV diverticuli-
tis (most series) or a visible perforation, and those with distention or obstruction
limiting technical feasibility of lavage.
Results of Randomized-Controlled Trials
Of the 22 studies identified, 3 are recent randomized controlled multicenter trials,
all rated high quality based on the GRADE system [37, 38, 39]. The results of these
studies are summarized in Table 27.3. To allow for better comparison between tri-
als, the author of this chapter utilized supplementary data from these trials to report
on similar outcomes; that is 30–90 day morbidity beyond IIIb, and mortality, exclud-
ing Hinchey IV patients.
The DILALA Trial [37] included patients at 9 Swedish and Danish institutions
from February 2010 to February 2014. All patients had extra-digestive fluid or gas
on radiologic evaluation, were intraoperatively determined to have Hinchey III gen-
eralized purulent peritonitis, and were randomized to either lavage or open
Hartmann’s procedure. The primary end-point of the published study was short- term
morbidity and mortality [37]; the primary endpoint of the trial will be the number of
re-operations at 12-month follow-up with additional secondary endpoints [25].
27 Role of Lavage in Hinchey III Diverticulitis