increasing the number of attacks increases the conversion rate in laparoscopic diverticulitis...
TRANSCRIPT
Increasing the number of attacks increases the conversion ratein laparoscopic diverticulitis surgery
Karin Cole Æ Steven Fassler Æ Sree Suryadevara ÆD. Mark Zebley
Received: 10 December 2007 / Accepted: 3 May 2008 / Published online: 5 June 2008
� Springer Science+Business Media, LLC 2008
Abstract
Background This study aimed to determine whether the
number of diverticulitis or complicated diverticulitis episodes
affects the conversion rate or postoperative complication rate
in elective laparoscopic sigmoid colectomy.
Methods In this study, 216 charts were reviewed for
baseline characteristics, diverticulitis history, and intra-
and postoperative complications. Analysis was performed
with the Student’s t-test, the chi-square test, and Fisher’s
exact tests.
Results Of 216 sigmoid colectomies, 151 were laparo-
scopic, 19 were converted, and 46 were open. Baseline
characteristics were similar for patients with zero to two
and those with three or more inpatient diverticulitis attacks.
Patients with uncomplicated diverticulitis had a higher rate
of conversion after three or more inpatient episodes (2.6%
vs 25%; p = 0.04). There was no difference in operative
times or postoperative complication rates. Patients with a
history of abscess had a 23% chance of conversion. Those
with no abscess history had an 8% chance of conversion
(p = 0.02). In general, converted procedures required more
time than open procedures but were associated with
decreased hospital length of stay (LOS) and a decreased
rate of postoperative ileus.
Conclusion Multiple inpatient diverticulitis attacks and a
history of abscess were associated with laparoscopic con-
version. Converted procedures required more time than
open procedures, but had reduced LOS and postoperative
ileus. Laparoscopic sigmoid colectomy can be attempted
safely for patients with three or more inpatient attacks or a
history of complicated diverticulitis.
Keywords Complicated diverticulitis � Conversion �Diverticulitis � Laparoscopic colorectal surgery �Sigmoid colectomy
Laparoscopic colectomy for sigmoid diverticulitis was first
introduced in the 1990s. Since then, studies have demon-
strated it to be a safe and effective alternative to open
surgery for this condition [1–8]. The effect of diverticular
complications, such as abscess, on the feasibility of lapa-
roscopic resection has been investigated by several authors,
who have found that the rate of conversion to open
resection is higher [4–7, 9]. No studies, however, have
addressed the effect of multiple, uncomplicated attacks of
diverticulitis requiring inpatient hospitalization.
Patients with a history of multiple diverticulitis attacks
severe enough to require inpatient care might be expected
to have more severe or more extensive inflammatory
changes than patients who present for surgery after only
one or two inpatient attacks.
We hypothesized that patients with a history of multiple
hospitalizations for diverticulitis would experience a longer
operation time, a higher conversion rate, or a higher post-
operative complication rate than patients with a history of
milder disease. We undertook a retrospective study of
patients undergoing elective surgery for diverticulitis at a
large community teaching hospital to address this
hypothesis.
K. Cole (&) � S. Fassler � S. Suryadevara � D. M. Zebley
Department of Surgery, Abington Memorial Hospital,
Price Medical Office Building, Suite 604, 1245 Highland
Avenue, Abington, PA 19001, USA
e-mail: [email protected]
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Surg Endosc (2009) 23:1088–1092
DOI 10.1007/s00464-008-9975-z
Methods
We performed a retrospective chart review of 216 elective
sigmoid colectomies for diverticulitis performed between
January 1996 and July 2006. Data sources included the hos-
pital’s electronic medical record, outpatient charts, and patient
information databases prospectively maintained by the two
laparoscopic colorectal surgeons. The data collected included
baseline demographics, diverticulitis history (including the
number of inpatient and outpatient episodes and the presence
of complications such as abscess, fistula, stricture, or perfo-
ration), operative time, type of operation, intraoperative
complications, hospital length of stay (LOS), postoperative
complications, and readmission within 30 days of surgery.
Hand-assisted operations (2 in 151) were considered to
have been completed laparoscopically. Converted cases
were those in which a laparotomy was necessary to com-
plete some or all of the open dissection. All patients
underwent a standard mechanical bowel preparation with
parenteral antibiotics administered preoperatively and for
24 h postoperatively. All laparoscopic and converted cases
were managed by one of two fellowship-trained colorectal
surgeons (M.Z. and S.F.) along with a resident assistant.
Three trocars (one umbilical and two on the right side of
the abdomen) were used, and a left lower quadrant incision
was created for specimen removal. A fourth trocar was
inserted occasionally for difficult dissections. Dissection of
the sigmoid colon mesentery proceeded from medial to
lateral or from lateral to medial, depending on the extent
and location of the patient’s disease.
The Student’s t-test was used for comparison of para-
metric data. The chi-square test and Fisher’s exact test
when appropriate were used for comparison of nonpara-
metric data. Open source statistical software was used for
some calculations. All p values are two-tailed and con-
sidered significant at a level less than 0.05. The study was
approved by the hospital’s institutional review board.
Results
Of the 216 charts reviewed, 151 (70%) described opera-
tions completed laparoscopically, 19 (9%) described
operations converted to open procedures, and 46 (21%)
described operations performed as open procedures. Dur-
ing the study period, the number of cases managed per
month increased from 1.5 (January 1996 to December
1999) to 3.6 (January 2003 to July 2006). The percentage
of cases managed laparoscopically increased from 39% to
89% during the same period (Fig. 1).
Open cases were managed by 1 of 14 general surgeons.
Laparoscopic cases were predominantly managed during
the later part of the study period, and open cases during the
earlier part. There was a transition period during which
open and laparoscopic approaches both were used with
similar frequency (October 1997 to April 2000). During
this period, the approach offered to each individual patient
was dependent on the type of surgeon to whom the patient
had been referred (general vs colorectal) and not on the
presumed extent of the patient’s disease.
The overall conversion rate was 11.2%. There was some
variation in the conversion rate by time period. During the
first part of the study (October 1997 to December 1999),
the conversion rate was 10%, whereas during the second
part (January 2000 to December 2003), it was 8.7%, and
during the third part (January 2004 to July 2006), it was
13.6%.
The reason for conversion in all but four cases was
inflammation or adhesions. Two of these four cases were
converted because of bleeding and two because of persis-
tent anastomotic leaks.
For 138 (81%) of the 170 patients who underwent lap-
aroscopic or converted procedures, complete information
on their diverticulitis history was available. This part of the
analysis excluded 54 of these patients because of compli-
cated diverticulitis (phlegmon, abscess, fistula, stricture),
leaving 84 patients with a well-documented history of
uncomplicated diverticulitis.
The patients were classified according to the number of
hospitalizations for diverticulitis before elective surgery
(B2 vs C3 episodes). For the patients who underwent
elective sigmoid resection after no hospitalizations or only
one hospitalization, the indication for surgery was typically
a chronic, relapsing course of disease managed in the
outpatient setting.
Fig. 1 Sigmoid colectomy cases per month (line) and percentage of
cases begun laparoscopically (bar) during two periods
Surg Endosc (2009) 23:1088–1092 1089
123
Baseline characteristics were compared between
patients with zero to two hospitalizations and those with
three or more hospitalizations for diverticulitis (Table 1).
Patients in the group with three or more hospitalizations
were approximately 12 years older than the patients in the
group with fewer attacks. Other characteristics (body mass
index [BMI], sex, rates of prior open abdominal and pelvic
surgery) were similar.
Patients with a history of zero to two inpatient divertic-
ulitis attacks had a conversion rate of 2.6%, whereas those
with three or more attacks had a conversion rate of 25%
(Table 2). When these two groups were compared, the dif-
ference was found to be statistically significant (p = 0.04).
The operative time for laparoscopic cases did not differ
significantly according to number of attacks. The postop-
erative complications were infrequent and did not seem
related to the number of prior inpatient diverticulitis attacks.
The most frequent indication for surgery for compli-
cated diverticulitis was abscess (21% of all patients, 47%
of patients with complicated disease). Patients presenting
with a history of diverticular abscess were compared with
patients who had no history of abscess. Patients with an
abscess history had a 23% chance of requiring conversion
to an open procedure, whereas patients with no abscess
history had an 8% chance of such conversion. This dif-
ference was found to be statistically significant (p = 0.02).
Patients with a history of abscess, whether they underwent
laparoscopic or converted procedures, had an operation
time and LOS similar to those of patients without abscess
(Table 3).
When all the patients undergoing converted procedures
were compared with all the patients undergoing open
procedures, a statistically significant difference in opera-
tion times (158 vs 125 min; p = 0.003) was found. The
rates of postoperative ileus also showed a difference (5%
for the converted group vs 15% for the open group), but
this difference did not reach statistical significance, nor did
the average hospital LOS (7 days for the converted group
vs 7.9 days for the open group).
Discussion
Prior studies have demonstrated the safety of a laparoscopic
approach to sigmoid colectomy for diverticulitis [1–8]. The
findings also show that the safety profile of the procedure
increases with increasing institutional experience [10–12].
This review of laparoscopic sigmoid resection for diver-
ticulitis at our institution demonstrated that as institutional
experience increased, the number of resections performed
per month also increased, despite the fact that only two
surgeons performed most of these resections (compared
with 14 surgeons who performed open resections in pre-
ceding years). This suggests that patient referrals increased
or patients’ willingness to undergo a recommended resec-
tion increased with the availability of laparoscopic resection
at our institution.
Our overall conversion rate of 11.2% is within the range
of rates reported in the literature (5.2–26%) [1, 2, 7, 11,
13]. Multiple risk factors influencing the need for conver-
sion to an open procedure have been reported previously
including male sex, advanced age, high BMI, surgeon
experience, and the presence of complicated diverticular
disease [7, 11–13]. A previously published report from our
institution considering patients undergoing laparoscopic
colorectal surgery for any indication demonstrated not only
a higher conversion rate in the presence of prior abdominal
surgery but also a higher rate of inadvertent enterotomy,
postoperative ileus, and reoperation [14]. The effect of
multiple uncomplicated diverticulitis episodes on the need
for conversion to an open procedure, however, has not been
reported previously. This was the focus of our data
collection.
Table 1 Characteristics of patients with 0–2 versus 3 or more hos-
pitalizations for diverticulitis before elective sigmoid resection
0–2 inpatient
attacks
3 or more
inpatient attacks
p-value
Age 53.2 64.9 \0.05
Sex: %male 51.3 37.5 NS
BMI 27.6 26.9 NS
Abdominal surgery (%) 31.5 37.5 NS
Pelvic surgery (%) 26.3 25 NS
NS, not significant
Table 2 Conversion rate according to number of prior inpatient
diverticulitis attacksa
No. of inpatient diverticulitis attacks
0 1 2 3 4+
Conversion rate (%) 5.3 0 4.3 25 25
a p = 0.04 for comparison of 0–2 attacks versus 3 or more attacks
Table 3 Comparison of conversion rate, operation time, and length
of stay for patients with and without a history of abscess undergoing
laparoscopic or converted resection
Abscess No abscess p-value
Conversion rate (%) 23 8 0.02
Lap OR time (min) 141 127 NS
Converted OR time (min) 156 159 NS
Lap LOS (days) 4.2 4.4 NS
Converted LOS (days) 6.9 7.1 NS
Lap, laparoscopic; OR, operation; NS, not significant; LOS, hospital
length of stay
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123
We hypothesized that an increasing number of hospital-
izations, even in the absence of diverticular complications,
would have an effect on conversion rate, operative time, or
complications due to the presence of more severe or more
extensive inflammatory changes. Although the retrospective
nature of the study limited our ability to collect detailed data
for all patients, we were able to analyze complete data from
84 cases. This demonstrated a trend toward a higher con-
version rate for patients who had a greater number of
inpatient diverticulitis attacks, with an apparent cutoff point
between two and three attacks. When this cutoff point was
chosen for further analysis, a statistically significant differ-
ence in conversion rates was demonstrated.
The appropriate timing of elective surgery for divertic-
ulitis has been a matter of debate in the literature
essentially ever since the topic was first addressed. The
most recent guidelines from the American Society of Colon
and Rectal Surgeons acknowledge that resection usually is
offered to patients after two uncomplicated attacks of
diverticulitis [15]. Our finding of a higher conversion rate
for patients who have had more than two attacks strongly
supports these guidelines. Patients presenting for elective
laparoscopic resection after more than two inpatient div-
erticulitis attacks should be counseled that they are more
likely to require conversion to an open procedure.
Several investigators have established the feasibility of
laparoscopic resection for patients with a history of com-
plicated diverticulitis [4–7, 9]. Our results were in
agreement with their findings. Although a history of abscess
increases the rate for conversion to an open procedure, it
does not result in a longer operation time, an increased LOS,
or an increased complication rate. These results suggest
that, at least in the case of diverticulitis, converting a lap-
aroscopic procedure to an open one has few, if any,
disadvantages compared with starting a case in an open
fashion. Our findings of a decreased LOS and a decreased
rate of postoperative ileus in the converted group compared
with the open group further support this conclusion.
Although these findings were not statistically significant,
we believe that the latter, at least, is clinically significant.
Our study does have several limitations. It is a single-
institutional experience, with data collected retrospectively
for the most part. Obtaining a detailed diverticulitis history
for each patient was especially challenging. The use of
multiple data sources, however, including hospital and
outpatient records, allowed us to compile the necessary
data for a sufficiently large group of patients to permit
statistical analysis.
Another factor that should be considered in the inter-
pretation of our results is the presence of a learning curve
for the two laparoscopic surgeons within the study period.
Although variations in conversion rate were relatively
minor over the course of the study period and did not seem
related to the accumulation of experience by the two lap-
aroscopic surgeons whose patients formed the study group,
an analysis of recently completed cases could yield dif-
ferences in operation times and conversion rates. It is
difficult to speculate whether these differences would be
significant or not.
References
1. Bouillot JL, Berthou JC, Champault G, Meyer C, Arnaud JP,
Samama G, Collet D, Bressler P, Gainant A, Delaitre B (2002)
Elective laparoscopic colonic resection for diverticular disease:
results of a multicenter study in 179 patients. Surg Endosc
16:1320–1323
2. Dwivedi A, Chahin F, Agrawal S, Chau WY, Tootla A, Tootla F,
Silva YJ (2002) Laparoscopic colectomy vs open colectomy for
sigmoid diverticular disease. Dis Colon Rect 45:1309–1314
3. Gonzalez R, Smith CD, Mattar SG, Venkatesh KR, Mason E,
Duncan T, Wilson R, Miller J, Ramshaw BJ (2004) Laparoscopic
vs open resection for the treatment of diverticular disease. Surg
Endosc 18:276–280
4. Kockerling F, Schneider C, Reymond MA, Scheidbach H,
Scheuerlein H, Konradt J, Bruch HP, Zornig C, Kohler L, Bar-
lehner E, Kuthe A, Szinicz G, Richter HA, Hohenberger W
(1999) Laparoscopic resection of sigmoid diverticulitis: results of
a multicenter study. Surg Endosc 13:567–571
5. Reissfelder C, Buhr HJ, Ritz J-P (2006) Can laparoscopically
assisted sigmoid resection provide uncomplicated management
even in cases of complicated diverticulitis? Surg Endosc
20:1055–1059
6. Scheidbach H, Schneider C, Rose J, Konradt J, Gross E, Bar-
lehner E, Pross M, Schmidt U, Kockerling F, Lippert H (2004)
Laparoscopic approach to treatment of sigmoid diverticulitis:
changes in the spectrum of indications and results of a prospec-
tive, multicenter study on 1,545 patients. Dis Colon Rect
47:1883–1888
7. Vargas HD, Ramirez RT, Hoffman GC, Hubbard GW, Gould RJ,
Wohlgemuth SD, Ruffin WK, Hatter JE, Kolm P (2000) Defining
the role of laparoscopic-assisted sigmoid colectomy for diver-
ticulitis. Dis Colon Rect 43:1726–1731
8. Sardella WV, Vignati PV (2000) Laparoscopic surgery for div-
erticulitis. Semin Colon Rectal Surg 11:231–234
9. Schwandner O, Farke S, Fischer F, Eckmann C, Schiedeck TH,
Bruch HP (2004) Laparoscopic colectomy for recurrent and
complicated diverticulitis: a prospective study of 396 patients.
Langenbecks Arch Surg 389:97–103
10. Marusch F, Gastinger I, Schneider C, Scheidbach H, Konradt J,
Bruch HP, Kohler L, Barlehner E, Kockerling F, Laparoscopic
Colorectal Surgery Study Group (LCSSG) (2001) Experience as a
factor influencing the indications for laparoscopic colorectal
surgery and the results. Surg Endosc 15:116–120
11. Marusch F, Gastinger I, Schneider C, Scheidbach H, Konradt J,
Bruch HP, Kohler L, Barlehner E, Kockerling F, Laparoscopic
Colorectal Surgery Study Group (LCSSG) (2001) Importance of
conversion for results obtained with laparoscopic colorectal sur-
gery. Dis Colon Rect 44:207–214
12. Schlachta CM, Mamazza J, Seshadri PA, Cadeddu MO, Poulin
EC (2000) Predicting conversion to open surgery in laparoscopic
colorectal resections: a simple clinical model. Surg Endosc
14:1114–1117
13. Schwander O, Schiedeck TH, Bruch H (1999) The role of con-
version in laparoscopic colorectal surgery: do predictive factors
exist? Surg Endosc 13:151–156
Surg Endosc (2009) 23:1088–1092 1091
123
14. Franko J, O’Connell BG, Mehall JR, Harper SG, Nejman JH,
Zebley DM, Fassler SA (2006) The influence of prior abdominal
operations on conversion and complication rates in laparoscopic
colorectal surgery. J Soc Laparoendosc Surg 10:169–175
15. Wong WD, Wexner SD, Lowry A, Vernava A III, Burnstein M,
Denstman F, Fazio V, Kerner B, Moore R, Oliver G, Peters W,
Ross T, Senatore P, Simmang C (2000) Practice parameters for
the treatment of sigmoid diverticulitis–supporting documentation.
The Standards Task Force. The American Society of Colon and
Rectal Surgeons. Dis Colon Rect 43:290–297
1092 Surg Endosc (2009) 23:1088–1092
123