updated management of colonic diverticulitis dr. tsang yi-po department of surgery pamela youde...
TRANSCRIPT
![Page 1: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/1.jpg)
Updated Management of Colonic Diverticulitis
DR. TSANG YI-PO
DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL
JOINT HOSPITAL SURGICAL GRAND ROUND
![Page 2: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/2.jpg)
Diverticulosis
False diverticulum Herniation of mucosa and submucosa via
weak point of muscular wall where vasa recta penetrate
Colonic wall weakening
Intraluminal pressure
Age related changes
Segmentation
Dietary fibre deficiency
![Page 3: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/3.jpg)
Diverticulosis
Prevalence 30% by age 60 60% by age 80
Presentation Asymptomatic: 70% Diverticulitis: 10-25% Bleeding: 5-10%
![Page 4: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/4.jpg)
Modified Hinchey ClassificationStage Description
0 Mild clinical inflammation
1a Confined pericolic inflammation
1b Confined pericolic abscess
2 Pelvic, distant intraabdominal or retroperitoneal abscess
3 Generalised purulent peritonitis (no open communication with bowel lumen)
4 Faecal peritonitis (free open perforation)
Fistula
Obstruction
![Page 5: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/5.jpg)
Uncomplicated diverticulitis 70-80% of all diverticulitis Absence of
Abscess Perforation Fistula Stricture / obstruction
Management Bowel rest Antibiotics Colonoscopy 6-8 weeks after acute episode to
exclude underlying malignancy [1]1. Feingold et al. Dis Colon Rectum 2014;57:284-294
![Page 6: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/6.jpg)
Uncomplicated diverticulitis
Elective colectomy in an individualized basis [1] Low risk of recurrence [1,2]
13-23% risks of subsequent uncomplicated attacks
6% risks of subsequent complicated attacks
Mortality and morbidity not increased after >2 uncomplicated attacks [1,3]
Routine elective surgery for <50years not recommended [1]
1. Feingold et al. Dis Colon Rectum 2014;57:284-2942. Salem et al. Dis Colon Rectum 2007;50:1-5
3. Wieghard et al. Ann Gastroenterol 2015;28:25-30
![Page 7: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/7.jpg)
Complicated diverticulitis
Percutaneous drainage? Surgery
Peritoneal lavage? Stoma vs primary anastomosis? Laparoscopic?
![Page 8: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/8.jpg)
Percutaneous drainage
For Hinchey II disease [1] Size of abscess >5cm: likely not successful
with antibiotics alone [2,3] Feasibility of drainage Availability of expertise
Successful rate ~70-80% [1]
1. Soumian et al. World J Gastroenterol 2008;14:7163-7169
2. Siewart et al. Am J Roentgenol 2006;186:680-6863. Ambrosetti et al. Dis Colon Rectum 2005;48:787-
791
![Page 9: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/9.jpg)
Surgery
Indication Unstable haemodynamics Hinchey III / IV on CT scan Failure to respond conservative therapy Complications
![Page 10: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/10.jpg)
![Page 11: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/11.jpg)
Hartmann’s operation
Gold standard since 1980’s For quick and efficient sepsis control High mortality ~20% Significant morbidities
> 1/3 of patient never have stoma reversed Reversal of stoma also has significant
morbidities
![Page 12: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/12.jpg)
Peritoneal lavage
Possible alternative for selective group of patient [1]
Expected benefit [2] Avoid urgent laparotomy and colostomy Reduced morbidity and mortality Significantly reduced inflammatory
environment minimize complications from subsequent colonic resection
1. Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607
2. Corocci et al. Medicine (Baltimore) 2015;94:e334
![Page 13: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/13.jpg)
Peritoneal lavage
Systematic review 19 papers from 1996 to 2013 Total 871 patients
Cirocchi et al. Medicine (Baltimore) 2015;94:e334
![Page 14: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/14.jpg)
Peritoneal lavage
Overall success rate: 24.3% (212/871) Alive without surgical treatment for recurrent
diverticulitis or complication
Overall conversion rate to open: 3.8% (17/444) (for Hinchey I-IV) [45% for Hinchey IV]
30-day mortality rate: 4.8%
Cirocchi et al. Medicine (Baltimore) 2015;94:e334
![Page 15: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/15.jpg)
Peritoneal lavage
Hospital readmission rate: 6.9% (29/419) Recurrent diverticulitis (16/29) Peritonitis (6/29) Fistula (3/29) Undetected Ca colon (2/29) Abscess (1/29) Intestinal obstruction (1/29)
69% of readmitted patients required surgical treatment
Cirocchi et al. Medicine (Baltimore) 2015;94:e334
![Page 16: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/16.jpg)
Study No.
Design
Hinchey
Conversion (%)
Hospital stay (Day)
Amount of lavage (L)
Complication (%)
Readmission
Death (%)
Elective colectomy
I II IIIIV
Swank 2013
38Retro
0 533
0 3 10 4 32 3 5 0
Edeiken 2013
10 Pros 0 1 8 1 20 4 NR 40 4 0 2
Rogers 2012
427
Retro
0 0 427 NR 10 NR 14 NR 4 NR
Liang 2012
47Retro
0 0 47 2 6 NR 4 0 0 21
White 2010
35Retro
2 011
2 0 14 1 54 8 0 8
Lam 2009
9Retro
0 1 5 3 33 N/A NR N/A 3 0 3
Karoui 2009
35 Pros 0 035
0 0 8 15 28 1 0 25
Favuzza 2009
7Retro
0 1 6 0 0 7 NR NR 1 0 4
Mazza 2009
25 Pros 2 8 9 6 0 14 NR 12 NR 0 16
Lippi 2009
13 Pros 0 5 7 1 0 N/A NR N/A 3 2 0
Myers 2008
100
Pros 025
67
8 8 8 4 4 3 3 0
Bretagnol 2008
24 Pros 0 518
1 0 12 10 8 0 0 24
Franklin 2008
40Retro
0 532
3 0 8 15 20 0 0 24
Galleano 2007
4 Pros 0 2 2 0 0 10 10 0 0 0 4
Mutter 2006
10Retro
0 010
0 0 8 NR 0 1 0 6
Taylor 2006
14Retro
0 210
2 0 6 3 21 0 0 8
Da Rold 2004
7Retro
1 1 5 0 14 N/A NR 0 0 0 0
Faranda 2000
18 Pros 0 016
2 0 8 15 17 0 0 15
O’Sullivan 1996
8 Pros 0 0 8 0 0 10 NR 25 2 0 0
![Page 17: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/17.jpg)
Peritoneal lavage
No histological diagnosis - ?underlying Ca colon
Leaving septic foci with persistent / recurrent infection / inflammation [1]
Recurrence Not an appropriate alternative to
colectomy [1]
1. Feingold et al. Dis Colon Rectum 2014;57:284-294
![Page 18: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/18.jpg)
Peritoneal lavage
Mainly for Hinchey III Absolutely contraindicated for Hinchey IV
(high risk of treatment failure) [1-3] Experienced laparoscopic surgeon
1. Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607
2. White et al. Dis Colon Rectum 2010;53:1537-15473. Rogers et al. Dis Colon Rectum 2012;55:932-938
![Page 19: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/19.jpg)
Anastomosis or not?
Effective alternative [1,2] Primary anastomosis not worse than
stoma in terms of mortality and morbidity [1-3]
Small-scale retrospective studies with selection bias [1,3,4]
1. Feingold et al. Dis Colon Rectum 2014;57:284-2942. Hupfeld et al. Biomed Res Int 2014:380607. doi: 10.1155/2014/380607
3. Abbas. Int J Colorectal Dis 2007;22:351-3574. Cirocchi et al. Int J Colorectal Dis 2013;28:447-457
![Page 20: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/20.jpg)
Anastomosis or not?
Cirocchi et al. Int J Colorectal Dis 2013;28:447-457
Lower mortality rate for anastomosis (P < 0.02)
Shorter hospital stay (P < 0.001)
![Page 21: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/21.jpg)
Anastomosis or not?
Selection bias and heterogeneity Age, sex, ASA scale, co-morbidity Hinchey stage Faecal diversion in anastomosis group Critically ill patients in Hartmann’s group
![Page 22: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/22.jpg)
Laparoscopic
After complicated attacks…
![Page 23: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/23.jpg)
Laparoscopic
Gaertner et al. World J Surg 2013;37:629-638
![Page 24: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/24.jpg)
Laparoscopic
Short-term outcomes [1-3] Less blood loss / postoperative ileus [1-3] Less postoperative pain [1-3] Similar complication rate [2,3] Shorter hospital stay [1-3] Improved quality of life [1-3]
1. Feingold et al. Dis Colon Rectum 2014;57:284-2942. Klarenbeek et al. Ann Surg 2009;249:39-44
3. Gervaz et al. Ann Surg 2010;252:3-8
![Page 25: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/25.jpg)
Laparoscopic
Long-term outcomes Comparable quality of life and morbidity [1-3]
Laparoscopic approach preferred when expertise available [4]
1. Klarenbeek et al. Ann Surg 2009;249:39-442. Klarenbeek et al. Surg Endosc 2011;25:1121-1126
3. Gervaz et al. Surg Endosc 2011;25:3373-33784. Feingold et al. Dis Colon Rectum 2014;57:284-294
![Page 26: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/26.jpg)
Summary Uncomplicated vs complicated Percutaneous drainage – for large abscess Peritoneal lavage?
Controversial (NOT for free perforation) Expertise in laparoscopic surgery
Anastomosis? Hartmann’s operation – gold standard Primary anastomosis with proximal diversion
in selected group Laparoscopic?
Expertise in laparoscopic surgery
![Page 27: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/27.jpg)
![Page 28: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/28.jpg)
End
![Page 29: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/29.jpg)
Age-related changes
Increased elastin deposition in taenia coli Increased type III collagen synthesis Increased collagen crosslinking
Irreversible state of contracture and reduced resistance of colonic wall
![Page 30: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/30.jpg)
Segmentation
Diverticulum
Contraction Contraction
![Page 31: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/31.jpg)
Dietary fiber deficiency
Longer transit time Increases intraluminal pressure
![Page 32: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/32.jpg)
Uncomplicated diverticulitis
Low threshold of surgery for immunocompromised [1] E.g. transplant, long-term steroid, renal failure Medical treatment more likely to fail [2] Higher mortality rate for medical treatment
alone [2] Higher risks of complicated attacks [3]
1. Feingold et al. Dis Colon Rectum 2014;57:284-2942. Hwang et al. Dis Colon Rectum 2010;53:1699-1707
3. Klarenbeek et al. Ann Surg 2010;251:670-674
![Page 33: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/33.jpg)
Percutaneous drainage
Potential benefit Reducing pain, fever, leukocytosis [1] Avoid emergency operation and stoma Facilitate elective single-stage laparoscopic
colectomy [2]
1. Beckham et al. Clin Colon Rectal Surg 2009;22:156-160
2. Dharmarajan et al. Dis Colon Rectum 2011;54:663-671
![Page 34: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/34.jpg)
Study No.
Design
Hinchey
Conversion (%)
Hospital stay (Day)
Amount of lavage (L)
Complication (%)
Readmission
Death (%)
Elective colectomy
I II IIIIV
Swank 2013
38Retro
0 533
0 3 10 4 32 3 5 0
Edeiken 2013
10 Pros 0 1 8 1 20 4 NR 40 4 0 2
Rogers 2012
427
Retro
0 0 427 NR 10 NR 14 NR 4 NR
Liang 2012
47Retro
0 0 47 2 6 NR 4 0 0 21
White 2010
35Retro
2 011
2 0 14 1 54 8 0 8
Lam 2009
9Retro
0 1 5 3 33 N/A NR N/A 3 0 3
Karoui 2009
35 Pros 0 035
0 0 8 15 28 1 0 25
Favuzza 2009
7Retro
0 1 6 0 0 7 NR NR 1 0 4
Mazza 2009
25 Pros 2 8 9 6 0 14 NR 12 NR 0 16
Lippi 2009
13 Pros 0 5 7 1 0 N/A NR N/A 3 2 0
Myers 2008
100
Pros 025
67
8 8 8 4 4 3 3 0
Bretagnol 2008
24 Pros 0 518
1 0 12 10 8 0 0 24
Franklin 2008
40Retro
0 532
3 0 8 15 20 0 0 24
Galleano 2007
4 Pros 0 2 2 0 0 10 10 0 0 0 4
Mutter 2006
10Retro
0 010
0 0 8 NR 0 1 0 6
Taylor 2006
14Retro
0 210
2 0 6 3 21 0 0 8
Da Rold 2004
7Retro
1 1 5 0 14 N/A NR 0 0 0 0
Faranda 2000
18 Pros 0 016
2 0 8 15 17 0 0 15
O’Sullivan 1996
8 Pros 0 0 8 0 0 10 NR 25 2 0 0
![Page 35: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/35.jpg)
Heterogeneity for lavage
Hinchey stages Amount of lavage Indications for lavage
Failed conservative treatment with antibiotics Failed percutaneous drainage
Treatment for failed lavage Colectomy +/- anastomosis or stoma Percutaneous drainage Medical treatment Primary repair for colonic perforation
![Page 36: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/36.jpg)
Laparoscopic surgery
Klarenbeek et al. Ann Surg 2009;249:39-44
![Page 37: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/37.jpg)
Laparoscopic surgery
1. Gervaz et al. Ann Surg 2010;252:3-82. Klarenbeek et al. Ann Surg 2009;249:39-44
Laparoscopic surgery
![Page 38: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/38.jpg)
Laparoscopic surgery
1. Gervaz et al. Ann Surg 2010;252:3-82. Klarenbeek et al. Ann Surg 2009;249:39-44
![Page 39: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/39.jpg)
Laparoscopic surgery
Scarce data on emergency setting Mainly retrospective reviews Comparable in morbidity and mortality Selection bias
1. Latarte et al. Am J Surg 2015;209:992-998
![Page 40: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/40.jpg)
Conservative for Hinchey Ib / II
1. Lamb et al. Dis Colon Rectum 2014;57:1430-1440
![Page 41: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/41.jpg)
Conservative for Hinchey Ib / II
1. Lamb et al. Dis Colon Rectum 2014;57:1430-1440
![Page 42: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/42.jpg)
Right-sided diverticulitis
More common in Asian population Often misdiagnosed as acute appendicitis More indolent compared with left-sided
disease with usually mild severity [1-4] More long-term remission and disease
control solely with medical treatment +/- drainage only [1,2]
Similar treatment algorithm as left-sided disease
1. Law et al. Int J Colorectal Dis 2001;16:280-2842. Telem et al. Gastroenterol Res Pract 2009;359485
3. Kim et al. J Korean Soc Coloproctol 2010;26:402-406
4. Tan et al. Int J Colorectal Dis 2013;28:849-854
![Page 43: Updated Management of Colonic Diverticulitis DR. TSANG YI-PO DEPARTMENT OF SURGERY PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL JOINT HOSPITAL SURGICAL GRAND](https://reader035.vdocuments.us/reader035/viewer/2022081420/5697bf7c1a28abf838c83de5/html5/thumbnails/43.jpg)
Right-sided diverticulitis
Diverticulitis found during surgery (esp during appendicectomy) without prior imaging If obviously perforated with contamination
colectomy If mild no role for colectomy [1]; proceed to
appendicectomy
1. Tan et al. Int J Colorectal Dis 2013;28:849-854