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All patients with perforated diverticulitis admitted as emergency cases and having undergone colon resection during their initial hospitalisation in the period from 1 January 2003 to 30 June 2008 at one institution were analysed with regard to morbidity and mortality. The group consisted of 106 patients (mean age 65 years, range 32-98 years), 60% of whom had comorbidity. Hartmann's procedure was the initial procedure in 77% and primary resection and anastomosis in 23%. Of these patients 18% underwent reoperation, leading to a mean number of surgical procedures during the initial hospitalisation of 1.3 (range 1-10). The mean length of stay was 17 days, the median stay 12 days (range 1-111 days). A total of 43% of the patients underwent surgery during readmissions. Among the 82 patients operated with Hartmann's procedure, permanent stoma was the end result for 35 patients (43%). Six patients died. This retrospective study confirmed that perforated diverticulitis requiring colon resection was associated with a high risk of reoperation, long hospital stay, readmittance with renewed surgery and permanent stoma. Furthermore, the procedure caused suffering and a considerable drain on resources. The results will be used as the basis for a randomised trial on laparoscopic lavage versus Hartmann's procedure.
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DANISH MEDICAL BULLETIN ϣDan Med Bul ϧϪ/ϣ January ϤϢϣϣ
ABSTRACT
All patients with perforated diverticulitis admitted as
emergency cases and having undergone colon resection
during their initial hospitalisation in the period from
1 January 2003 to 30 June 2008 at one institution were
analysed with regard to morbidity and mortality. The
group consisted of 106 patients (mean age 65 years,
range 32-98 years), 60% of whom had comorbidity. Hart-
mann’s procedure was the initial procedure in 77% and
primary resection and anastomosis in 23%. Of these pa-
tients 18% underwent reoperation, leading to a mean
number of surgical procedures during the initial hospi-
talisation of 1.3 (range 1-10). The mean length of stay
was 17 days, the median stay 12 days (range 1-111
days). A total of 43% of the patients underwent surgery
during readmissions. Among the 82 patients operated
with Hartmann’s procedure, permanent stoma was the
end result for 35 patients (43%). Six patients died. This
retrospective study confirmed that perforated diverticu-
litis requiring colon resection was associated with a high
risk of reoperation, long hospital stay, readmittance with
renewed surgery and permanent stoma. Furthermore,
the procedure caused suffering and a considerable drain
on resources. The results will be used as the basis for a
randomised trial on laparoscopic lavage versus Hart-
mann’s procedure.
In industrial countries, diverticulosis of the colon has a
prevalence of 5% in persons under the age of 40, and
the prevalence rises with age [1]. Most such patients are
asymptomatic, but 15-25% develop diverticulitis [2], and
they are mostly uncomplicated cases. Patients with mild
to moderate lower abdominal pain and subfebrility are
often treated conservatively as outpatients with restric-
tion on oral fluids for the first 2-3 days. Oral antibiotics
have frequently been part of such a regimen; however,
evidence in support of their use is limited [3]. Active
therapy is required for patients with diverticulitis who
develop more complicated disease. The clinical manifes-
tations of such disease may include moderate to severe
abdominal pain, signs of peritonitis, fever and septic
symptoms. Hinchey’s classification of colonic diverticular
disease [4] has been known for decades. Even if it is
rarely used by surgeons, it is useful for disease staging in
connection with the discussion of alternative treatment
modalities.
Stage Ia: Phlegmona
Stage Ib: Diverticulitis with pericolic or mesenteric
abscess
Stage II: Diverticulitis with walled-off pelvic abscess
Stage III: Diverticulitis with generalised purulent
peritonitis
Stage IV: Diverticulitis with generalised faecal
peritonitis.
Stages I and II are generally treated with intravenous
antibiotics, but some cases may require surgery. A re-
cent study provided evidence in support of conservative
treatment for Hinchey I and some Hinchey II cases [5].
Stages III and IV (Figure 1) are considered an indication
for emergency surgery. Hartmann’s procedure (HP)
(Figure 2) or primary resection and anastomosis (PRA)
are the most common surgical procedures performed in
acute perforated diverticulitis, and of these HP is the
most frequently used procedure [6]. However, evidence
that HP and PRA are, indeed, the best options remain
low-grade and needs to be substantiated in empirical
studies with higher levels of evidence [7].
The present study aims to describe the results of
emergency surgery for perforated diverticulitis at our in-
stitution. The study will focus on suffering and resource
consumption in terms of number of operations, length
of hospital stay, reoperations during readmissions, per-
manent stoma and mortality. The results will be used as
the point of departure for a randomised trial investigat-
ing recently described alternative treatment [8].
MATERIAL AND METHODS
An application to the Research Ethics Committee was
not filed as retrospective quality control studies require
no such approval under Swedish law.
This retrospective study was undertaken at the
Departments of Surgery at Sahlgrenska University
Hospital from 1 January 2003 to 30 June 2008. The pa-
tient population was identified via the hospital record
system which contains data on all admitted and dis-
ORIGINAL ARTICLE
1) Department of
Surgery, Alingsås
Lasarett, and
2) SSORG/Göteborg,
Department of Surgery,
Sahlgrenska University
Hospital/Östra
Dan Med Bul
2011;58(1):A4173
Perforated diverticulitis operated at
Sahlgrenska University Hospital 2003-2008
Anders Thornell1, Eva Angenete2 & Eva Haglind2
Ϥ DANISH MEDICAL BULLETIN
charged patients registered with the International
Classification of Diseases coding system (ICD-10) and the
specific Swedish surgical procedure codes. The search
criteria were:
Admission on an emergency basis
Discharge diagnosis: ICD-10 code K572 or K573
Abdominal surgery with colon resection during the
hospital stay.
We excluded patients with pathologies like cancer, ap-
pendicitis or gynaecologic conditions.
The study period saw the inclusion of 1,519 patients
admitted from the Emergency Rooms and later dis-
charged with a diagnosis of diverticulitis. A total of 106
of these patients (51 men and 55 women) underwent
colonic resection during their initial hospital stay with
findings of complicated or perforated diverticulitis and
no other pathologies. These patients were included for
further analysis. The follow-up period lasted until 1 June
2009. Hinchey grading had only been used in two cases,
and the population could therefore not be classified ac-
cording to Hinchey.
Data were collected from case records. The follow-
ing information was collected:
– Age
– Comorbidity
Length of hospital stay
– Initial surgical procedure
– Mortality
Reoperation during first hospital stay
Reasons for reoperation
– Readmittance
Reoperation during readmissions
– Type of operations
– Permanent stoma.
The definition of co-morbidity was cancer, chronic ob-
structive pulmonary disease, cardio-vascular disease or
treatment with immuno-modulating drugs.
The SPSS software was used for statistical analysis.
RESULTS
The patients’ mean age was 65 and it was significantly
lower in men than in women (Table 1). The mean length
of the hospital stay was 17 days, and the median length
was 12 days, (range: 1-111) for the first emergency ad-
mittance. A total of 82% of the patients were operated
once during their first hospital stay, 12% were operated
twice and 6% more than twice. The mean number of op-
erations was 1.3 (range: 1-10). HP was performed in 77%
of the cases and 23% underwent PRA. Comorbidity was
seen in 60%, and 44% of the patients were re-operated
during a later admission, including elective procedures
such as colonic reanastomosis (Table 2). The rate of re-
operation at readmission was 43% (Table 2). Reopera-
tion was more common among men (57%) than women
(31%), p < 0.007. Among patients who underwent Hart-
mann’s procedure (n = 82), 17% (n = 14) were either lost
to follow-up or died, and the stoma was not reversed in
43% (n = 35) of the cases. The decision to leave the
stoma permanently was made by the surgeon in 20
cases and by the patient in 15 cases. Six patients died
during their first admittance, three of whom had faecal
peritonitis, Hinchey IV.
DISCUSSION
Perforated diverticulitis is a potentially lethal condition.
The mortality rate after emergency surgery has been re-
ported to reach 20% [9]. Based mainly on experience
and retrospective case-series, HP or PRA have evolved to
Dan Med Bul ϧϪ/ϣ Januar ϤϢϣϣ
Perforated diverticulitis of the sigmoid colon
FIGURE 1
Illustration of the anatomy after Hartmann’s procedure with resection of
the perforated, inflamed sigmoid colon and construction of a colostomy
FIGURE 2
DANISH MEDICAL BULLETIN ϥ
become recommended emergency procedures [7]. Over
a 5.5-year period in a large University Hospital with a
catchment area of 700,000 inhabitants, 106 patients
underwent emergency colonic resection for diverticuli-
tis. Having two surgery departments, the hospital was,
and still is, the only hospital with an emergency service
in the city of Göteborg and the surrounding areas. The
annual incidence of perforated diverticulitis treated by
emergency colonic resection was three cases/100,000
inhabitants. Thus, each individual surgeon’s experience
with this procedure is limited. The frequency and sever-
ity of the complications, the postoperative mortality and
the high rate of permanent stomas found in our popula-
tion suggest that patients may suffer unduly and that re-
source consumption is high.
We found a lower mortality than reported in many
previous studies [19] which could reflect selection bias.
Included were all patients admitted as emergency cases
and later diagnosed as having diverticulitis and in whom
a colonic resection was performed during the initial hos-
pital stay. Only if the hospital administrative records are
inaccurate and lack a correct ICD code or surgery code
would cases be missed. However, these records are also
the basis for the hospital’s economic reimbursement.
The lower mortality observed in this population than in
other populations could also be rooted in improvements
in care, e.g. operative care and intensive care as well as
improvements related to diagnostics and treatment of
complications. If the indications for emergency surgery
at our hospital exclude from surgery the oldest and most
severely ill patients, this would also explain the observed
low mortality. We found nothing to suggest the pres-
ence of a systematic bias due to stricter indications for
emergency surgery at any of the surgery departments at
our hospital. Given the retrospective nature of the
present study, it is, however, important to interpret the
results with caution and make no firm conclusions on
the present basis.
The rate of complications was high, and could large-
ly explain the length of hospital stay and the reoperation
rate observed during the initial hospital stay. In a retro-
spective study, Kotzampassakis et al found that patients
younger than 50 years less frequently underwent emer-
gency surgery than older patients, and when they did,
they were more frequently underwent PRA than pa-
tients above this age [11]. In the only large prospective
study on laparoscopic lavage for acute, perforated di-
verticulitis, the mean age was the same as in our retro-
spective material [12].
Earlier studies have reported that older patients are
more likely to require emergency surgery than younger
patients [13], and that a poor outcome is associated
with elderly patients with significant comorbidity [14].
With a mean age of 65 years and significant comorbidity
in 60% of the patients, our findings underline that our
population was, indeed, a risk population. Recently,
Klarenbeek et al discussed the indications for elective
sigmoid resection after diverticulitis and found immuno-
suppression, renal failure and collagen vascular disease
to be risk factors [10]. The mortality after emergency
sigmoid resection in their 10-year material was 13%.
An issue often overseen is the rate of permanent
stomas. In our study, 43% ended up with a permanent
stoma, which is comparable to the findings in a registry-
based study which reported that in 44% of patients with
a colostomy after surgery for diverticulitis the colostomy
was not reversed [15]. Constantinides et al presented a
risk analysis for morbidity and mortality after sigmoid
resection with primary anastomosis or Hartman’s
proced ure and found, among other results, that 27% be-
came permanent stoma carriers after Hartman’s proced-
ure. They advocated a choice between primary resection
and anastomosis with a loop-ileostomy or Hartman’s
procedure, as primary resection with anastomosis with-
out a covering ileostomy entailed a higher risk [7]. The
rate of permanent stoma carriers may also be influenced
by cultural differences.
Recent years have seen several reports on laparo-
scopic lavage and drainage as the surgical choice for
Hinchey III, along with two prospective cohort studies,
which were all recently ‘‘meta-analysed’’ [16, 17].
Toorenvliet et al concluded that at present we only have
low-grade evidence for this ‘‘minimally invasive’’ alter-
native treatment [16]. However, the reported results are
such that if reproduced in a randomised trial, they rep-
resent an improvement of therapy, both in terms of
complications, number of operations and resource con-
sumption. A health technology assessment (HTA) per-
Dan Med Bul ϧϪ/ϣ Januar ϤϢϣϣ
TABLE 1
Male Female Total
n 51 55 106
Age, years
Mean ± standard deviation 58 ± 15.5 71 ± 12.4 –
Minimum 32 36 32
Maximum 88 98 98
Age of all included patients by gender.
Reoperations.
TABLE 2
Male Female Total
no yes total no yes total no yes total
n 22 29 51 38 17 55 60 46 106
% 43 57 100 69 31 100 53 47 100
Ϧ DANISH MEDICAL BULLETIN
formed by the HTA-unit of the Västra Götalands-regi on,
Sweden, concluded that the alternative treatment is in-
teresting and that prospective randomised trials are
needed [18]. A randomised trial called ‘‘DILALA’’ was re-
cently initiated with inclusion of patients from 14 hos-
pitals in Scandinavia. The aim of the trial is to compare
laparoscopic lavage with HP for perforated diverticulitis
Hinchey III.
In summary, this report confirms earlier reports
that perforated diverticulitis requiring emergency sur-
gery comprises a high-risk condition with prolonged con-
sequences for patients. In our hands, mortality was con-
siderable, but possibly somewhat lower than in many
previous reports. Any treatment that may hypothetically
reduce complications and the need for surgery and hos-
pital care should be considered candidates for a ran-
domised trial.
CORRESPONDENCE: Eva Haglind, SSORG/Göteborg, Department of Surgery,
Sahlgrenska University Hospital/Östra, 416 85 Göteborg, Sweden.
E-mail: eva.haglind@vgregion.se
ACCEPTED: 2 November 2010
CONFLICTS OF INTEREST: None
ACKNOWLEDGEMENTS: The authors wish to express their gratitude to An-
ders Rosemar, MD, and Göran Kurlberg, MD, for their interest and support.
The Scandinavian Surgical Outcomes Research Group has supported the work
and also the resulting protocol for a randomised trial of laparoscopic lavage as
a new treatment for perforated diverticulitis (DILALA). The work was sup-
ported by grants from Sahlgrenska University Hospital.
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Dan Med Bul ϧϪ/ϣ Januar ϤϢϣϣ
... Another option is resection with primary anastomosis of the colon [3]. A retrospective study at the Sahlgrenska University Hospital, Gothenburg studied all patients (n = 106) admitted and operated for complicated diverticulitis between 2003 and 2008 [7]. Eighteen percent underwent at least one re-operation during their first admission, and the mean length of hospital stay was 17 (1-111) days. ...
... Mortality was 6%, not different from similar studies [2,6] . The number of complications indicated considerable suffering, morbidity and resource consumption [7]. Only 56% of patients operated with Hartmann's procedure later underwent surgery for stoma reversal [7]. ...
... The number of complications indicated considerable suffering, morbidity and resource consumption [7]. Only 56% of patients operated with Hartmann's procedure later underwent surgery for stoma reversal [7]. Other studies have shown that the reversal of Hartmann's Procedure alone has a morbidity rate of 20% (3-39) and mortality of 1-6% [8,9]. ...
Article
Full-text available
Perforated diverticulitis is a condition associated with substantial morbidity. Recently published reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomised study has published any results. DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional Hartmann's Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpoints consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patients are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient is included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally, placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months. A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40). HP is associated with a high rate of complication. Not only does the primary operation entail complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe, minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer re-operations, decreased morbidity, mortality, costs and increased quality of life. British registry (ISRCTN) for clinical trials ISRCTN82208287http://www.controlled-trials.com/ISRCTN82208287.
... Traditionally, the treatment of perforated diverticulitis (Hinchey grade III and IV) has been either resection with a colostomy (Hartmann's procedure) or, less often, primary resection and anastomosis with or without a temporary diverting stoma 3,4 . Both surgical procedures are associated with a high risk of reoperation, prolonged hospital stay and readmissions, and for some patients the result will be a permanent stoma 5 . ...
... The results of the present 2-year follow-up correspond well with these rates, and concerns about subsequent resection may have been overemphasized. In earlier studies 5,18,19 of patients with diverticulitis, about 40 per cent of the patients treated by Hartmann's procedure had a persisting stoma compared with 23 per cent (9 of 40) in this trial at 24 months. One factor contributing to this could be a greater focus on reversal of stomas here as the patients were participants in a trial, with regular follow-up according to the trial protocol. ...
Article
Full-text available
Background Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here. Methods Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287. Results Forty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months. Conclusion Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.
... In Hinchey grades III and IV, diverticular perforation into the abdominal cavity has resulted in purulent or fecal peritonitis, respectively. These conditions require emergency surgical intervention and are associated with high morbidity (25% to 75%) and mortality (2% to 30%) (7)(8)(9)(10). Historically, the Hartmann procedure has been most commonly performed, which includes colon resection and colostomy; another option is resection of the affected part of the colon with primary anastomosis with or without diverting ileostomy (9,11,12). ...
... All additional surgeries due to perforated diverticulitis must be considered as disadvantageous for patients. For a large proportion of patients who had colon resection and stoma formation for diverticulitis, the stoma is not reversed (7). In our study, 11 of 40 patients who had the Hartmann procedure for perforated diverticulitis had a colostomy 12 months later. ...
Article
Full-text available
Background: Perforated diverticulitis with purulent peritonitis has traditionally been treated with open colon resection and stoma formation with risk for reoperations, morbidity, and mortality. Laparoscopic lavage alone has been suggested as definitive treatment. Objective: To compare laparoscopic lavage with open colon resection and colostomy (Hartmann procedure) for perforated diverticulitis with purulent peritonitis. Design: Randomized, controlled, multicenter, open-label trial. (ISRCTN registry number: ISRCTN82208287). Setting: 9 hospitals in Sweden and Denmark. Patients: Patients who have confirmed Hinchey grade III perforated diverticulitis with purulent peritonitis at diagnostic laparoscopy. Intervention: Randomization between laparoscopic lavage and the Hartmann procedure. Measurements: Primary outcome was the percentage of patients having 1 or more reoperations within 12 months. Key secondary outcomes were number of reoperations, hospital readmissions, total length of hospital stay during 12 months, and adverse events. Results: A total of 43 and 40 patients were randomly assigned to laparoscopic lavage and the Hartmann procedure with a median (first, third quartiles) follow-up of 372 days (336, 394) and 378 days (226, 396), respectively. Fewer patients in the laparoscopic group (12 of 43; 27.9%) than in the Hartmann group (25 of 40; 62.5%) had at least 1 reoperation within 12 months (relative risk reduction, 59%; relative risk, 0.41 [95% CI, 0.23 to 0.72]; P = 0.004). Mortality and severe adverse events did not differ between groups. Total length of hospital stay (days) within 12 months was shorter for the laparoscopic group than the Hartmann group, with a reduction of 35% (relative risk, 0.65 [CI, 0.45 to 0.94]; P = 0.047). After 12 months, 3 patients in the laparoscopic group and 11 in the Hartmann group had a stoma. Limitation: Not all patients presenting with suspected diverticulitis were enrolled. Conclusion: Laparoscopic lavage reduced the need for reoperations, had a similar safety profile to the Hartmann procedure, and may be an appropriate treatment of choice for acute perforated diverticulitis with purulent peritonitis. Primary funding source: ALF; Sahlgrenska University Hospital, Gothenburg.
... Perforated diverticulitis with generalized peritonitis requires surgical treatment in most cases. Nevertheless, both the Hartmann procedure (HP) and sigmoidectomy with primary anastomosis (PA) have been associated with significant morbidity and mortality rates [6][7][8]. Therefore, after its introduction in 1996, laparoscopic peritoneal lavage (LL) has increasingly been investigated as a promising alternative to sigmoidectomy [9][10][11][12][13][14][15][16][17]. ...
Article
Full-text available
Aim Laparoscopic peritoneal lavage has increasingly been investigated as a promising alternative to sigmoidectomy for perforated diverticulitis with purulent peritonitis. Most studies only reported outcomes up to 12 months. Therefore, the objective of this study was to evaluate long‐term outcomes of patients treated with laparoscopic lavage. Methods Between 2008 and 2010, 38 patients treated with laparoscopic lavage for perforated diverticulitis in ten Dutch teaching hospitals were included. Long‐term follow‐up data on patient outcomes, e.g. diverticulitis recurrence, reoperations and readmissions, were collected retrospectively. Characteristics of patients with recurrent diverticulitis or complications requiring surgery or leading to death, categorized as ‘overall complicated outcome’, were compared with patients who developed no complications or complications not requiring surgery. Results Median follow‐up was 46 months (interquartile range: 7‐77), during which seventeen episodes of recurrent diverticulitis (seven complicated) in twelve patients (32%) occurred. Twelve patients (32%) required additional surgery with a total of 29 procedures. Fifteen patients (39%) had a total of 50 readmissions. Of initially successfully treated patients (n=31), twelve (31%) had recurrent diverticulitis or other complications. At 90 days, 32 (84%) patients were alive without undergoing a sigmoidectomy. However, seven (22%) of these patients eventually had a sigmoidectomy after 90 days. Diverticulitis‐related events occurred up to six years after the index procedure. Conclusion Long‐term diverticulitis recurrence, reintervention and readmission rates after laparoscopic lavage were high. A complicated outcome was also seen in patients who had initially been treated successfully with laparoscopic lavage with relevant events occurring up to six years after initial surgery. This article is protected by copyright. All rights reserved.
... Традиционно для лечения таких больных применялись открытые операции с резекцией ободочной кишки и формированием колостомы (операция Гартмана -ОГ). ОГ сопровождалась большой частотой осложнений [7], и ввиду этого многим пациентам не выполнялись повторные операции с закрытием колостомы и восстановлением непрерывности толстой кишки [8]. Несовершенство такого метода лечения требовало разработки менее инвазивных хирургических вмешательств [9][10][11][12]. ...
... After the 1-year follow-up in the trial, there are patients who may still have a stoma. Although it is possible to reverse the colostomy, many studies have concluded that the colostomy may not be reversed 16 . This is important when considering the comparative costs of the procedures because a stoma will incur costs each year for the duration of the patient's expected lifetime. ...
Article
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Background: Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial. Methods: Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life. Results: The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses. Conclusion: The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.
... Considerable morbidity has been reported after the Hartmann procedure 3 and many patients will never undergo secondary surgery with reversal of the stoma and restored bowel continuity. 4 Less invasive types of surgical treatment have thus been considered. [5][6][7][8] One such procedure is laparoscopy with abdominal lavage, which in a large prospective case series reported good results. ...
Article
To evaluate short-term outcomes of a new treatment for perforated diverticulitis with purulent peritonitis in a randomized controlled trial. Perforated diverticulitis with purulent peritonitis (Hinchey III) has traditionally been treated with surgery including colon resection and stoma (Hartmann procedure) with considerable postoperative morbidity and mortality. Laparoscopic lavage has been suggested as a less invasive surgical treatment. 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. Eighty-three patients were randomized, out of whom 39 patients in laparoscopic lavage and 36 patients in the Hartmann procedure groups were available for analysis. 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. In this trial, laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III was feasible and safe in the short-term.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Chapter
Acute diverticulitis is a significant and growing problem within the United States, accounting for over 160,000 hospitalizations per year and 875,000 days of inpatient care [1]. Rates of admission for acute diverticulitis are increasing, especially in the younger population [1, 2]. While the vast majority of cases can be managed without surgery, approximately 14 % require surgical intervention [1].
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When patients present with a perforation of a colon cancer (CC), this situation increases the challenge to treat them properly. The question arises how to deal with these patients adequately, more restrictively or the same way as with elective cases. Between January 1995 and December 2009, 52 patients with perforated CC and 1206 nonperforated CC were documented in the Erlangen Registry of Colorectal Carcinomas (ERCRC). All these patients underwent radical resection of the primary including systematic lymph node dissection with CME. The median follow-up period was 68 months. The median age of the patients in the perforated CC group was significantly higher than in the nonperforated CC group (p = 0.010). Significantly, more patients with perforated CC were classified in ASA categories 3 and 4 (p = 0.014). Hartmann procedures were performed significantly more frequently with perforation than with the nonperforated ones (p < 0.001). If an anastomosis was performed, the leakage rate of primary anastomoses did not differ (p = 1.0). Cancer-related survival was significantly lower with perforated cancer (difference 12.8 percentage points) and by 9.6 percentage points for observed survival, if postoperative mortality was excluded. Perforated CC patients should be treated basically following the same oncologic demands, which are CME for colonic cancer including multivisceral resections, if needed. This strategy can only be performed if high-quality surgery is available, permanently.
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The classic surgical treatment of acute complicated sigmoid diverticulitis with peritonitis is often a two-stage operation with colon resection and a temporary stoma. This approach is associated with high mortality and morbidity and the reversal of the stoma is in many cases not performed because of concurrent diseases and age. Recently, several studies have experimented with laparoscopic lavage as a treatment of acute complicated diverticulitis. The aim of this review was to give an overview of the literature for this new approach and to determine the safety compared with Hartmann's procedure for patients with acute complicated sigmoid diverticulitis. A PubMed search was performed for publications between 1990 and May 2008. The terms acute, perforated, diverticulitis, lavage, drainage, and laparoscopy were used in combination. The EMBASE and Cochrane databases were also searched. Eight studies met the inclusion criteria and reported 213 patients with acute complicated diverticulitis managed by laparoscopic lavage. None of these studies were randomized. The patients' mean age was 59 years and most patients had Hinchey Grade 3 disease. All patients were treated with antibiotics and laparoscopic lavage. Conversion to laparotomy was made in six (3%) patients and the mean hospital stay was nine days. Ten percent of the patients had complications. During the mean follow-up of 38 months, 38% of the patients underwent elective sigmoid resection with primary anastomosis. Primary laparoscopic lavage for complicated diverticulitis may be a promising alternative to more radical surgery in selected patients. Larger studies have to be made before clinical recommendations can be given.
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This prospective study was done to compare acute left-sided colonic diverticulitis in young patients (50 years of age or less) and older patients (more than 50 years of age) for severity of disease and immediate and late outcome. Of the 265 patients studied, 61 were 50 years of age or less; of these, 49 were men. In all instances, diagnosis was confirmed radiologically or histologically. Operations were performed less often upon younger patients than older patients (15 versus 33 percent, p = 0.001). Severe diverticulitis was found more often in younger men than older men (39 versus 23 percent). After successful conservative treatment during the first hospitalization period, younger men had a statistically greater risk of poor outcome than older men (29 versus 5 percent, p = 0.003). Although younger men have severe acute diverticulitis more often than older men, operative treatment during the first episode is less often needed. On the other hand, after conservative treatment, younger men have a statistically greater chance of poor secondary outcome than older men.
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To prevent an acute surgery, classic indications for elective sigmoid resections concerning diverticulitis have usually been based on the number of recurrent episodes. Since 2005 these indications have been challenged, primarily because the majority of patients first present themselves with acute complications at their first episode. Between 1990 and 2000, a cohort analysis was conducted involving all patients admitted to the VU University Medical Center with the diagnosis of diverticulitis, with a follow-up until January 2009. To identify those patients who might benefit from elective sigmoid resection, several risk factors were analyzed. Of 291 patients examined, 111 (38%) were treated conservatively and 180 (62%) underwent surgery, of which 108 acute and 72 elective. The conservatively treated episodes of diverticulitis showed a recurrence rate of 48% (88 patients). Indications for elective surgery were recurrent attacks of diverticulitis with persistent complaints (36%), complaints of stenosis (40%), fistula (14%), persistent abscesses (3%), and recurrent diverticular bleeding (7%). Of the 74% of the patients approached laparoscopically, the overall morbidity was 22% with no mortality. The main indication for an AO was perforation with general peritonitis, holding for 57% of the acutely operated patients. Other indications were abscesses (22%), stenosis with obstruction (11%), failure of conservative therapy (6%), or diverticular bleeding (4%). Hartmann's procedure was the most frequently performed procedure (58%). This acutely operated population was associated with high morbidity (56%) and mortality (13%), perforation leads to 10% mortality and other causes to 3%. Of those patients undergoing acute surgery, 20% had a history of diverticulitis. Moreover, risk factor analysis showed that those patients having one or more of the following indications: (1) using immunosuppression therapy, (2) having chronic renal failure, or (3) collagen-vascular diseases, had a significant 5-fold greater risk (36% vs. 7%) of a perforation in recurrent episodes of diverticulitis. In the treatment of diverticular disease, indications for an elective sigmoid resection should not be based on the number of episodes only. Clear indications for elective sigmoid resections are complaints of stenosis, fistulas, or recurrent diverticular bleeding. Furthermore, an elective sigmoid resection might be justified in high-risk patients, after a conservatively treated episode of diverticulitis, who use immunosuppression therapy and have chronic renal failure or collagen-vascular diseases.
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The severity and most appropriate treatment of diverticulitis in young patients are still controversial. The aim of this study is to compare young patients (<or=50 years) with older patients (>50 years) regarding clinical and radiologic parameters of acute left colonic diverticulitis and to determine whether differences exist in presentation and treatment. We reviewed medical records of 271 consecutive patients with left colonic acute diverticulitis admitted to our institution from 2001 through 2004: 71 patients were aged 50 years or younger and 200 patients were older than 50. Clinical and radiologic parameters were analyzed. Conservative treatment was standardized, and included antibiotic therapy and bowel rest. Criteria for emergency surgical treatment were diffuse peritonitis, pneumoperitoneum, and septic shock. Conservative treatment alone was successful in 64 patients (90.1%) in the younger group and in 152 patients (76%) in the older group (P = .017). The percentage of patients requiring surgery at admission or during the hospital stay was significantly lower in younger than in older patients (5.6% vs 20.5%, P = .007), and the percentage of patients requiring emergency end colostomy was higher (although not significantly) in the older group (1.4% vs 9.0%, P = .059). No differences in rate of successful conservative treatment were observed between patients with a first episode and those with recurrence in either age group (P = .941 in the younger group; P = .227 in the older group). Young age is not a predictive factor of poor outcome in the management of first or recurrent episodes of acute diverticulitis. Patients older than 50 years more frequently need emergency surgical treatment.
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This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.
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Diverticular disease has a changing disease pattern with limited epidemiological data. To describe diverticular disease admission rates and associated outcomes through national population study. Data were obtained from the English 'Hospital Episode Statistics' database between 1996 and 2006. Primary outcomes examined were 30-day overall and 1-year mortality, 28-day readmission rates and extended length of stay (LOS) beyond the 75th percentile (median inpatient LOS = 6 days). Multiple logistic regression analysis was used to determine independent predictors of these outcomes. Between the study dates 560 281 admissions with a primary diagnosis of diverticular disease were recorded in England. The national admission rate increased from 0.56 to 1.20 per 1000 population/year. 232 047 (41.4%) were inpatient admissions and, of these, 55 519 (23.9%) were elective and 176 528 (76.1%) emergency. Surgery was undertaken in 37 767 (16.3%). The 30-day mortality was 5.1% (n = 6735) and 1-year mortality was 14.5% (n = 11 567). The 28-day readmission rate was 9.6% (n = 21 160). Increasing age, comorbidity and emergency admission were independent predictors of all primary outcomes. Diverticular disease admissions increased over the course of the study. Patients of increasing age, admitted as emergency and significant comorbidity should be identified, allowing management modification to optimize outcomes.
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Diverticular disease of the colon now is recognized to be functional disease resulting from altered neuromuscular activity in the colon. Inflammatory complications, when they occur, usually result from inflammation around a single diverticulum. This may lead to the formation of a pericolic or pelvic abscess. Free perforation of these leads to purulent peritonitis. The original communication with the lumen of the bowel usually is obliterated. More rarely, with either rapid evolution or failure of the diverticular neck to obliterate, a free communication develops between the bowel lumen and the peritoneal cavity, leading to fecal peritonitis. Fecal peritonitis results in an extremely high mortality rate. The operative approach for a patient with perforated diverticular disease should be individualized and depends on the stage of the disease present, the general condition of the patient, the experience of the surgeon in colon surgery and the availability of facilities and personnel to provide intensive care. In larger institutions when these conditions are optimal, primary resection of the diseased bowel with or without anastomosis is becoming the procedure of choice. In smaller institutions or if conditions are not optimal, right transverse colostomy with drainage of the perforated segment can be relied on to control the disease with a mortality rate compared to that of primary resection. If free perforation and fecal peritonitis are present, exteriorization or primary resection of the perforated segment must be carried out. We would not recommend primary anastomosis under these circumstances.
Article
The purpose of this paper is to examine the course and prognosis of diverticular disease of the colon, particularly symptomatic diverticular disease. The following aspects are dealt with: increase in incidence with age; diverticular disease in the elderly; diverticular disease in the young; the changing sex incidence; increase in the number and size of diverticula; prognosis according to the number of diverticula; increase in the extent of the disease lengthwise in the colon; prognosis according to the extent of the disease; the development of peridiverticular inflammation; duration of symptoms; correlation between symptoms and pathologic findings; prognosis relative to symptomatology; prognosis in inflammatory diverticular disease; effect of high residue diet on the natural history of the established disease; the influence of surgery on the natural history of diverticular disease; residual diverticula; development of diverticula after resection of affected segment; effect of colostomy on the course of the disease; closure of colostomy without resection; mortality; development of associated disorders; possible relevance of irritable bowel syndrome to diverticular disease; and diverticular disease and cancer. (67 references)
Article
The use of laparoscopic peritoneal lavage in conjunction with parenteral fluids and antibiotic therapy in the management of generalized peritonitis secondary to perforated diverticular disease of the colon was assessed. This cohort comprised 8 patients with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopically. All the patients had purulent peritonitis, but no fecal contamination. They were treated with laparoscopic peritoneal lavage and intravenous fluids and antibiotics. All patients made a complete recovery, with resumption of normal diet within 5 to 8 days. No patient has required surgical intervention during a 12- to 48-month follow-up. This approach merits further assessment as an alternative to the traditional open surgical management.