Surgical Management of Acute Sigmoid Diverticulitis

1
Surgical Management of Acute Sigmoid
Diverticulitis

• N.P.Blair

2
Background

• Drainage /- prox colostomy Mayo 1907
• Drainagecolostomy /- later resection
• 3 stage resection
• Primary resection with stoma Hartmann
• Krukowski Br J Surg 1984 71 921-927

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Background

• Primary resection and anastomosis
• E Letwin 68th meeting NPSA 1981
• 46 patients surgery for diverticulitis
• 19 patients with primary anastomosis
• 13/19 for perforation
• no deaths, 2 leaks

Am J Surg 1982 143 579
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Primary Anastomosis vs Hartmann

• Immediately establishes bowel continuity
• No stoma better for patient psyche
• No need for later major operation
• Less time away from work for patient
• Lower health care costs

5
Background

• In colorectal surgery bowel preparation a sacred
  cow
• Small studies report safety of omitting prep in
  elective and emergency left sided colon surgery
• peritoneal inflammation delays healing

Letwin. CJS. 196710109
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Purpose

• To determine the frequency of use of resection
  and primary anastomosis in the management of
  acute sigmoid diverticulitis at Royal Columbian
  Hospital
• To compare patient profiles and outcomes with
  patients undergoing Hartmann resection

7
Method

• Retrospective chart review 1989-2000
• Admitting diagnosis of acute sigmoid
  diverticulitis operated upon within 48 hours
• Patients undergoing bowel preparation
• pre-op or on table excluded

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Results

• 97 cases met the criteria
• 33 (34) underwent primary anastomosis
• 5 had protective stoma
• 85 of primary anastomosis group had unprotected
  anastomosis
• no bowel preparation

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Demographic data
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Results

• Anastomosis group 17 over 70 yrs
• Hartmann group 49 over 70 yrs

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American Society of Anesthesiology Physical
Status Scale

• Class 1 No physiologic, biochemical, or
  psychiatric disturbance. Surgery unlikely to lead
  to clinically significant systemic illness.
• Class 2 Mild to moderate systemic problems
  related either to the underlying surgical illness
  or associated pathophysiologic processes.
• Class 3 Relatively severe systemic disturbance,
  related to surgical illness or underlying medical
  problems.

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ASA physical status scale continued

• Class 4 Severe and life-threatening systemic
  disturbance, not necessarily correctable by
  surgery.
• Class 5 Moribund patient undergoing surgery as a
  desparate life-saving effort.

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ASA Status
p0.012
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Hinchey Classification

• I pericolic abscess
• II pelvic abscess
• III purulent peritonitis
• IV fecal peritonitis
• Hinchey et al Adv Surgery. 1978 1285-109

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Hinchey classification
Pearsons Chi Square 11.2 p0.011
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Hinchey classification
Pearsons Chi Square 11.2 p0.011
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Complications
All values are NS by Yates corrected Chi square.
Fishers Exact Test was applied.
18
Mortality in anastomosis group

• 85 yr old female, ASA 4, Hinchey IV
• CRF, peritoneal dialysis
• day 4 dialysate cloudy, sepsis, ?leak
• 74 yr old male, ASA 4, Hinchey II, MOF
• 71 yr old female, ASA 3, Hinchey III, CVA
• all 3 hand sutured anastomosis

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Length of stay
t test with unequal variance formula was applied
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Re-admission rate
Fishers Exact Test Two-Tail probabilities
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Conclusions

• Primary anastomosis gave acceptable morbidity and
  mortality at RCH
• In general RCH surgeons chose primary anastomosis
  cautiously
• Primary anastomosis with loop ileostomy likely
  acceptable as a minimum in all but unstable,
  critically ill patients

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Conclusions continued

• No objective criteria known to assess risk for
  primary anastomosis
• Converted surgeons likely unwilling to
  participate in RCT
• Prospective, non randomized trials recording data
  for APACHE II, Mannheim Peritonitis Index are
  needed

Zeitoun G et al. Br J Surg 87 1366-1374
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Acknowledgement

• Thanks to E Germann, MSc for statistical
  analysis and advice.