Abstract
Introduction: For "acute complicated diverticulitis" means the presence of complications related to the evolution of the acute inflammatory process.
Objectives of the Study: To identify which surgical technique will achieve the best results; verify the feasibility and applicability of non-resective surgical techniques.
Materials and Methods: This retrospective observational study was developed from
January 1st. 2000 to April 30 th. 2013. The Observation Period has been divided into two: First Period (1st Jan 2000 – 31st Dec 2009) and Second Period (1st Jan 2010 – 30th Apr 2013). For each of the two periods, the sample was divided into two groups: Group A (Patients undergoing a NOT resection treatment,NRT) and Group B (Patients who underwent surgical RESECTION, RT). The Surgical Outcomes used for statistical comparisons between the different groups were: post-operative morbidity, surgical site infections, Re-interventions, Mortality and average Hospitalization.
Results: 78 patients were enrolled in the study, 55 patients in the First Period and 23 patients in the Secondo Period. In the First Period, diverticular peritonitis was characterized by a high rate of mortality, 9 patients died. In the Second Period the 87.5% of patients in Group A presented a score of Hinchey III compard with 20% of patients in group B.
Conclusion: Certainly, further prospective, randomized studies on a larger scale, will need to check what are the short-and long-term results by one surgical technique over any other. Meanwhile the experience and skill of the surgeon associated with post-operative intensive care remain the key variables that improve the prognosis of these patients
Introduction
In industrialized Western Society diverticular disease of the colon is very common, this comprises in the United Statesalone approximately 130,000 hospital admissions per year [1].
Equally distributed between both sexes, the prevalence increases with age involving 50 to 70% of subjects over the age 80 [2,3].
The sites most involved are the sigma in isolation (in 65% of cases) and in association with other areas (in 30% of cases), only in 5-7% of cases is the sigma not involved; the caecum (up to 7% of cases in various statistics), rectum and appendix are all very rarely involved.
Whether the terms "diverticulosis" or "diverticular disease" are used to describe the presence of diverticula without signs of inflammation.(is of secondary importance). For "diverticulitis" means, however, the inflammation of one or more diverticulae generally associated with "micro" or "macro" perforations of the bowel [4]. Let's talk about "acute complicated diverticulitis" in the presence of complications related to the evolution of the acute inflammatory process, or in the presence of a paracolic abscess or diffuse peritonitis due to perforation. In fact, the severity of the inflammation is related to the extent of bacterial contamination: if this is modest , the phenomenon is limited to peri-diverticular level correlated to the local defense mechanisms and thus tends to resolve itself spontaneously, instead if the contamination is extensive purulent collections are formed.
The choice of the surgical techniques is based on the clinical condition of the patient, the severity of the peritonitis and septic area around it, as well as on the experience of the surgeon [5,6].
We divide the surgical procedures into two broad categories: Treatment NOT resection (laparoscopic or open surgery, NRT) and resection treatment (RT), which provides the technique of resection and primary anastomosis (PRA) as opposed to the traditional procedure of resection according to Hartmann.
Methods
Rationale of Work:
Our work aims to compare the clinical experience of a UniversityCenterwith a high level of specialization in Emergency Surgery regarding this disease of current interest and evolving as the "acute, complicated, diverticulitis."
In our clinic we have witnessed an evolution in the surgical treatment and surgical techniques that succeeded each other and were characterized by a progressive development of laparoscopic techniques and a minimally invasive approach to the genesis of diverticular peritonitis.
If one the one side (First Period), there is a tendency to treat in a single time the acute phase and the underlying pathology by resective and reconstructive treatment simultaneously, on the other (Second Period) the introduction of a laparoscopy using minimally invasive techniques have led us to develop less aggressive approaches aimed at solving the acute phase of the disease, with the aim of postponing the resection, if possible, to in a single planned intervention.
Objectives of the Study
The aim of our research is to identify, through critical evaluation of the retrospective cases of 78 patients, which surgical technique is the best and will achieve the best results of post-operative morbidity and mortality in the treatment of acute complicated diverticulitis. .
Our second objective is to verify the feasibility and applicability of non-resective surgical techniques, minimally invasive in patients with acute complicated diverticulitis, and subsequently to compare any statistically significant differences regarding the morbidity and postoperative mortality after surgical resection (RT) and non resection (NRT) in the acute phase.
Third fundamental objective of this study is to identify, depending on the results and as reported in the literature up to now, what treatment is "ideal" to be given to the patient with acute complicated diverticulitis depending not only on the degree of peritoneal contamination (such as previously believed), but taking into account also the general conditions of the patient, his hemodynamic condition, as well as functional reserves and other pathologies present at the time of admission.
Materials and Methods
This retrospective observational study was developed in the period between January 1st. 2000 and April 30 th. 2013. During that time all patients operated on in an emergency for acute complicated diverticulitis were examined.
78 patients were enrolled in the study who were undergoing surgery for acute complicated diverticulitis on basic perforation (peritonitis in diverticular genesis).
The Observation Period has been divided into two.
First Period, lasting 10 years, from January 1, 2000 December 31, 2009, characterized by the alternation of different surgical teams with "mixed" laparoscopic and open surgical experience.
Second Period, which lasts 3 years and 4 months, from 1 st. January 2010 to 30 th. April 2013, characterized by a uniform surgical team with a laparoscopic vocation.
It was considered necessary to split the firm in two time intervals, mainly due to two factors.
The first factor is the substantial heterogeneity that characterizes the different surgical schools of thought that have passed through our clinic from 2000 to2009, inturn composed by teams operating in vocationally mixed-laparoscopy or laparotomy. In the first period urgent surgical indications for patients with diverticular peritonitis genesis were affected by the different experiences and the different surgical methods adopted. Conversely, the Second Period is characterized by a greater homogeneity of the operating team, belonging to the same Surgical School and operating under the same direction, with high specialization in laparoscopy and therefore devoted to a greater laparoscopic approach (where possible) than in the past (second factor).
For we must consider that the introduction of laparoscopy has taken place progressively in the 13 years covered by the study, during which surgeons have followed a new learning curve in colonic - rectal laparoscopy
For each of the two periods of observation, the sample was divided into two main groups:
Group A: Patients undergoing a routine type of treatment, ie washing and drainage, NOT RESECTION, (NRT); Group B: Patients who underwent surgical RESECTION (RT).
In the analysis of clinical cases the personal data of the patients (age and sex), the ASA score, the Hinchey classification, the value of PSS (Peritonitis Severity Score) were extracted. Operating data, type of surgery: (surgical treatment resection, primary anastomosis, adjustment according to Hartmann,) and surgical approach (laparotomy, laparoscopy,possibile laparotomic conversion) have been considered. The postoperative period was processed and data on postoperative complications compiled: including the following: infection or respiratory failure, heart failure, IMA, IRA, gastrointestinal bleeding, septic shock, MOF, post-operative ileus (medical complications), intra-abdominal abscess,surgical wound infection, entero-cutaneous fistula (surgical complications). Finally the performance listing such procedures as the surgical anastomosis dehiscence (when performed), the re-operations, deaths and the average length of hospital stay were evaluated.
The Surgical Outcomes used for statistical comparisons between the different groups of patients were identified in the following variables: the post-operative morbidity, the surgical site infections, the Re-interventions, Mortality and average Hospitalization.
Criteria for inclusion and exclusion
The following were eligible for the study: Patients suffering from acute complicated diverticulitis, sexes on the basis of perforation (peritonitis, diverticular abscesses that can not be treated conservatively). Patients selected were subjected to surgery or conservative (NRT) or resection (RT), with video laparoscopic or open techniques.
Those patients were excluded who: underwent surgery for gastrointestinal bleeding from diverticulum, for fistulous disease (of any kind), and patients detected with definitive neoplasm by histopathological examination.
Patients suffering from diverticulosis of the colon underwent surgery in the regime of choice.
Patients undergoing surgery for chronic diverticulitis without clinical signs and symptoms of acute illness in place.
Patients suffering from diverticular stricture due to previous episodes of diverticulitis.
Statistical Considerations
Descriptive analyzes were performed on the results collated in the database and simple comparisons made between the non dichotomous values, by performing non-parametric, statistical tests ( Fisher's exact test, Chi-square test, Mann-Whitney U Test). The software used for these analyzes was OpenStat ®. Values were considered statistically significant for p <0.05.
Results
The first period (see Table 1)
In the initial Observation Period from January 1 st. 2000 -December 31st. 2009.
55 patients underwent surgery for the diagnosis of acute complicated diverticulitis in the Division of General Surgery. Of these, 17 patients (30.9%) belong to Group A and 38 patients (69.1%) in Group B.
The average age in the overall sample is 66.3 years; range: 20-92; standard deviation: 15.7. In Group A the average age is 67.1 years, standard deviation 15.2. In Group B, the average age is 64.8 years, standard deviation: 17.2. Applying the Mann-Whintey U test for age, compared between the two groups, there is no significant, statistical difference (p-value = 0.622).
The ASA score average of 2.6 (standard deviation 0.83) of the total number of patients, the value was 2.3 (standard deviation 0.92) in Group A (NRT), 2.8 (standard deviation 0.75).in Group B (RT). From the statistical comparison, performed with Mann-Whintey U Test, between the two groups no statistically significant differences with regard to the value of average ASA score (p-value = 0.051) became apparent.
Of the overall sample, the value of the PSS is 8.38, standard deviation: 2.0. In Group A it is 7.8, standard deviation: 2.0. In Group B it is 8.6, standard deviation: 2.0. Applying the Mann-Whintey U Test for the PSS when comparing the two groups, there is no significant, statistical, difference (p-value = 0.171).
The Hinchey average score of 2.5 (SD 1.1) of the total number of patients, the value is 2.4 (SD 0.87) in Group A (NRT), 2.6 (SD 1.1) in Group B (RT). From the statistical comparison, performed with Mann-Whintey U Test, between the two groups there is no significant, statistical, difference (p-value = 1,000).
As regards the operative technique, in particular, in Group B (RT) no intervention was approached using the laparoscopic technique. Of the 13 laparoscopic interventions (Group A, NRT), in 2 cases it was converted to a laparotomy. As a result, in the First Period, surgery for diverticular peritonitis, conducted entirely in laparoscopic techniques were 11 out of 55, all belonging to Group A (Treatment NOT resection).
Patients who presented postoperative complications were 31 (56.4%) of the total sample, 5 (29.4%) in Group A and 26 (68.4%) in Group B. When applying the Fisher's exact test we obtained a statistically significant difference (p-value = 0.0007).
Total sample on the average length of stay is 14.8 days, standard deviation: 9.7. In Group A it is 11 days; standard deviation: 4.3. In Group B is 16.6, standard deviation: 11. Applying the Mann-Whintey U Test for the average length of hospital stay when comparing the two groups, there is a statistically, significant difference (p-value = 0.049).
Second period (see Table 2)
In the Second Observation Period from 1st. January 2010 to 30 th. April 2013, 23 patients underwent surgery for the diagnosis of acute complicated diverticulitis. Of these, 8 patients (34.8%) belong to group A and 15 patients (65.2%) to Group B. The total sample of the average age was 62.4 years, range: 30-87; standard deviation: 14.81. In Group A the average age was 54.9 years, range: 30-78; standard deviation: 16.77. In Group B, the average age was 66.4 years, range: 49-87; standard deviation: 12.43. When applying the Mann-Whintey U test for age comparison between the two groups, there is no statistically significant difference (p-value = 0.0533). The ASA score average of 2.78 (standard deviation 1.04) of the total number of patients, the value is 2.63 (standard deviation 1.06)
In Group A (NRT), 2.87 (standard deviation 1, 06)
in Group B (RT). From the statistical comparison, performed with Mann-Whintey U Test, between the two groups, no statistically, significant differences were revealed as regards to the value of average ASA score (p-value = 0.2916).
Total sample of the value of the PSS is 8.74, standard deviation: 2.34.
In Group A is 8.63, standard deviation: 2.13.
In Group B it is 8.8, standard deviation: 2.51. Applying the Mann-Whintey U Test for the PSS comparing the two groups, there is a statistically significant difference (p-value = 0.4614).
The Hinchey average score is 2.7 (standard deviation 0.88) in the total sample, the value is 2.88 (standard deviation 0.35) in Group A (NRT) and 2.6 (standard deviation 1, 06). in Group B (RT).From the statistical comparison, performed with Mann-Whintey U Test, there are no statistically, significant differences between the two groups.(p-value = 0.2289).
As regards the operative technique, in 5 cases out of a total of 23 patients opted for a laparotomy, while in 18 cases out of 23, the initial approach was of the laparoscopic approach. Of the 18 interventions initiated in videolaparoscopy, in 4 cases it was necessary to convert to laparotomy. The 4 conversions to a laparotomy occurred in Group B (RT). The conversion rate was thus 40.0% (p-value = 0.0425) .
Patients who presented postoperative complications were 8 (34.8%) of the total sample, 2 (25.0%) in Group A, and 6 (40.0%) in Group B. Applying the Fisher's exact test we did not get a statistically significant difference (p-value = 0.8819).
Total sample of the average length of hospital stay was of 19.61 days, SD: 17.72.
In Group A it was 10.38 days; standard deviation: 5.32.
In Group B it was 24.53, SD: 20.11. Applying the Mann-Whintey U Test for the average length of hospital stay comparing the two groups, there is a statistically, significant difference (p-value = 0.0284).
Discussion
First Period (See Table 3)
In the First Period, diverticular peritonitis was characterized by a high rate of mortality, 9 patients died (16.4% of the total, ie 1 patient in every 6 operated on, died): this figure is in line with the results of further case studies reported in medical literature. An analysis of mortality in the two study groups, we recorded 8 deaths under Group B and 1 death belonging to Group A, so there was a clear predominance in Group B (Treatment resection).
Total sample on the average length of stay is approximately 15 days (14.8 days). In Group A the average hospital stay was less, that is to say,11 days compared to about 17 days in Group B. This difference, which is statistically significant, is explained by the fact that the patients of Group A underwent a resection which led to a more rapid recovery, due to the less invasive techniques adopted and the lower peritoneal contamination detected intraoperatively.
The statistical analysis of surgical outcomes took into account the post-operative morbidity, surgical site infections, the necessity to re-operate, deaths and hospital stay. The statistical significance was only reached for the data of the average hospital stay and post-operative morbidity that was lower in Group A, in which we recorded fewer post-operative complications compared to Group B.
Second period (See Table 4)
In the second observation period, we have witnessed an evolution in surgical indications and operative techniques, as the Patients with Hinchey score III, or suffering from diverticular suppurative peritonitis, received predominantly a treatment type not resection and, in fact, the ' 87.5% of patients in Group A presented a score of Hinchey III compard with 20% of patients in group B.
The indication to not resective treatment in patients with Hinchey III was probably preferred so as to avoid the Hartmann procedure where there was a peritoneal contamination of a fecal type, thus trying to treat of emergency peritonitis with laparoscopic washing and drainage. In order to differ the elective regime resection and anastomosis in a single time.
In 23 patients of the total sample, 9 patients were treated with laparotomic surgery and 14 patients with laparoscopic surgery, reporting a conversion rate of 22.2%. For the Group A (not resective treatment) the approach has always been laparoscopic, ie the intervention of washing and drainage was conducted entirely in laparoscopy and there were neither conversions in to laparotomy nor, obviously, laparotomic interventions.
As for Group B (resective treatment), in the Second Period 9 of 15 patients were treated with laparotomy and 6 patients out of 15 with laparoscopy, so there is a prevalence of the laparotomy approach in 60% of cases, compared to 40 % of cases where laparoscopic resection was used.It 'is significant, therefore,to report the net increase in laparoscopic resective treatment, among which are included those patients treated with Hartmann's procedure.
Conclusion(s)
Despite the many advances in the field of antibiotic therapy and post-operative intensive care, diverticular peritonitis continues to be an acute pathology burdened by a high rate of morbidity and mortality, thus optimizing its treatment continues to be the subject of numerous studies .
Currently the debate within the scientific community sees opposing surgical camps: that of the resective treatment of perforated colonic segment with an increasing tendency to perform primary anastomosis (with or without protective stoma), which is opposed to the conservative technique, used most frequently by means of mini-invasive techniques, in particular washing and drainage of the peritoneal cavity for laparoscopic surgery.
Supporters of resective treatment (RT) emphasize the need to remove the perforated segment of colon, considering its septic source (source control), with the ability to restore the intestinal transit by primary anastomosis (PRA), with a rate of post-operative morbidity and mortality, less than that observed after HP [5,7].
The peritoneal lavage by laparoscopy is a viable alternative in the management of purulent peritonitis caused by widespread perforated diverticulitis. Laparoscopy allows, in particular, to avoid the morbidity related to the presence of the HP terminal colostomy or ostomy protection, reducing a large rate of infection in the surgical wound and the appearance of incisional hernias.
Ultimately, in agreement with the recent international literature and according to the evidence resulting from the Second Period of our research, we can draw the following conclusions:
1. The primary anastomosis procedure using a single step (PRA) can be performed safely on patients with peritonitis circumscribed (Hinchey Stage II) or in the case of diffuse purulent peritonitis (Hinchey III), in the presence of favorable criteria for the evaluation of comorbidity , good general condition and stable hemodynamic conditions.
2. The Hartmann's procedure (HP) remains the treatment of choice in patients with severe peritonitis (peritonitis stercoracea, Hinchey stage IV) or diffuse purulent peritonitis (Hinchey III), in cases of severe sepsis, septic shock with MOF, poor functional reserves, immunosuppression and unstable hemodynamic conditions.
3. Treatment not resection (NRT, washing and laparoscopic drainage) should be considered in patients with a low degree of peritoneal contamination or an abscess if it is impossible to proceed through a percutaneous drainage. This type of treatment is, moreover, also, a viable alternative in the management of acute perforated diverticulitis with diffuse suppurative peritonitis (Hinchey Stage III), however, this method should be considered only in selected patients (younger and in good condition) and hemodynamically stable.
4. The use of laparoscopy is the only real novelty in the Surgical Treatment of peritonitis in diverticular genesis, however this technique should be used only in selected cases and it’s indications for use arise from multicenter studies, taking into account the experience of the surgeon and technologies available.
Certainly, further prospective, randomized studies on a larger scale, will need to check what are the short-and long-term achievable results by one surgical technique over any other. Meanwhile the experience and skill of the surgeon associated with post-operative intensive care remain the key variables that improve the prognosis of these patients.
Abbreviation(s)
PRA: Primary Anastomosis
HP; Hartmann Procedure
NRT: Not Resective Treatment
RT: Resective Treatment
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Source(s) of Funding
No funding for the research conducted in this article
Competing Interests
Authors declaire they have no conflict of interest
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