Perforated Diverticulitis: Advantages and Disadvantages of Resection

Educational Objectives

The goal of this program is to improve management of perforated diverticulitis. After hearing and assimilating this program, the clinician will be better able to:

1. Compare efficacy, mortality, and complications among surgical procedures for perforated diverticulitis.
2. Summarize a proposed algorithm for pre- and perioperative management of perforated diverticulitis in patients with septic shock.

Summary

Collected case series of patients with peritonitis: lower incidence of mortality with 2-stage procedure (ie, Hartmann procedure) than with 3-stage procedure because of improvements in antibiotics and supportive care

Prospective randomized trials: single-center study from Denmark showed that 2-stage procedure associated with greater mortality than 3-stage procedure; however, study from France showed mortality similar between procedures but 20% incidence of postoperative peritonitis with 3-stage procedure; in 2000, practice parameters from American Society of Colon and Rectal Surgeons (ASCRS) stated preference for 2-stage procedure; however, reports from colorectal surgeons stated that only ≈50% achieve closure of colostomy with Hartmann procedure, and closure procedure has high morbidity

Systematic review of 15 comparative studies: included mostly retrospective case series (1984-2001); compared one-stage primary resection plus anastomosis to Hartmann procedure; in patients with Hinchey score >2, mortality similar between procedures; complication rate tended to be lower with primary resection and anastomosis; however, studies had notable selection bias (ie, patients with most severe diverticulitis more likely to receive 2-stage procedure); operative time equivalent between procedures

Recommendations in 2006: ASCRS amended practice guidelines to indicate that either primary resection with anastomosis or Hartmann procedure acceptable; debate about indication for proximal diverting ileostomy in patients receiving primary resection with anastomosis

Prospective randomized trial: included patients with Hinchey grade 3 or 4 who received Hartmann procedure or primary resection with ileostomy; equivalent operative time, length of hospital stay, serious complications, mortality in hospital, and cost; with stoma reversal following Hartmann procedure, closure of ileostomy occurred in 57%, operative time and hospital stay longer, 20% incidence of serious complications, and cost greater

Recommendations in 2012: ASCRS recommended primary resection and anastomosis

Complications: systematic review of 17 studies — rate of complications 13% and mortality 3%; study of 100 patients with peritonitis or free air — 8 patients with Hinchey grade 4 received Hartmann procedure; 92 patients with Hinchey grade 2 or 3 received lavage, and of these, 3 patients died, 2 patients did not resolve, one patient underwent Hartmann procedure, one patient received interventional radiology drainage, and 88% of patients resolved; 2 recurrences over 36-mo follow-up period; unrandomized study from single surgeon — laparoscopic lavage associated with shorter procedure duration, less blood loss, fewer conversions, fewer complications, and shorter hospital stay than laparoscopic Hartmann procedure; 45% underwent elective resection; prospective cohort study of 38 patients — lavage had 18% failure rate, which was associated with poor outcomes; concluded that lavage contraindicated for Hinchey grade 4 or grade 3 with major comorbidity, immunosuppression, or high C-reactive protein

Algorithm for Complicated Diverticulitis

Septic shock: perform preoperative optimization in emergency department or intensive care unit

Surviving Sepsis campaign: stated need for source control ≤6 hr of diagnosis; at Methodist Hospital in Houston, mortality from severe septic shock decreased from 35% in 2006 to 14% in 2009, after development of tools for screening and clinical decision support and implementation of steps to manage septic shock in electronic medical records; must diagnose sepsis early

Epidemiology: risk, injury, failure, loss, end-stage renal disease (RIFLE) scoring system for acute kidney injury showed that 65% of patients developed acute kidney injury; progression to kidney injury or failure category drastically increases risk for mortality

Preoperative optimization: includes volume resuscitation, broad-spectrum antibiotics, and management of patient to prepare for operating room

Operating room: vasodilating anesthetic can cause patient to go back into septic shock; addition of phenylephrine may cause problems related to vasoconstriction of gastrointestinal tract and kidneys; therefore, damage control surgery recommended; septic shock associated with ≈40% mortality (≈10% with sepsis)

Perforectomy: involves performing laparotomy, stapling proximal and distal ends of hole in sigmoid colon, and placing temporary abdominal closure; then resuscitate, normalize, and optimize patient in operating room (≈12 hr); next day, perform second operation

Ostomy vs primary anastomosis: rate of anastomotic leak ranges from 7% to 30%; speaker recommends ostomy followed by delayed anastomosis for most patients; data from speaker’s institution showed that mortality rate was ≈28% (vs ≈40% in National Surgical Quality Improvement Program database) with resuscitation, damage control, and delayed procedure

No septic shock: for low-risk patient with Hinchey grade 3 or 4, laparoscopy with lavage and drainage recommended; for high-risk patient (ie, immunocompromised, severe comorbidity, worsening multiple organ failure with sepsis, Hinchey grade 4), perform definitive resection

Prospective Randomized Trials in Europe

Hypotheses: all 3 hypothesized that lavage superior to resection or Hartmann procedure

LADIES study: stopped early because of increase in short-term serious adverse events, primarily driven by need for surgical reintervention; 6 of 9 patients had Hinchey grade 4 at time of reoperation; however, follow-up at 12 mo showed similar composite of morbidity and mortality; concluded that laparoscopic lavage not superior to sigmoidectomy, but ≈75% of patients who received lavage required one operation, avoided colostomy, and had similar rates of morbidity and mortality

SCANDIV trial: groups had similar rates of serious complications and mortality ≤90 days; resection associated with higher incidences of wound infection, intra-abdominal abscesses, secondary peritonitis, second operation, and stoma ≤3 mo; concluded that lavage does not reduce long-term rate of major complications; 20% required second operation to control sepsis and 5% had delay in treatment for colon cancer; however, only 16% with lavage required colostomy; failure to recognize Hinchey grade 4 leads to problems

DILALA study: shorter operative time and duration of hospital stay with lavage than with resection, with similar in-hospital mortality and incidence of second operations; at 12 mo, resection had higher rates of reoperation and number of total hospital days ≤1 yr, but similar rates of severe complications and mortality; concluded that lavage feasible and safe, associated with fewer operations and number of hospital days ≤1 yr; speaker’s review concluded that laparoscopic lavage in low-risk patients eliminates need for ostomy and second reversal procedure; problems include failure to control sepsis, need for second operation, and failure to detect Hinchey grade 4 disease

Controversies

Colonoscopy: data show low yield for patients with diverticulitis, but recommended for perforated diverticulitis (especially with abscess) because of concern for cancer

Delayed elective colon resection: speaker refers patients to colorectal surgeon to perform delayed laparoscopic sigmoid resection and primary anastomosis as long as patient does not have multiple comorbidities

Readings

Bridoux V et al: Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: A prospective multicenter randomized trial (DIVERTI). J Am Coll Surg. 2017 Dec;225(6):798-805; Catry J et al: Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients. Int J Colorectal Dis. 2016 Oct;31(10):1693-9; Swank HA et al: The LADIES trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg. 2010 Oct 18;10:29; Trenti L et al: Generalized peritonitis due to perforated diverticulitis: Hartmann’s procedure or primary anastomosis? Int J Colorectal Dis. 2011 Mar;26(3):377-84; Vermeulen J and Lange JF: Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future. World J Surg. 2010 Mar;34(3):587-93.

Disclosures

For this program, members of the faculty and planning committees reported nothing to disclose.

Acknowledgements

Dr. Moore was recorded at the 22nd Annual Medical and Surgical Approaches to GI Disorders, held July 17-21, 2017, in Kiawah, SC, and presented by Georgia Medical College at Augusta University. For information on future CME activities from this sponsor, please visit augusta.edu/ce/medicalce. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE320401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.