Emergency General Surgery

Behind Enemy Lines

Every battle is won before it is fought.

Sun Tsu

Hello guys…

If you remember, quite a while ago we published a post on the management of uncomplicated acute diverticulitis. In that post we focused on conservative management, trying to explain why the surgical option should be avoided. However, interventional treatments are fundamental in the management of patients with complicated acute diverticulitis.

Definition

Remember that we used the Modified Hinchey Classification by Wasvary et al. to grade acute diverticulitis. In case you don’t remember it, you can find it in our previous post.

Last time we defined “uncomplicated” grade 0-Ia acute diverticulitis. Intuitively, complicated acute diverticulitis would be those graded as Ib-IV.

The problem with this generalization is quite evident. How is it possible to compare patients with grade Ib acute diverticulitis to patients with grade IV?… They are two different worlds… The first one has a pericolic or mesocolic abscess, the other has generalized fecal peritonitis… Therefore, as patients are substantially different, so are the treatment options we have at our disposal.

The basic principle is the same as always: the more advanced the disease, the more aggressive the treatment.

Upon this principle, we can divide patients with complicated acute diverticulitis into three categories:

  1. Those with an abscess (i.e. grade Ib-II);
  2. Those with generalized purulent peritonitis (i.e. grade III);
  3. Those with generalized fecal peritonitis (i.e. grade IV).
Brief Introduction

Before exploring our treatment options in each group of patients, we want to make a couple of general statements… We know they are obvious, but we think it is better to make them… Just in case…

  1. The diagnostic workup is the same as in uncomplicated acute diverticulitis;
  2. All patients with complicated acute diverticulitis need to start broad-spectrum antibiotics as soon as possible (remember to take a blood sample as for a septic patient);
  3. All patients need to be admitted;
  4. Remember that we are talking about complicated ACUTE diverticulitis… Chronic complications will not be considered in this post.
Patients with Abscess

The management of patients with abscesses depends upon abscess dimensions. However, the cutoff to divide small from large abscesses is not well defined. It is generally between 3 and 5 cm.

Small abscesses (i.e. <3 cm) can be safely treated conservatively with only antibiotics and medical support, reaching good response rates. In case of treatment failure, CT-guided percutaneous drainage is warranted.

On the other hand, patients with bigger abscesses (i.e. >5 cm) should undergo CT-guided percutaneous drainage along with antibiotics. Needless to say that during this procedure a sample of the fluid should be taken to perform cultures. If these patients failed to respond to drainage, the next step in line is surgery. However, remember that the procedure can be repeated safely in case of early removal or self-dislodgement.

Hinchey 2 acute diverticulitis with a large pelvic abscess

Recently, Mali et al. showed that patients with an abscess >8 cm often require immediate surgery. However, their explanation doesn’t rely on abscess dimension, but on conditions usually found in these patients (e.g. peritonitis, free air, etc…). Another interesting concept they reported in their paper is the difference in dimensions between pericolic and pelvic abscesses. They found that over 60% of abscesses larger than 6 cm were located in the pelvis, where 10% of those smaller than 4 cm were pelvic. They concluded their paper stating that percutaneous drainage with antibiotics is not superior to antibiotics only in terms of treatment failure, recurrence, and elective resections, advising the use of percutaneous drainage only in case of conservative treatment failure no matter the abscess size. This may seem fabulous, but we want you to be cautious before taking these conclusions too easily. Consider this: it’s a retrospective study; their final statements were based on two matched groups with 18 patients each; indeed, the difference in failure rate was not statistically significant (P=0.49), but it was from a clinical point of view (44% in antibiotics vs. 33% in drainage).

Patients with Peritonitis

As stated above, patients with Hinchey III and Hinchey IV acute diverticulitis need surgery… No doubts here… But the real problem rises now: which is the best procedure to perform?… Laparoscopic lavage and drainage? Resection and anastomosis? Hartmann procedure? Other?… Let us analyze what the literature says and try to make a couple of suggestions…

The use of laparoscopic lavage and drainage (Lap/Lav) for perforated acute diverticulitis with purulent peritonitis (i.e. Hinchey III) has been a matter of great discussion in the literature. The LOLA group of the LADIES Trial was structured to compare Lap/Lav with primary resection and anastomosis (RA), but it was stopped earlier because of the excess deaths in the Lap/Lav arm compared to the RA group. On the other hand, the SCANDIV Trial showed how Lap/Lav was associated with higher rates of deep surgical-site infections and unplanned reoperations, but also it carried a lower stoma rate at 1 year. The DILALA Trial, which compared Lap/Lav with Hartmann’s procedure, reported similar short-term outcomes and a shorter length of stay in the Lap/Lav group.

In 2016, a meta-analysis considering these three randomized controlled trials was published. In this paper, the authors demonstrated that Lap/Lav carried a higher rate of reoperations and a higher rate of intra-abdominal abscess compared to resection, but the mortality was similar between the two groups.

So then, Lap/Lav seems a good option in selected patients… But, how to select those who can benefit from this approach?

Recent papers tried to determine which are the risk factors for failure of Lap/Lav, and they reported that immunosuppressive therapy and severe comorbidities (i.e. ASA ≥3) increases the failure rate of this approach in Hinchey III diverticulitis. However, immunosuppressive therapy seemed the only independent risk factor for failure.

Ok… Now we have a clearer picture of what we can do when we need to treat a patient with a Hinchey III acute diverticulitis without risk factors for Lap/Lav failure. Let us explore the options we have in frail patients or those presenting with Hinchey IV diverticulitis.

Here the story is a little bit simpler. We have two possible choices: primary resection and anastomosis (i.e. sigmoidectomy) with/without diverting loop ileostomy, or the Hartmann’s procedure (i.e. rectosigmoid resection, closure of the rectal stump, and end colostomy).

The literature stated quite clearly that Hartmann’s procedure carries a low rate of bowel continuity restoration. This means that patients have to keep the colostomy for the rest of their lives, reducing their quality of life. On the other hand, RA appears feasible and safe even in patients with fecal peritonitis, making it the optimal approach for these patients. Still, Hartmann’s procedure remains the gold standard in high-risk patients with peritonitis and patients in a septic shock, as a damage control procedure. In the last case, as damage control surgery, there are two possible alternatives to Hartmann’s procedure: (1) to resect the colon and to abandon the two bowel stumps inside the abdomen (i.e. clip & drop technique), or (2) to cobble the hole in the colon. In both options, the abdomen must be left open and the patient must undergo a second look operation when stable enough or after 48-72 hours. These two alternatives should be considered in “young” and healthy patients presenting in a shock, aiming to avoid the stoma. In fragile and/or elderly patients with Hinchey III or IV diverticulitis, Hartmann’s procedure should be the first choice.

Before the end of this post, we want to resume the first-line treatment options we have in patients with complicated acute diverticulitis:

IndicationMain Procedure
Pericolic or pelvic abscess <3-5 cmAntibiotics
Pericolic or pelvic abscess >3-5 cmCT-guided percutaneous drainage
Generalized purulent peritonitisLaparoscopic lavage and drainage (selected pts) Primary resection and anastomosis with/without diverting loop ileostomy (if high risk of failure of Lap/Lav)
Generalized fecal peritonitisPrimary resection and anastomosis with/without diverting loop ileostomy
Fragile and/or elderly patients with generalized peritonitisHartmann’s procedure
Patient hemodynamically unstableDamage control surgery (e.g. Hartmann’s procedure, clip & drop, cobble the hole)

If you have enjoyed this post, please share it with your friends… You’ll make us very happy…

Until next time: be brave and stay safe.

Matane…

Acknowledgment

We want to thank our colleague and dear friend Giulio Del Zotto for all the help he provided us in writing and reviewing this post.

References
  1. Sartelli M, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020;15:32.
  2. Schultz JK, et al. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Disease 2020. DOI: 10.1111/codi.15140
  3. Klarenbeek BR, et al. Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 2012; 27:207-14.
  4. Mali J, et al. Determinants of treatment and outcomes of diverticular abscesses. World J Emerg Surg 2019;14:31.
  5. Vennix S, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomized, open-label trial. Lancet 2015;386:1269-77.
  6. Schultz JK, et al. One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. Br J Surg 2017;104:1382-92.
  7. Angenete E, et al. Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis – The first results from the randomized controlled trial DILALA. Ann Surg 2016;263:117-22.
  8. Kohl A, et al. Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis. Br J Surg 2018;105:1128-34.
  9. Ceresoli M, et al. Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials. World J Emerg Surg 2016;11:42.
  10. Beyer-Berjot L, et al. Emergency surgery in acute diverticulitis: a systematic review. Dis Colon Rectum 2020;63:397-405.
  11. Cirocchi R, et al. Laparoscopic lavage versus surgical resection for acute diverticulitis with generalized peritonitis: a systematic review and meta-analysis. Tech Coloproctol 2017;21:93-110.
  12. Greilsamer T, et al. Is the failure of laparoscopic peritoneal lavage predictable in Hinchey III diverticulitis management? Dis Colon Rectum 2017;70:965-970.
  13. Bridoux V, et al. Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am College Surg 2017;225:798-805.
  14. Ryan OK, et al. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann’s procedure for the management of acute perforated diverticulitis with generalized peritonitis. Tech Coloproctol 2020;24:527-43.
How to Cite This Post

Bellio G, Del Zotto G, Marrano E. Behind Enemy Lines – The Complicated Diverticulitis. Surgical Pizza. Published on April 4, 2021. Accessed on May 5, 2021. Available at [https://surgicalpizza.org/emergency-surgery/behind-enemy-lines].

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