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M&M ConferenceM&M Conference

9/9/089/9/08

M&M ConferenceM&M Conference MMMM 78 y/o F presented with a 5 day hx of left lower 78 y/o F presented with a 5 day hx of left lower

quadrant pain and abdominal distention.quadrant pain and abdominal distention. Pt admittledly has chronic constipation, but Pt admittledly has chronic constipation, but

noticed a recent increase in difficulty to defecatenoticed a recent increase in difficulty to defecate The patient did have a large bowel movement a The patient did have a large bowel movement a

day before presentation to the erday before presentation to the er After that BM she began to experience LLQ pain, After that BM she began to experience LLQ pain,

at times “intense” at times “intense” Also, during the last 5 day she claimed to have Also, during the last 5 day she claimed to have

lost her appetitelost her appetite Denied Nausea/Vomiting. Denied dysuriaDenied Nausea/Vomiting. Denied dysuria


PMHx- Recurrent diverticulitis, DM, PMHx- Recurrent diverticulitis, DM, HTN, Hyperlipidemia, HTN, Hyperlipidemia,

PSHx-Mastoidectomy, AppendectomyPSHx-Mastoidectomy, Appendectomy Meds- Atenolol, MetforminMeds- Atenolol, Metformin SHx-lives with daughter; denies SHx-lives with daughter; denies

alcohol, smoking, drugsalcohol, smoking, drugs FHx- HTN, DMFHx- HTN, DM Allergies-NKDAAllergies-NKDA

M&M ConferenceM&M Conference VitalsVitals

– Tmax 36.4 P-87 BP-110/64 O2 sat-98 % RATmax 36.4 P-87 BP-110/64 O2 sat-98 % RA GEN-AAOx3, No acute distressGEN-AAOx3, No acute distress Skin- Poor skin turgorSkin- Poor skin turgor HEENT-PERRL , No LymphadenopathyHEENT-PERRL , No Lymphadenopathy CVS-RRRCVS-RRR Lung-CTAB, no rales, no rhonchiLung-CTAB, no rales, no rhonchi Abd- Soft, Abd- Soft, ND, LLQ tenderness, +BSND, LLQ tenderness, +BS

– No rebound tendernessNo rebound tenderness, No mass, minimal LLQ guarding, No mass, minimal LLQ guarding Ext- L UE congenital deformityExt- L UE congenital deformity Rectal- Good tone, No stool, No bloodRectal- Good tone, No stool, No blood


LabsLabs– Na 134 K 4.9 Cl 95 CO2 24 BUN 70 Crea Na 134 K 4.9 Cl 95 CO2 24 BUN 70 Crea

3.03.0– Glu 157 AST 30 ALT 16 ALP 37Glu 157 AST 30 ALT 16 ALP 37– WBC 4.8 Hgb 10.4 Hct 31.1 Plt-302WBC 4.8 Hgb 10.4 Hct 31.1 Plt-302


RadiologyRadiology– Free intraperitoneal air c/w bowel Free intraperitoneal air c/w bowel

perforationperforation– SBO secondary to inflammatory process SBO secondary to inflammatory process

due to acute diverticulitisdue to acute diverticulitis


A/PA/P– 78 y/o Female 78 y/o Female – recurrent diverticulitis with localized recurrent diverticulitis with localized

tendernesstenderness– no signs of diffuse abdominal tendernessno signs of diffuse abdominal tenderness– DehydrationDehydration

PlanPlan– Aggressive fluid resuscitationAggressive fluid resuscitation– NPONPO– Serial abdominal examsSerial abdominal exams– Cipro, FlagylCipro, Flagyl

M&M ConferenceM&M Conference HD #1HD #1

– 6 am6 am Pt feels wellPt feels well LLQ pain resolving, Minimal residual tendernessLLQ pain resolving, Minimal residual tenderness No N/V, +Flatus No N/V, +Flatus Plan-cont NPO, serial abdominal exams, cont abxPlan-cont NPO, serial abdominal exams, cont abx

– 12 pm12 pm Acute decompensationAcute decompensation

– Mistakenly received CLDMistakenly received CLD– Lethargic, change in mental statusLethargic, change in mental status– Dyspnea, use of accessory muscleDyspnea, use of accessory muscle– AbdomenAbdomen

Marked distentionMarked distention Increased tenderness in LLQIncreased tenderness in LLQ

Intubated at bedsideIntubated at bedside To OR for ExplorationTo OR for Exploration

M&M ConferenceM&M Conference Post Op Dx- Acute Diverticulitis with free Post Op Dx- Acute Diverticulitis with free

perforationperforation Procedure- Exploratory Laparotomy/ Procedure- Exploratory Laparotomy/

Moblization of Splenic flexure/ Hartmann’s Moblization of Splenic flexure/ Hartmann’s ProcedureProcedure

Details of ProcedureDetails of Procedure– Feculant material found surrounding sigmoid colonFeculant material found surrounding sigmoid colon– Perforation noted at center of sigmoid colonPerforation noted at center of sigmoid colon

Specimen- Descending and Sigmoid ColonSpecimen- Descending and Sigmoid Colon EBL-100ccEBL-100cc Complication- noneComplication- none


Post Operative CoursePost Operative Course– POD#1POD#1

Increase Cardiac enzymeIncrease Cardiac enzyme– Cardiology consultedCardiology consulted

No urgent intervention- more related to overall No urgent intervention- more related to overall condition and renal insufficiency opposed to condition and renal insufficiency opposed to obstructive diseaseobstructive disease

– POD#4POD#4 Extubated progressing wellExtubated progressing well Transferred out of ICU Transferred out of ICU Later that eveningLater that evening

– Atrial FibrillationAtrial Fibrillation Rate controlled started on Amiodarone, diltiazemRate controlled started on Amiodarone, diltiazem Transferred back to ICU Transferred back to ICU

M&M ConferenceM&M Conference POD#5POD#5

– Stabilized Stabilized – Rate controlledRate controlled

POD#7POD#7– Transferred back to floorTransferred back to floor– StableStable

Ostomy functioning wellOstomy functioning well Remained afebrileRemained afebrile ABX stopped POD#7ABX stopped POD#7

POD#9POD#9– Discharged to Rehab facilityDischarged to Rehab facility– To follow Cardiology- anticoagulationTo follow Cardiology- anticoagulation


MorbidityMorbidity– Recurrent Diverticulitis with free Recurrent Diverticulitis with free

perforationperforation– Delay in Operative InterventionDelay in Operative Intervention

DiverticulitisDiverticulitis

Many controversies lie within the Many controversies lie within the topic of diverticulitistopic of diverticulitis– Conservative vs OperativeConservative vs Operative– Operative intervention in acute setting Operative intervention in acute setting

vs. electivevs. elective– When to Operate in younger ptsWhen to Operate in younger pts– When or if to operate in older ptsWhen or if to operate in older pts– FocusFocus

What type of operative intervention does the What type of operative intervention does the literature support?literature support?


Clinical presentations of diverticular Clinical presentations of diverticular disease range from asymptomatic disease range from asymptomatic diverticulosis, diverticulosis with diverticulosis, diverticulosis with periodic spasmodic abdominal pain periodic spasmodic abdominal pain and bloating, diverticulosis with and bloating, diverticulosis with hemorrhage, and finally, hemorrhage, and finally, diverticulitis. diverticulitis.

Two commonly utilized classifications Two commonly utilized classifications of diverticulitis of diverticulitis

DiverticulitisDiverticulitis 1) European Association for Endoscopic 1) European Association for Endoscopic

Surgeons developed a classification Surgeons developed a classification scheme based upon the severity of its scheme based upon the severity of its clinical presentation clinical presentation – diverticulitis is divided into symptomatic diverticulitis is divided into symptomatic

uncomplicated disease, recurrent symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease disease, and complicated disease

2) Hinchey 2) Hinchey – In 1978, In 1978, HincheyHinchey and colleagues devised a and colleagues devised a stagingstaging system for grading the degree of system for grading the degree of perforation in diverticulitis perforation in diverticulitis Use of radiologicand intra-operative findingsUse of radiologicand intra-operative findings

Stage Description

I Pericolic or mesenteric abscess

II Walled off pelvic abscess

III Generalized purulent peritonitis

IV Generalized fecal peritonitis

Hinchey ClassificationHinchey Classification


Operations are mainly reserved for Operations are mainly reserved for cases of complicated diverticulitiscases of complicated diverticulitis– i.e., patients with perforation and i.e., patients with perforation and

peritonitis, abscess formation, fistula, or peritonitis, abscess formation, fistula, or obstruction. obstruction.

Although this may seem clear-cut, Although this may seem clear-cut, decisions regarding if and when to decisions regarding if and when to operate patients with diverticulitis operate patients with diverticulitis remain a topic of significant debate. remain a topic of significant debate.


Operation is clearly indicated when the Operation is clearly indicated when the patient presents with perforation and diffuse patient presents with perforation and diffuse peritonitis, whether it is purulent or feculent peritonitis, whether it is purulent or feculent (Hinchey stages III and IV). (Hinchey stages III and IV). – However, the ideal surgical procedure in such However, the ideal surgical procedure in such

cases of perforation remains a matter of debate. cases of perforation remains a matter of debate. simple washout of the abdomen with drainage simple washout of the abdomen with drainage resection with a Hartmann pouch resection with a Hartmann pouch primary resection with anastomosis with diverting primary resection with anastomosis with diverting

ileostomyileostomy primary resection with anastomosis and no temporary primary resection with anastomosis and no temporary

stoma stoma


Hartmann’s resection has proven to Hartmann’s resection has proven to be a safe and effective approach, be a safe and effective approach, and is based upon the idea that an and is based upon the idea that an anastomosis in the setting of acute anastomosis in the setting of acute infection/inflammation is dangerous infection/inflammation is dangerous and associated with a high rate of and associated with a high rate of suture line breakdown. suture line breakdown.


simple washout with drainagesimple washout with drainage– paucity of data to support a minimalist, simple paucity of data to support a minimalist, simple

washout approachwashout approach there are only 18 case reports in the literature there are only 18 case reports in the literature

describing the technique and its resultsdescribing the technique and its results– Moderate successModerate success

Primary Anastomosis with and without Primary Anastomosis with and without diversiondiversion– Some evidence of low leak rate with primary Some evidence of low leak rate with primary

anastomosis w/o ostomyanastomosis w/o ostomy Questionable studies where patient status not evenly Questionable studies where patient status not evenly

evaluated evaluated – Pt’s comorbidities not comparedPt’s comorbidities not compared


Hartmann’s procedure vs Primary Hartmann’s procedure vs Primary anastomosis with or without ostomyanastomosis with or without ostomy– Systematic literature review of 50 studies Systematic literature review of 50 studies

comparing a Hartmann’s procedure to a primary comparing a Hartmann’s procedure to a primary resection with anastomosis for perforated resection with anastomosis for perforated diverticulitis found 569 reported cases of primary diverticulitis found 569 reported cases of primary anastomoses anastomoses mortality and morbidity in the patients with an mortality and morbidity in the patients with an

anastomosis was the same as in the patients who anastomosis was the same as in the patients who underwent the Hartmann’s procedure underwent the Hartmann’s procedure

– patient conditionpatient condition– Comorbidites Comorbidites – Not evenly facotredNot evenly facotred


OverallOverall– There is intriguing data about the surgical There is intriguing data about the surgical

management of acute diverticulitis, management of acute diverticulitis, But it must be viewed with caution,But it must be viewed with caution,

– especially in the case of toxic patients with multiorgan especially in the case of toxic patients with multiorgan system failure and/or shock system failure and/or shock

– Safest method Safest method Perform a Hartmann’s procedure in the face of an Perform a Hartmann’s procedure in the face of an

acute perforated diverticulitis with perotionitsacute perforated diverticulitis with perotionits

– There is a viable argument to perform a There is a viable argument to perform a primary ananstomosis even in the face of primary ananstomosis even in the face of feculant contamination, especially in relatively feculant contamination, especially in relatively healthy patientshealthy patients

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