Colonic Diverticulosis

Recent Updates and Guidelines on Colonic Diverticulosis

1. Diverticulosis Guidelines and Recent Updates

2. Prevalance is increasing compared to past century ~ 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime

3. Initial evaluation – Acute Diverticulitis Problem-specific history and physical examination Complete blood count, urinalysis, and abdominal radiographs in selected clinical scenarios Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C. CT scan of the abdomen and pelvis is the IOC Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.

4. Ultrasound and MRI can be useful alternatives in the initial evaluation of a patient with suspected acute diverticulitis Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

5. Medical Treatment of Acute Diverticulitis Nonoperative treatment typically includes oral or intravenous antibiotics and diet modification. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C Image-guided percutaneous drainage is usually the most appropriate treatment for stable patients with large diverticular abscesses. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

6. Elective Surgery for Acute Diverticulitis The decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B Elective colectomy should typically be considered after the patient recovers from an episode of complicated diverticulitis Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

7. Routine elective resection based on young age (<50 years) is no longer recommended Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

8. Emergency Surgery for Acute Diverticulitis Urgent sigmoid colectomy is required for patients with diffuse peritonitis or for those in whom nonoperative management of acute diverticulitis fails Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B Following resection, the decision to restore bowel continuity must incorporate patient factors, intraoperative factors, and surgeon preference. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

9. In patients with purulent or feculent peritonitis, operative therapy without resection is generally not an appropriate alternative to colectomy. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

10. Technical Considerations The extent of elective resection should include the entire sigmoid colon with margins of healthy colon and rectum Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C When expertise is available, the laparoscopic approach to elective colectomy for diverticulitis is preferred Grade of Recommendation: Strong recommendation based on high-quality evidence, 1A

11. A leak test of the colorectal anastomosis should be performed during surgery for sigmoid diverticulitis Grade of Recommendation: Strong recommendation based on low-quality evidence 1C Ureteral stents are used at the discretion of the surgeon Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C

12. Oral mechanical bowel preparation is not required; however, the use of oral antibiotics may decrease surgical site infections after elective colon resection Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B Elective colectomy for diverticulitis may be performed by sparing the superior hemorrhoidal artery or according to cancer surgery principles Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

13. Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain Acute surgery should be reserved for critically ill patients failing non-operative treatment Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials

14. Results Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann’s procedure (P00.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P<0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P<0.001).

15. Conclusions Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

16. Accumulated empirical experience during the last two decades shows that laparoscopy is undeniably a promising adjunct in the management of complicated colonic diverticulitis Analysis of presently available data also highlights the urge to build largescale prospective RCTs in order to elucidate the exact benefits of laparoscopy and to define patients who are the best candidates for each approach Like the ongoing trials NCT01019239 (IRISH) and NCT01047462 (SCANDIV), solid data are particularly awaited in order to clarify the exact place of LLD and to determine the most appropriate sigmoid resection procedure (laparoscopic HP or RPA) in Hinchey 3 and 4 peritonitis. The advantages provided by laparoscopy in chronic complications of diverticulitis and HP reversal also need to be confirmed In the absence of precise recommendations, we suggest the following algorithm that may assist general surgeons in their decision-making when dealing with complicated colonic diverticulitis (Figure 1).

17. Multicenter, randomized clinical superiority trial recruiting participants from 21 centers in Sweden and Norway from February 2010to June 2014. The last patient follow-up was in December 2014 and final review and verification of the medical records was assessed in March 2015 Patients with suspected perforated diverticulitis, a clinical indication for emergency surgery, and free air on an abdominal computed tomography scanwere eligible Of 509 patients screened, 415 were eligible and 199 were enrolled.

18. Assigned to undergo laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98) based on a computer-generated, center-stratified block randomization All patients with fecal peritonitis (15 patients in the laparoscopic peritoneal lavage group vs 13 in the colon resection group) underwent colon resection Patients with a pathology requiring treatment beyond that necessary for perforated diverticulitis (12 in the laparoscopic lavage group vs 13 in the colon resection group) were also excluded from the protocol operations and treated as required for the pathology encountered

19. RESULTS The primary outcome - severe postoperative complications ( Clavien-Dindo score >IIIa) within 90 days 31 of 101 patients (30.7%) in the laparoscopic lavage group 25 of 96 patients (26.0%) in the colon resection group (difference, 4.7% [95%CI, −7.9%to 17.0%]; P = .53). Mortality at 90 days did not significantly differ Laparoscopic lavage group (14 patients [13.9%]) and the colon resection group (11 patients [11.5%]; difference, 2.4%[95%CI, −7.2%to 11.9%]; P = .67). The reoperation rate was significantly higher Laparoscopic lavage group (15 of 74 patients [20.3%]) Colon resection group (4 of 70 patients [5.7%]; difference, 14.6%[95%CI, 3.5%to 25.6%]; P = .01) for patients who did not have fecal peritonitis. The length of operating time was significantly shorter in the laparoscopic lavage group Length of postoperative hospital stay and quality of life did not differ significantly between groups Four sigmoid carcinomas were missed with laparoscopic lavage

20. CONCLUSIONS AND RELEVANCE Among patients with likely perforated diverticulitis and undergoing emergency surgery, the use of laparoscopic lavage vs primary resection did not reduce severe postoperative complications and led to worse outcomes in secondary end points These findings do not support laparoscopic lavage for treatment of perforated diverticulitis

21. The Ladies trial is a multicentre , parallel-group, randomised , open-label superiority trial done in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and the Netherlands Designed to compare laparoscopic lavage and sigmoidectomy for purulent perforated diverticulitis in the LOLA group To compare Hartmann’s procedure versus sigmoidectomy with primary anastomosis in both purulent and faecal perforated diverticulitis in the DIVA group Patients with signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion Radiological examination by radiography or a CT scan had to show diffuse-free intraperitoneal air or fluid for patients to be classified as having perforated diverticulitis

22. Exclusion criteria Dementia, previous sigmoidectomy , pelvic irradiation, chronic treatment with high-dose steroids (>20 mg daily), being aged younger than 18 years or older than 85 years, and having preoperative shock needing inotropic support, Hinchey I and II perforated diverticulitis Patients with Hinchey IV peritonitis or overt perforation could only be included in the DIVA group Diagnostic laparoscopy was done to confirm the diagnosis of perforated diverticulitis Distinguish between purulent and faecal peritonitis or overt perforation

23. Only patients with purulent perforated diverticulitis without overt perforation were randomly assigned within the LOLA group with secure online computer randomization Patients were randomly assigned (2:1:1) to receive either Laparoscopic lavage, Sigmoidectomy without primary anastomosis, or Sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) Allowing for a 1:1 comparison between lavage and sigmoidectomy in the LOLA group Patients with an overt perforation or faecal peritonitis were included in the DIVA group of the study and not analysed within the LOLA group

24. The DIVA section of this trial is still underway Results of the LOLA section Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA section of the Ladies trial The study was terminated by the data and safety monitoring board because of an increased event rate in the lavage group Two patients were excluded for protocol violations The primary endpoint major morbidity and mortality within 12 months 30 (67%) of 45 patients in the lavage group 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54–3·03, p=0·58) By 12 months, 4 patients died after lavage and 6 patients died after sigmoidectomy (p=0·43)

25. First randomised trial to report the long-term results of laparoscopic lavage and sigmoidectomy for purulent perforated diverticulitis. The trial was stopped early at 33% of the planned sample size as advised by the Data Safety Monitoring Board High major morbidity and mortality rate in the lavage group Despite the promising results of previous case series, the study could not show superiority of laparoscopic lavage with regard to major morbidity and mortality Failure to properly distinguish Hinchey III from Hinchey IV perforated diverticulitis and underlying colorectal cancer accounted for most of the lavage failures Improved preoperative diagnostics— eg , CT with rectal contrast might optimize the results of laparoscopic lavage

26. Laparoscopic lavage was compared with colon resection and stoma in a randomized controlled multicenter trial, DILALA (ISRCTN82208287) Initial diagnostic laparoscopy showing Hinchey III was followed by randomization Clinical data was collected up to 12 weeks postoperatively Patients were included at 9 surgical departments in Sweden and Denmark from February 2010 to February 2014 83 were randomized, out of whom 39 patients in laparoscopic lavage and 36 patients in the Hartmann procedure groups Morbidity and mortality after laparoscopic lavage did not differ when compared with the Hartmann procedure Laparoscopic lavage resulted in shorter operating time, shorter time in the recovery unit, and shorter hospital stay Laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III was feasible and safe in the short-term

27. Aim - to compare the results of sigmoid resection with laparoscopic lavage Methods - systematic review was performed to select randomized controlled trials comparing laparoscopic lavage versus resection in Hinchey III diverticulitis LADIES, DILALA, SCANDIV trials included In the LADIES and the DILALA trials patients were randomized after the demonstration of Hinchey III purulent diverticulitis at the diagnostic laparoscopy In SCANDIV trial patients were randomized after the CT scan There were also randomized patients with evidence of Hinchey I-II diverticulitis at laparoscopy In all the studies patients with Hinchey IV-fecaloid peritonitis were drop out from the study and received Hartmann procedure

28. Treatment In all studies patients received empiric antibiotic therapy before surgery. Laparoscopic lavage was performed with at least 3–4 L of warm saline water. After the laparoscopic lavage patients received a colonoscopy after a time variable between 4 and 12 weeks but routine sigmoidectomy was not recommended In the SCANDIV trial colonic resection was performed in laparoscopy or with open surgery according to the centre /surgeon’s preference, with or without primary anastomosis in the LADIES trial patients in resection group were further randomized to receive Hartmann procedure or primary anastomosis In the DILALA trial patients randomized to resection all underwent Hartmann procedure All the included patients had an abdominal drain after operation and were treated according to the local standards

29. Results Three RCT were selected for the meta-analysis including 315 patents Laparoscopic lavage was associated with significantly more reoperations (OR 3.75, p = 0.006) more intra-abdominal abscesses (OR 3.50, p = 0.0003) no differences in mortality (OR 0.93, p = 0.92) At 12 months follow up laparoscopic lavage was associated lesser reoperations (OR 0.32, p = 0.0004) No differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR 0.74 p = 0.51)

30. Conclusions The present meta-analysis shows that in acute perforated diverticulitis with purulent peritonitis laparoscopic lavage is comparable to sigmoid resection in terms of mortality but it is associated with a significantly higher rate of reoperations and a higher rate of intra-abdominal abscess. No differences in term of mortality were demonstrated at follow-up. Further studies are needed to better define the safety and appropriateness of this treatment.

31. Purpose Compared current guidelines on the disease in order to identify concordant and discordant recommendations Eleven national and international guidelines on diverticular disease Last 10 years have been identified by a systematic literature review on PubMed Compared in detail for 20 main and 51 subtopics

32. Results The available evidence for the most aspects was rated as moderate or low There was concordance for the following items: Diagnosis of diverticulitis should be confirmed by imaging methods (10 of 10 guidelines) Mild forms may be treated outpatient (10/10) Abscesses are treated non-surgically (9/9) Elective surgery should be indicated by individual patient-related factors, only, and be performed laparoscopically (10/10, 9/9 respectively)

33. Main differences were found in the questions of Appropriate classification imaging diagnostic (computed-tomography versus ultra-sound) need for antibiotics in out-patient treatment mode of surgery for diverticular perforation Despite growing evidence that antibiotics are not needed for treating mild diverticulitis only 3/10 guidelines have corresponding recommendations Hartmann’s procedure has been abandoned several years ago and is now recommended for feculent peritonitis by the three most recent guidelines In contrast, laparoscopic lavage without resection is not recommended anymore