Feasibility and outcome of laparoscopic management of complicated diverticulosis

Feasibility and outcome of laparoscopic management of complicated diverticulosis

Nabil Shedid, FRCS; Gamal I. El-Habbaa, MD;  Hazem Sobieh, MD

Departments of General  Surgery, Benha University, Egypt.

Abstract

Objectives: To evaluate the surgical feasibility and short-term outcome of laparoscopic management of complicated cases of diverticular disease.

Patients and methods:  The study included 12 patients; 9 males and 3 females with mean age of 57±5.8 years. All patients had preoperative colonoscopy and CT imaging to assure diagnosis. All patients had exploratory laparoscopy to either proceed or convert to open laparotomy and in all cases, a sigmoidectomy was performed with primary intracorporeal anastomosis using a circular end-to-end stapling device. Intraoperative data including duration of surgery, estimated blood loss, length of excised specimen, type and number of managed diverticular complications and number of cases converted to open surgery and time till first ambulation, time till first oral intake, length of hospital stay and postoperative morbidity and mortality were recorded.

Results: Eight cases had successfullaparoscopic management and 4 patients were converted to open surgery with a conversion  rate of 33.3%. Exploratory  laparoscopy detected  variant pathologies  in the  same  case;  7 patients  had  diverticular  abscess  that  was  drained  with peritoneal  lavage  and primary  colectomy  with anastomosis  was performed.  Two cases  had single colo-vesical fistula that was closed with inverting  burse-string  suture, then colectomy was conducted successfully. Two females had colosalpingeal fistula; left salpingectomy was performed.  Mean  operative  time  was  180.6±32.9  minutes  and  mean  operative  blood  loss was 89±11.6 cc, mean time till 181 mobilization  and till having audible intestinal sounds was

13.2±3.1 and 2.6±0. 7 days, respectively. Mean time till 1st oral intake was 3.2±0.8 days and length of hospital stay was 6.2±1.2 days. One patient required re-admission for signs of acute abdomen, clinical and CT examination revealed a localized left iliac fossa collection indicating anastomotic line leakage and the patient had open peritoneal lavage and diversion colostomy.

Conclusion: Laparoscopic management of complicated diverticulitis is feasible and safe approach provided proper surgical decision was adequately taken concerning to proceed or not after laparoscopic exploration.

Key words: Complicated diverticulitis, laparoscopic approach, colo-vesical fistula, colosalpingeal fistula.

Introduction:

Diverticulosis is considered to  be mainly a problem  of  old age,  with  a prevalence of

35-50%.  About   10-25%  of  patients   with diverticulosis       will      develop            diverticular disease   compilation  in  their   lifetime.   The clinical  presentation of  diverticular  disease depends  on the severity of the inflammatory process        and         whether complications   are

present.    Complicated   diverticulitis   refers to the presence of perforation, obstruction, bleeding and abscess  or fistula  formation. Between 25 and 55% of the patients with complicated diverticulitis will require surgery during their initial  hospitalization.l ,2

The first attack of uncomplicated diverticulitis 1s treated   conservatively. Sigmoid      resection       1s     indicated    for

recurrent diverticulitis, in patients with manifest stenosis or fistula and for such emergencies as perforation, ileus or bleeding. Early surgery after the first episode is recommended  for patients under 50 years of age, or immunocompromised patients. This is particularly true for patients with radiological signs of severe diverticulitis.3

Elective laparoscopic resection for recurrent,   uncomplicated    diverticulitis    of the sigmoid  is considered safe and effective and may fare better than its conventional counterpart not only in short-term outcome including preservation of the abdominal wall and shorter disability, but also in the long term as decreased rates of late symptomatic  small bowel obstruction. Five-year recurrence rates show  that  a  laparoscopic   or  conventional access is unlikely to have an impact, provided that  the  oral  bowel  end  is  anastomosed  to the proximal rectum rather than to the distal sigmoid.4,5

Little data exist on complicated cases and multiple   non-randomized   studies  indicated that the role of laparoscopic  surgery should be limited to resection for uncomplicated diverticulitis of the sigmoid performed by adequately trained surgeons.  Benefits can be expected with this procedure, provided that indications for surgery are not influenced by the mode of access and that postoperative complication rates remain within the range of that for traditional colorectal surgery.6,7

Elective sigmoid resection became a laparoscopic procedure that if properly carried out, the operation affects a definitive cure, the morbidity and mortality ofthe operation is low, and re-operations  for recurrent  diverticulitis are the exception. In the emergency situation a two-stage procedure is often necessary. The superiority  of laparoscopy should be proven by measuring health-related and patient­ centered outcome rather than surrogate endpoints. Areas of concern include replacing a conventional resection with laparoscopic suture,  drainage,  and colostomy  in  patients with free perforation and peritonitis. 8,9

The current  study  aimed to  evaluate surgical  feasibility  and  short-term  outcome of laparoscopic  management of complicated

cases of diverticular disease.

Patients and methods:

The present  study was  conducted  at General  Surgery  Department,  Benha University  Hospital since June 2007 till October 2010. The study intended to include complicated  diverticulitis   patients,  patients with urological complaint were subjected to urological diagnosis workup, those who had anemia were investigated for its cause with regard  to  malignancy  especially  if  anemia was associated with weight loss. Patients presenting with manifestations of acute diverticulitis,  malignancy,  other  indications for   left  colectomy,   or   who   had   scar   of previous abdominal open surgery hampering peritoneal insufflations were excluded of the study

All  surgeries  were  conducted  under general anesthesia.  Patients  were positioned in a modified lithotomy position, with table adjusted to 15° Trendelenburg position and slightly  to  the  right  side,  but  during  left flexure  mobilization,  the table  was kept  in an anti-Trendelenburg position to move the small bowel toward the pelvis. Four trocars were  used,  the  first  trocar  was  introduced

4-cm above the umbilicus by an open Hasson technique,   and  a   pneumoperitoneum   was insufflated to 12-14 mmHg. The 2nd and 3rd trocars were placed under direct vision at the left hypochondria!and  right lumbar regions, respectively. The 4th trocar was placed 4-cm above the pubic bone. The laparoscope  was introduced through the supraumbilical trocar and exploratory laparoscopy was conducted.

For      laparoscopic      colonic      resection,

sigmoid     colon     mobilization      began     by dividing  natural  attachments  to  the  lateral abdominal  wall,  retroperitoneum,  and other adjacent organs using Harmonic  scissor and continues   along  the   peritoneal   reflection. Then,   the        phrenocolic      and              splenocolic attachments  were  divided  to  mobilize  the splenic  flexure  of the  colon  in some  cases to  create  a  tension-free   anastomosis.   The dissection was completed  with mobilization of the  descending  colon, the sigmoid  tract, and  the  upper  third  of  the  rectum,  which

was divided by a linear stapler cutter. The suprapubic trocar opening was extended for about a 3-6 em and minilaparotomy was performed   for   extraction   of   the  sigmoid colon for signoidectomy. A 29-head circular stapler was inserted in the colonic stump and tied with a 2.0 polypropylene  purse-string suture. The colonic stump was returned to the peritoneal cavity, the minilaparotomy incision was closed in layers and pneumoperitoneum was recreated. A circular end-to-end stapler was  advanced   via  the  anus  with   its  pin pushed   directly   above  the   center   of  the stapler line at the upper third of the rectum, and a double-stapled primary intracorporeal anastomosis was obtained, Figure(la&b). Paraanastomotic    areas   were   drained,   the trocars were removed, and the deep fascias of the ports were closed

Patients' evaluation and  data collection

1- Preoperative  evaluation  included  personal data; age and sex, constitutional data including                    body    weight,     height     and

Table (1): Patients enrollment data.

calculation of body mass index (BMI). Patients' clinical data including American Society     of    Anesthesiologists      (ASA) grade, preoperative antibiotic use, and preoperative colonoscopic and CT findings were determined.

2- Intraoperative  data  included  duration  of surgery, estimated blood loss, length of excised specimen, type and number of managed diverticular complications and number of cases converted to open surgery.

3- Postoperative  data  included  time  till first ambulation,   time   till   first   oral   intake, length of hospital stay and postoperative morbidity and mortality.

Results:

The study  included  12  patients;  9 males and 3 females with mean age of57±5.8; range:

48-66 years. Mean BMI was 31.7±1; range:

30.8-34.2 kg!m2. All patients had repeated courses of antibiotics; 7 patients were ASA-1 grade, 3 patients were ASA-11 grade and only

2 patients were ASA-111 grade, Table(l).

Data are presented  as mean±SD  and numbers;  ranges and percentages are in parenthesis. BMI:  body mass index. ASA: American Society of Anesthesiologists.

All patients had preoperative colonoscopy that assured the diagnosis and defined the presence of single or multiple diverticular orifices, Figure(2). Colonoscopy was difficult in  some   cases   due  to   colonic   tortuosity and lack of distensibility. Preoperative CT imaging showed positive data indicating the diagnosis  of diverticular  disease  with  fluid

and air collection, Figure(3). CT examination of the two females who had laparoscopic management   showed  left  adnexal  mass  in both of them  and left colosalpingeal  fistula with fluid collection, Figure(4).

Eight cases passed smooth intraoperative course  without  conversion  to  open  surgery with  a laparoscopic  success  rate  of 66.7%.

Four  patients  were  converted  to  open surgery;   the   first   was   a  postmenopausal female  who  had  multiple  colo-uterine  and colo-vesical fistulas with left adnexal abscess including  the   left  fallopian   tube  and  left ovary.   Exploratory   laparotomy   confirmed the    laparoscopic    findings    and    assured healthy right ovary, subtotal supra-vaginal hysterectomy including the left adnexal mass with the ovary and the tube was done. Then, colectomy was conducted  and the phlegmon en-bole   was   removed,   and   no   diversion was required. The patient passed smooth postoperative  course and was discharged on the 17th postoperative day without developing additional morbidities.

The  second  patient  was  a  male  patient in whom exploratory laparoscopy defined multiple separate points of tight adhesions between  small  intestine  and  sigmoid  colon with  non-adherent  intervening  enteric segments, this finding aroused suspicion of multiple entero-colic fistulas that was assured during laparotomy. These multiple fistulas required  multiple small  intestinal  resections in  addition  to  the  intended  colectomy  and open    prophylactic    diverting    entrostomy was performed to safeguard the performed anastomoses. This patient received postoperative   care  at  ICU  for  being  ASA grade  III  with  previous  history  of  cardiac attack and was maintained on parentral nutrition  for  two  weeks.  Then, barium follow-through was performed through the entrostomy and complete anastomotic line healing was assured and a second setting was performed for entero-anastomosis and patient was discharged  after complete wound healing on the 36th day after the first surgery.

Table (2): Laparoscopic operative findings.

The remaining two patients were converted to open laparotomy  because of the extensive adhesions that divided the abdominal cavity into compartments,  hampering advancement of the laparoscope and obscuring the field visibility, so forsake of patients'safety surgical decision was changed to open surgery. These four patients were excluded from the data collected concerning laparoscopic surgery. However, these  cases indicated  the  efficacy of first look laparoscopy prior to surgical­ decision taking.

Exploratory laparoscopy detected varied pathologies  in combination with multiplicity of pathologies in the same case; differentially, phlegmon Figure(5) was detected in six cases Figure(6) and diverticular abscess in 7 cases. Abscess'  drainage  Figure(7) was  followed by peritoneal lavage with suction till the returning fluid was clear, then colectomy with anastomosis  was performed.  Two cases  had single colo-vesical fistula that was dissected till exposure of fistula orifices, Figure(8). Bladder   wall   was   closed   with   inverting purse-string suture placed in healthy bladder tissue and competence of orifice closure was assured by filling the bladder with methylene blue   stained   saline   injected   through   the trans-urethral catheter into the bladder, then colectomy  was  conducted  successfully.   In two females  who had colosalpingeal fistula; left  salpingectomy   was  conducted  but  the uterus and right tube were healthy and were left undisturbed Table(2).  All cases required left  splenic  flexure  mobilization   to  allow free colonic handling for resection and anastomosis.  Histopathological  examination of resected colonic specimens  showed signs of active inflammation.

Data are presented as numbers; percentages are in parenthesis.

Findings were presented per the studied 8 cases irrespective  of other pathologies so the total number of cases is over because multiplicity of pathologies detected.

Mean   operative   time   was   159.4±29.9; range: 115-200 minutes and mean operative blood  loss  was  89±11.6; range:  70-110  cc.

Table (3): Operative data.

The  mean   length   of  resected   colon   was

14±1.7; range: 11-16 em Table(3).

Data are presented as mean±SD; ranges are in parenthesis.

Mean   time   till     1st  mobilization    was

13.2±3.1;   range:   10-20  hours   and   mean time  till  having  audible   intestinal  sounds was 2.6±0.7; range: 2-4 days and mean time till  1st  oral  intake  was  3.2±0.8;  range:  2-5 days. For both patients who had colo-vesical fistulas,    urethral    catheter    was   removed on  the  6th  and  8th day  respectively,  after assurance of no leakage using ascending cystogram. Mean length of hospital stay was

6.2±1.2; range: 5-8 days Table(4).  Till home discharge, no mortality was reported and only

Table (4): Postoperative data.

one patient required re-admission for signs of acute abdomen. Clinical and CT examination revealed a localized left iliac fossa collection indicating anastomotic line leakage. After stabilization of general condition, the patient had laparotomy for peritoneal lavage and diversion colostomy was performed and the patient completed his postoperative care without   developing   additional   morbidities and  was  asked  to  attend  for  follow-up  at the outpatient clinic monthly till colostomy reversal 3 months later.

Data are presented as mean±SD; ranges are in parenthesis.

Figure (1): Shows laparoscopic colonic anastomosis.

Figure (2): Shows endoscopic images of diverticuli; several diverticula are encountered, increased colonic tortuosity.

Figure (3): Shows CT scan images of a patient who presented with complicated diverticulitis and an extraluminal air and fluid collection.

Fig. (4): Shows CT scan of a woman with sigmoid diverticulitis and colosalpingealfistula. Axial contrast-enhanced CT scan of pelvis shows normal size of right adnexum (short arrow), enlarged left adnexum containing fluid (long arrow) and foci of gas (heads).

Figure (5): Showing phlegmon including the sigmoid colon and adjacent viscera.

Figure (6): Showing the abscess site (blue arrow) while drained with definitely extruded pus (yellow arrow).

Figure (7): Showing both orifices ofthe colo-vesical fistula (arrowed).

Discussion:

Treatment  of colonic  diverticular disease has evolved over the past years. Most episodes are  simple  and  can  be  successfully treated with antibiotics alone. For complicated diverticulitis, a strong  trend  is developing towards  less invasive therapies including interventional radiology and laparoscopic lavage in an effort to avoid the morbidity and discomfort of a diverting colostomy. Based on a better  understanding of the natural  history of the disease,  the indication for prophylactic colectomy after  a few  episodes  of simple diverticulitis has  been  seriously  challenged and for those  patients  who need a colectomy, laparoscopy is being proposed.1o,11

Laparoscopic exploration detected  variant indications for  conversion to  open  surgery in four  cases including multiple  entero-colic fistulas that required  multiple  resections, involvement of other viscera  in the phlegmon with abscess formation and multiple adhesions which  hindered dissection; exploratory laparoscopy of these  cases   helped to change surgical   decision   to   open   laparotomy for completion with  a conversion rate of 33.3%. This high conversion rate could  be attributed to factors  associated with chronicity and complications which reflect the possibility of multiple  recurrent acute attacks that resolved medically. In hand with such explanation Nguyen  et ai.l2  reported a  36%  conversion rate  to  open  and  that  all  conversions were due to dense pelvic adhesions and severe inflammation resulting in difficult dissections. Also, Coli et a1.13 reported  that patients  with a history  of abscess  had a 23% chance  of conversion,  while   those   with   no   abscess history had an 8% chance of conversion. Natarajan et ai.l4 and Chouillard et ai.l5 attributed the  higher  rates  of  conversion to open  surgery  to  operative  circumstances without   direct  relationship to  timing  of surgery   after  an  acute  attack.  Zinzindohou

& Samama16 documented that as the  lesions

of resected  colon became  more severe  due to restricted indications, laparoscopic approach will require more surgical skill and conversion rate might increase. In selected cases, open surgery  should  be preferred

Three women had diverticulitis associated with gynecological pathology; two had left colosalpingeal fistula  with  amalgamation of the  left  ovary   and  underwent  laparoscopic left salpingo-oophrectomy in addition  to left colectomy, while the third patient had multiple colo-uterine and colo-vesical fistulas  with left adnexal  abscess  including the  left fallopian tube and left ovary and subtotal supra-vaginal hysterectomy including the left adnexal mass with  the  ovary  and the  tube  was  performed in addition to left colectomy.  Preoperative diagnosis  of  colo-salpingeal fistulas  relied on the CT findings  that showed  air and fluid collections in the  adnexia,  which  coincided with  Panghaal  et  a1.17 who  reported that  in patients   with  diverticulitis, a  collection of gas, either alone or in combination with fluid, within the adnexum is a sensitive  and specific predictor  of the presence  of a fistula  between the  colon  and  an  adnexum.  Similar   to  the applied  policy,  Breitenstein et ai.l8  reported two  women  suffering  from  diverticulitis and symptomatic uterus  myomatomas treated  by combined  laparoscopic   sigmoid   resection and laparoscopically assisted  transvaginal hysterectomy. Also,  Femandez19  reported cases oftuboovarian abscess  as a presentation for women with diverticulitis.

For both  patients  had colo-vesical fistula,

the fistulous openings  were identified  and bladder  wall was closed with inverting purse­ string suture placed in healthy  bladder  tissue. Such simple  closure coincided with Melchior et  aPD   who   managed   patients   with   colo­ vesical fistulas  with resection  of the fistulized bowel,     single    stage    bowel     anastomosis without  protective colostomy and closure  of the bladder  defect.  Urethral  catheter  removal is  a  point  of  controversy  concerning early or  late   removal,   the   current   study   relied on performing cystogram before  catheter removal  and after assurance of absence of leakage;   the   catheter   was   removed.   Such policy    goes   in   hand   and   supported  the findings of de Moya et aP1 who reported that patients with early Foley catheter removal  did not have significant complications compared with patients with late Foley catheter  removal after  simple   bladder   repair   of  colo-vesical

fistula  secondary to diverticulitis.

Diverticular  absceses   were   detected   in

7  cases,   all  were  drained   with   peritoneal lavage followed by primary resection and anastomosis; similarly, Di Stefano  et al.22 managed  20   of   35   cases   of   diverticular abscess  with primary  colonic  resection.

The higher frequency of abscess formation among studied cases indicated the misleading outcome   of  conservative management of uncomplicated cases of diverticulitis and point to the necessity  of early surgical  interference for  uncomplicated cases to guard  against  the development  of  complications  and  dealing with  the  case  as  complicated diverticulitis. Such opinion coincided with Ricciardi  et al.23 who  retrospectively  reported   the  following data: the ratio of diverticulitis discharges increased from  5.1 cases per 1,000 inpatients in  1991  to 7.6  cases  per 1,000  inpatients in

2005, but the proportion of patients  who underwent colectomy for  uncomplicated diverticulitis declined   from  17.9%  in  1991 to   13.7%  in   2005   and   during   the   same period, the proportion of free diverticular perforations as a fraction  of all diverticulitis cases remained unchanged, but even the proportion of diverticular abscess as a fraction of all diverticulitis cases increased from 5.9% in 1991 to 9.6% in 2005. In support of such opinion,  Zdichavsky et ai.24 reported  that patients   with   acute  diverticulitis  receiving a laparoscopic early single-stage procedure benefited from  an early postoperative convalescence with a minimum of disability.

The recorded operative  and immediate postoperative   data    were    acceptable   and go in hand with Li et al.25 who compared laparoscopic-assisted  versus  open  approach for management of complicated diverticulitis and  found  that  laparoscopic-assisted group had  significantly less blood  loss with significantly shorter  time  to  first  bowel motion  (3.5  vs. 5 days) in the  laparoscopic­ assisted group.

In  conclusion, laparoscopic management of  complicated diverticulitis is  feasible and safe approach provided that proper surgical decision was adequately taken  concerning to proceed  or not after laparoscopic exploration.

Laparoscopic  approach  for  management of complicated diverticulitis allowed  patients  to enjoy  all advantages of laparoscopic surgery as a minimally invasive  surgery.

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