Definition(s) of Diverticular Disease

Prof. Edmund Neugebauer, Dr. J. KrahnBiochem. & Exptl. Division,

Medical Faculty, University of Cologne

Falk-Symposium 148 "Divertikelkrankheit: Neue Erkenntnisse einer Volkskrankheit"München; 17.-18. Juni 2005; Session II 11:15-12:20

Presented by

Abe FingerhutCentre Hospitalier Intercommunal

Poissy, France

Historic Background

• Ernst Graser, Head of Surgery in Erlangen, in 1899:– Herniation of inner wall segments of the colon have

been called 'colon diverticula' since his publication– First accurately described the clinical entity of

inflamed diverticula in the sigmoid colon– He named this phenomenon 'peri-diverticulitis'

Graser E. Ueber multiple falsche Darmdivertikel in der Flexura sigmoidea. Münch Med Wochenschr 1899; 22: 721-723

Graser E. Ueber multiple falsche Darmdivertikel in der Flexura sigmoidea. Münch Med Wochenschr 1899; 22: 721-723

Technically 'Pseudo-diverticula' as not involving all layers of colon wall (as opposed to 'true' diverticula -> all layers)

Diverticula

Prevalence today

• Very common• True prevalence difficult to define (most patients

remain asymptomatic)• Rule of thumb: People who have diverticula in

their colon:5% in <40 year-olds65% in >65 year-olds

• In Western countries: majority in sigmoid colonIn Asian populations: more frequent in caecumJun, S. and Stollman, N. (2002) Epidemiology of diverticular disease. Best Practice & Research in Clinical Gastroenterology 16(4), 529-542

Terminology

• DiverticulosisDenotes the presence of diverticula in the colonic wall, asymptomatic

• Diverticular diseaseDiverticula have become clinically apparent with symptoms ('disease' indicating ill health)

• DiverticulitisDiverticula with superadded inflammation involving bowel wall and/or pericolic fat tissue

Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13: 430-6

Terminology• 'Diverticular disease' not consistently defined• ICD-10:

Diverticular disease of intestine includes (K57)– Diverticulitis– Diverticulosis– Diverticulumexcludes– congenital diverticulum of intestine– diverticulum of appendixInternational Classification of Diseases: http://www.who.int/classifications/icd/en

Clinical Classification

• Diverticular disease classified into:– symptomatic uncomplicated disease– recurrent symptomatic disease– complicated disease

Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13: 430-6

Clinical Classification

• Complicated diverticular disease

Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13: 430-6

Classification

• Hinchey classification– Describes severity of inflammation in perforated

diverticulitis– Used to guide surgical management– Advocated by E.A.E.S and the American Society of

Colon and Rectal Surgeons– Not yet validated with regard to prognostic value

Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12: 85-109

Hinchey Classification

Large Mesenteric Abscess(Hinchey Stage II)

Free Perforation(Hinchey Stage III) Free Perforation Causing

Fecal Peritonitis(Hinchey Stage IV)

Localised PericolicAbscess

(Hinchey Stage I)

Hinchey Classification• Modified classification as recommended by E.A.E.S consensus

conference:

Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13: 430-6

Stage I Pericolic abscess

Stage IIA Distant abscess amenable to percutaneous drainage

Stage IIB Complex abscess associated with/without fistula

Stage III Generalised purulent peritonitis

Stage IV Fecal peritonitis

APACHE II points

12 Physiologic parameters 0 to 4Age > 44, > 55, > 65, > 75 2 to 6Urgent surgery 5

Scores > 30 mortality > 70%

Manheim Peritonitis Index points

Age > 50 ans 5Female gender 5Preoperative delay >24 h 4 Generalized peritonitis 6 Exsudate: purulent - fecal 6 - 12Organ failure (one or more) 7

MPI > 21: Sensitivity 0.95 ; Specificity 0.25

Summary• Diverticulosis:

asymptomatic diverticula in colonic wall, whether they are 'true'/'pseudo' or left/right sided is not defined

• Diverticulitis:– inflammatory complication of diverticulosis

• Diverticular Disease: E.A.E.S consensus: symptomatic diverticulosis– ICD 10: umbrella term for colonic diverticula

• Hinchey Classification: – for perforated diverticulitis, accepted tool for planning

surgical intervention• Severity:

– APACHE, MPI

I thank you for your attention

Abe FingerhutCentre Hospitalier Intercommunal

Poissy, France

Colostomie

DrainageColostomy

Drainage

Resection

Colostomy

Emergency: Emergency: ResectionResection or not ?or not ?

2 2 RandomizedRandomized controlledcontrolled trialstrials1

TreatmentTreatment of of perforatedperforated sigmoidsigmoid diverticulitisdiverticulitis: a prospective : a prospective randomizedrandomized trialtrial

62 patients, 14 years, 27 surgeons, no scoring system

Suture Suture ResectionResectionColostomyColostomy

Number of patients 31 31Hartmann 19Double stoma 12

Hinchey III († %) 21 (0) p<0.02 25 (24) Hinchey IV († %) 10 (60) p=0.6 6 (33) Reoperations resection 17 15 H reversal

Stoma : permanent 4 7closure 4

Kronborg Br J Surg 1993

MRCT of MRCT of IIaryary vs vs IIIIaryary sigmoidsigmoid resectionresection in in generalizedgeneralized peritonitisperitonitiscomplicatingcomplicating sigmoidsigmoid diverticulitisdiverticulitis

105 patients, 7 years, 34 surgeons, MPI scoreSuture ResectionColostomy Hartmann

Number of patients 48 55Hinchey III († %) 34 (18) 43 (21)Hinchey IV († %) 14 (21) 12 (33)MPI > 21 († %) 39 (31) 36 (25)

Reoperations (early) 11 2# total operations 107 93Permanent stoma 2 5

p<0.001p<0.001

ZeitounZeitoun FASR FASR BrBr J J SurgSurg 20002000

ResectionResection++primaryprimary anastomosis anastomosis despitedespite peritonitisperitonitis ??

Author n n MPI Hinchey † 95%CI

III/IVBelmonte 227 200 ? 1 -Wedell 224 14 ? 33 0 – 21Schwesinger 89 6 ? ? -Biondo 127 23 ? ? 0 - 20Goozsen 45 45 18 9 0 – 33Schilling 13 13 21 6 0 - 22

Proposed RCT

Resection+primary anastomosis vs HartmannInclusion criteria: MPI- Generalized peritonitis 6- Purulent exsudate 6- Operative delay < 24h 0- No visceral failure 0- Age < 50 if female gender 5- Whatever the age if male gender 0 or 5

< 21

Lavage

Glue

Suture

Omentoplasty

Laparoscopic management of generalizedperitonitis due to perforated colonicdiverticula

+/- Drainage

3

Mannheim Peritonitis Index

Points Faranda• Age>50 years 5 mean age 53.7• Female gender 5 10 F / 8 H• Delay > 24 h 4 none• Generalized peritonitis 6 18

purulente 6 16fecal 12 2

• Organ failure 7 none

mean MPI score 18

LaparoscopicLaparoscopic management of management of generalizedgeneralized peritonitisperitonitis due to due to perforatedperforatedcoloniccolonic diverticuladiverticula

• « Don’t try this at home! ». ME Arregui• « The procedure of choice is immediate segmental

resection with colostomy ». ASCRS• Selection bias for laparoscopy ?

n 95% Confidence IntervalKrukowski 156 34 15 28 Kronborg 31 6 5 33FASR 48 9 8 30O’Sullivan 8 0 0 37Faranda 18 0 0 17

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The influence of Lavage on PeritonitisPlatell J Am Coll Surg 2000

• « Removing obvious peritoneal contamination isnot under question »

• « There is little evidence that supports routine peritoneal lavage in the management of patients with peitonitis »

• « May just be a ritual … »

Thank you for your attentionAbe Fingerhut

Centre Hospitalier Intercommunal

Poissy, France