| More acute advanced
disease can be treated surgically on an emergent basis where surgical
options may vary according to the preoperative factors, the patient's
condition, and intraoperative staging of peritonitis. These all contribute
to the peritonitis scoring system (Table 5).
There are many different staging systems that depend on the stage of presentation
of intra-abdominal pathology for evaluating and treating. Among these
systems, the Hinchey classification,7,49 recommended in the guidelines for treatment of diverticular disease by
the American
Society of Colon and Rectal Surgeons (http://www.fascrs.org/
displaycommon.cfm?an=1&subarticlenbr=150) and the American Gastroenterological
Association, is the most commonly used tool for making the surgical
decision based on intraoperative findings (Table
6). Surgical treatment options, with the contribution of auxiliary
methods like CT-guided drainage and on-table lavage to downstage the type
and complexity of the surgical operations, may be based on the Hinchey
classification.7,50
| Table
5: |
Peritonitis
Severity Score |
- Age
(<70 years versus >70 years)
- American
Society of Anesthesiologists score (I-II versus III versus
IV-V)
- Underlying
disease (ischemic colitis)
- Hinchey
Peritonitis Score (I-II versus III-IV)
- Preoperative
organ failure
- Immunocompromised
status
|
| Adapted
from reference 57. |
|
The most commonly
performed procedures are either single-stage or two-stage procedures that
can be performed either laparoscopically (in experienced hands) or by
the conventional open method, depending on the severity and stage of disease,
the patient's overall condition, and comorbidities. Primary resection
and anastomosis without a protective stoma is the so-called single-stage
procedure that is usually the treatment of choice for patients without
immunosuppression or immunocompromised status presenting with either uncomplicated
diverticulitis or a clinical picture that could be downstaged by means
of the above-mentioned methods (Figure
3). A two-stage procedure is commonly indicated for patients
with substantial fecal contamination, inflammation, and immunocompromised
or immunosuppressed status. The two-stage procedure consists of either
initial resection of the diseased segment and elective restoration of
the intestinal continuity later on (Hartmann's procedure) or resection
and primary anastomosis with a proximal loop ileostomy that again is to
be closed at a later appropriate time (Figure
4). The most commonly performed two-stage operation is Hartmann's
procedure, which has great variability of morbidity and mortality related
to the selection and application criteria to different patient populations (Figure 5). Mortality ranges
from 2.6% to 36.8%.51-56
To summarize, the
surgical treatment options and their stage-related clinical applications
are as follows.7,9,57 Hinchey stage 1 disease (Figure 6) is initially treated conservatively using IV antibiotics for the first
48 hours. If the clinical condition of the patient fails to improve within
this period, a repeat CT is usually indicated. An increase in abscess
size on CT renders CT-guided drainage the next available treatment option
in the treatment algorithm. Patients with abscesses that are not amenable
to CT-guided drainage or in whom signs and symptoms of peritonitis persist
despite appropriate antibiotic therapy and percutaneous drainage are candidates
for surgical intervention. In stage 2, diverticulitis is associated with
distant abscesses (retroperitoneal or pelvic) (Figure
7). Magnitude, location, patient's clinical factors determining
timing of surgery and treatment modality. Again, small abscesses may resolve
with antibiotic therapy and bowel rest. Large diverticular abscesses can
be either percutaneously or surgically drained. Percutaneous drainage
may allow stabilization of the patient and avoidance of a temporary stoma
and a second operation. Abscesses that are not amenable to CT-guided percutaneous
drainage and those that are resistant to conservative therapy in terms
of clinical improvement require surgical treatment. In extraordinary conditions,
as in an immunocompromised or toxic patient or in a patient with marked
pelvic inflammatory residue after resection of a diseased colonic segment,
a proximal loop ileostomy might be indicated (Figure
4) The occasional patient can undergo primary resection and anastomosis.
Stage 3 disease (Figure 8) is a state of purulent peritonitis, which is a surgical emergency requiring
preliminary optimization and immediate resuscitation with IV fluids, broad-spectrum
antibiotics, cardiovascular support when indicated, and prompt surgical
therapy. Depending on the degree of contamination, magnitude of sepsis,
and timeliness of surgical intervention, a 6% to 35% mortality rate can
be expected. The Hartmann procedure is still the main surgical option
according to the literature (Figure
5); however, resection and anastomosis with loop ileostomy may
still be an option in selected cases. Several retrospective analyses suggest
that primary resection and anastomosis is preferable.58-61 It is difficult to assess the relative safety of primary resection and
anastomosis with or without loop ileostomy versus
a Hartmann procedure. On the other hand, one must also consider the 30%
possibility that Hartmann's procedure is irreversible and the additional
morbidities that might be encountered related to this procedure. In patients
with a score of IV/V on the scale of the American Society of Anesthesiologists,
preoperative organ failure is best managed without an anastomosis. ASA
score along with the other criteria mentioned in the peritonitis severity
score (Table 5) are useful in decision
making and treatment of these patients.57
Again, patients with
an immunocompromised status, those more than 70 years old, and those with
signs and symptoms of systemic toxicity should have a diversion (Figure
4). In stage 4 disease, which is fecal peritonitis (Figure
9), patients require surgical intervention after preliminary optimization
and resuscitation. Almost all patients should be treated with Hartmann's
procedure and drainage. In rare prohibitive cases with adhesions and conditions
that hinder effective segmental resection, peritoneal lavage, proximal
fecal diversion, omentoplasty, and possible drainage may be considered (Figure 10). |
|
References
Part 1:
|
The outcomes of stage-related
surgical treatment modalities have been reviewed and reported in the literature.
In a retrospective study, 53 (87%) patients were treated with resection
and non-diverted coloproctostomy for stage I disease. In this group, only
2 (3.8%) anastomotic leaks occurred, and the observed overall morbidity
rate was only 22%. In stage II disease, 27(69%) underwent primary resection
with coloproctostomy. Eleven patients out of 27 had proximal diversion
whereas 16 had none. The overall leak rate was identical at 3.8%, but
the group's morbidity rate of 30% was slightly increased.62
According to the literature,
laparoscopic treatment of diverticulitis especially in Hinchey I and II
disease can be performed without additional morbidity and mortality. In
a comperative study, patients with Hinchey II disease had no statistical
difference between complication rates for laparoscopic surgery versus
conventional laparotomy.63,64
In Stage III and IV
disease, mortality rates of surgical treatment options such as diversion
and suture closure, Hartmann's procedure (resection and end colostomy),
primary resection and anastomosis, and finally resection with proximal
diversion were reviewed and reported as 26%, 12%, 9% and 6% for each individual
operation type respectively.58 The outcomes
as given favor resection with coloproctostomy over Hartmann's procedure.
However, in most of these studies they considered using primary resection
with coloproctostomy only in selected patients without any randomization.
Therefore, in stage III and IV disease this still needs to be tested by
means of prospective randomized trials before making any recommendation
regarding its therapeutic application.
Laparoscopic surgery
for acute complicated disease in association with Hinchey III and IV has
not been generally accepted as the treatment of choice. However, evidence
shows that laparoscopy has been used as a diagnostic tool along with the
laparoscopy assisted- lavage procudere in Hinchey III patients.65
In summary, diverticulitis is a commonly encountered clinical entity in
daily practice and needs to be taken into consideration especially in
the differential diagnosis of patients with abdominal complaints. The
increase in morbidity and mortality is determined to be associated with
the stage of the disease. It is worthwhile to emphasize that it requires
a multidisciplinary approach for its staging, diagnosis and treatment.
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