clinical outcomes of complicated diverticulitis managed nonoperatively
TRANSCRIPT
R. Scott Nelson D.O , B. Mark Ewing B.S., Timothy J. Wengert M.D. and Alan G. Thorson M.D.
Clinical outcomes of complicated diverticulitis managed
nonoperativelyThe Southwestern Surgical Congress
December 2008 (Vol. 196, Issue 6, Pages 969-974)1
• The incidence of diverticulitis within the United States is increasing, This is based in part on technology that is able to provide a noninvasive diagnosis
• Younger patients typically not thought of having this disease process are now more frequently being diagnosed
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• This technology, specifically computed tomography (CT) scans, is playing a more integral part in the diagnosis and management of the disease .
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• Frequently, a history of diverticulosis with the onset of typical symptomatology has been used to diagnosis a flare of diverticulitis without confirmatory study
• CT scanning has redefined the diagnosis of diverticulitis by its ability to visualize and distinguish between the different variants of this disease process
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• Acute diverticulitis:– Uncomplicated :
• evidence of colonic wall thickening • pericolonic inflammatory changes such as fat stranding
– Complicated :• Abscess• Fistula• Obstruction• localized or free perforation
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• Radiographic findings, in conjunction with the patient's history, comorbidities, and physical examination are now frequently used to establish whether an operation or nonoperative management should be prescribed.
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• Historically, recommendations for resection of uncomplicated disease were based on– 2 previous episodes of diverticulitis or– 1 episode if the patient was less than 50 years of
age
• Newer data and recommendations have called for a revision of the practice of aggressive surgical resection in patients with uncomplicated disease, despite recurrence or age.
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• The basis of these arguments is that a majority of patients do not seem to progress from uncomplicated to complicated disease over time.
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• Complicated diverticulitis is considered an indication for elective operation.
• Patients with an abscess or localized perforation in particular have been treated with antibiotics, and percutaneous drainage if indicated.
• Following this course of action they are typically scheduled for elective resection.
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• However, our understanding of the natural history of diverticulitis is changing as our ability to visualize the disease has changed.
• The aim of this study was to assess the outcomes of a group of individuals with complicated findings on CT scan that had been followed without an operation.
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Materials and Methods
• Retrospective study• 14-year period (1993 - 2006)• complicated diverticulitis (CT scan)
– Patient demographics (age and sex) – Operation performed– CT findings– Recurrence
• Patients without CT scan evidence of complicated diverticular disease were not included in the study.
• . P values ≤.05 were considered statistically significant.
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Results
• 256 patients (142 males).• mean age of the population was 63 years
(range 22–91)• 79% of the patients under the age of 70• 99 (38.6%) were initially managed
nonoperatively
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Age yr
21–30 31–40 41–50 51–60 61–70 71–80 81–90 91+
Operative group
2 24 38 19 38 24 9 3
Nonoperative group
3 8 11 27 33 12 5 0
Total group 5 32 49 46 71 36 14 3
Age distribution of population per decade
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256 Complicated Diverticulitis
99Followed
157Operated
46Recurrence
82Anterior
Resection
75Hartmann20
Operation
1Hartmann
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• Patients younger than age 50 were evaluated against those older than 50 years of age to determine if they were at risk of:– requiring an emergent operation, or– having more recurrent disease.
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86 ( < 50 Y )
22 ( non – operative )
64( Operative )
4 (18.2 %)Surgery
77 (> 50 Y )
Non-operative
16 (20.8 %)Surgery
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157Operated
82Anterior
Resection
75Hartmann
27 (42% )< 50 Y
48 ( 51.6 % )> 50Y
patients less than 50 years of age had fewer emergency operations17
• When followed without surgery, younger patients did not appear to be at higher risk for recurrent attacks compared with older patients.
• 11 of the 22 patients (50%) younger than 50 years of age had at least 1 recurrence, whereas 31 of the 77 patients (40.3%) older than 50 had at least 1 recurrence (P = .6453).
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• Thus, there was no difference between recurrence or need for emergency operation based on age.
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Reasons for nonoperative treatment
patient response to medical management 32no referral to a surgeon by the medical physicians 47patient's refusal of an operation 9patient being deemed too ill for an operation 11
total 99
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Initial CT scan findings for both groups
CT scan findings
Nonoperative group (n = 99)
Operative group (n = 156) P value
Abscess 56 55 .0011
Localized perforation 35 21 .0006
Free perforation 1 66 <.0001†
Fistula 2 13 .0713
Phlegmon 5 0 SD
Obstruction 0 2 SD
SD = sample deficiency.
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99 ( all recived Antibiotics )
11percutaneous drain placements
1Hartmann procedure
for obstruction
1elective sigmoid
resection
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Non Operative Group
• Mean follow-up of these 99 nonoperatively treated patients was 76.3 months.
• 75 recurrent episodes requiring some form of treatment occurred in 46 patients (46.4%).
• Of these recurrent episodes:– 62 were uncomplicated – 13 were complicated.
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• 20 of the 99 patients ultimately had an operation, greater than 6 months out from their first complicated attack, with 1 patient requiring the Hartmann procedure .
• These 20 patients had significantly more recurrent episodes of diverticulitis
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• Of the patients undergoing an operation within 6 months of their complicated episode of diverticulitis:– 82 (52.2%) had a sigmoid resection – 75 (47.7%) underwent a Hartmann procedure
• 19 CT-guided percutaneous drains were placed in this group– 17 were later treated with a sigmoid resection – 2 failed drainage, requiring a Hartmann
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Comments
• While diverticular disease appears to be increasing in incidence, less than 1% of patients will need to be managed operatively
• Different classification systems have been devised to better define the different presentations of diverticular disease.
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• Hinchey described his well-known 4 stages of complicated diverticulitis found at laparotomy
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• More recently, Ambrossetti et al have described a classification system for diverticulitis based on CT scan criteria.
• 2 categories :– Complicated :
• Abscess• extraluminal air• extraluminal contrast
– Uncomplicated
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• The American Society of Colon and Rectal Surgeons (ASCRS) consensus statement includes obstruction and fistula
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• In a recent study by Chapman et al :– morbidity and mortality rates were not
significantly different between patients who suffered multiple attacks (>3) versus those with only 1 or 2 attacks.
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• Haglund et al :– monitored 372 patients for 12 years and
concluded that patients with complicated diverticulitis usually presented with perforation, on their first episode and not later on, even with multiple recurrences.
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• Anaya et al:
• large population-based study of more than 20,000 patients admitted with nonoperatively managed diverticulitis, found that only 5.5% progressed to require an emergency colectomy or colostomy.
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• Our data similarly demonstrate that patients with complicated disease do not have a significant risk for returning on an emergency basis with perforation and need for colostomy.
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• Based on these findings, patients with diverticular disease who have had a complicated finding on CT scan should be informed that the risk of recurrence requiring fecal diversion is low.
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• However, the risk of recurrent disease is quite high and should be considered along with the patient's desires, lifestyle considerations, work requirements, and other comorbidities as a course of therapy is chosen.
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Conclusions• risk of perforation and need for colostomy after a
medically treated complicated episode of diverticulitis were extremely low.
• However, recurrence of disease within our mean follow-up period of 6 years was almost 50%.
• The patient's comorbidities, response to treatment, age, and their desires, as well as type of operation available, should all play a role when designing the treatment algorithm for this disease.
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Thank You
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