Definition(s) of Diverticular Disease

Transcription

1 Falk-Symposium 148 "Divertikelkrankheit: Neue Erkenntnisse einer Volkskrankheit" München; Juni 2005; Session II 11:15-12:20 Definition(s) of Diverticular Disease Prof. Edmund Neugebauer, Dr. J. Krahn Biochem. & Exptl. Division, Medical Faculty, University of Cologne

2 Presented by Abe Fingerhut Centre Hospitalier Intercommunal Poissy, France

3 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:

4 Diverticula Technically 'Pseudo-diverticula' as not involving all layers of colon wall (as opposed to 'true' diverticula -> all layers) Graser E. Ueber multiple falsche Darmdivertikel in der Flexura sigmoidea. Münch Med Wochenschr 1899; 22:

5 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-olds 65% in >65 year-olds In Western countries: majority in sigmoid colon In Asian populations: more frequent in caecum Jun, S. and Stollman, N. (2002) Epidemiology of diverticular disease. Best Practice & Research in Clinical Gastroenterology 16(4),

6 Terminology Diverticulosis Denotes the presence of diverticula in the colonic wall, asymptomatic Diverticular disease Diverticula have become clinically apparent with symptoms ('disease' indicating ill health) Diverticulitis Diverticula 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

7 Terminology 'Diverticular disease' not consistently defined ICD-10: Diverticular disease of intestine includes (K57) Diverticulitis Diverticulosis Diverticulum excludes congenital diverticulum of intestine diverticulum of appendix International Classification of Diseases:

8 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

9 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

10 Hinchey classification 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:

11 Hinchey Classification Localised Pericolic Abscess (Hinchey Stage I) Large Mesenteric Abscess (Hinchey Stage II) Free Perforation (Hinchey Stage III) Free Perforation Causing Fecal Peritonitis (Hinchey Stage IV)

12 Hinchey Classification Modified classification as recommended by E.A.E.S consensus conference: Stage I Stage IIA Stage IIB Stage III Stage IV Pericolic abscess Distant abscess amenable to percutaneous drainage Complex abscess associated with/without fistula Generalised purulent peritonitis Fecal peritonitis 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

13 APACHE II points 12 Physiologic parameters 0 to 4 Age > 44, > 55, > 65, > 75 2 to 6 Urgent surgery 5 Scores > 30 mortality > 70% Manheim Peritonitis Index points Age > 50 ans 5 Female gender 5 Preoperative delay >24 h 4 Generalized peritonitis 6 Exsudate: purulent - fecal 6-12 Organ failure (one or more) 7 MPI > 21: Sensitivity 0.95 ; Specificity 0.25

14 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

15 I thank you for your attention Abe Fingerhut Centre Hospitalier Intercommunal Poissy, France

16 1 Emergency: Resection or not? 2 Randomized controlled trials Colostomie Colostomy Drainage Drainage Resection Colostomy

17 Treatment of perforated sigmoid diverticulitis: : a prospective randomized trial 62 patients, 14 years, 27 surgeons, no scoring system Suture Colostomy Resection Number of patients Hartmann 19 Double stoma 12 Hinchey III ( %) 21 (0) p< (24) Hinchey IV ( %) 10 (60) p=0.6 6 (33) Reoperations resection H reversal Stoma : permanent 4 7 closure 4 Kronborg Br J Surg 1993

18 MRCT of I ary vs II ary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis 105 patients, 7 years, 34 surgeons, MPI score Suture Colostomy Resection Hartmann Number of patients Hinchey III ( %) 34 (18) 43 (21) Hinchey IV ( %) 14 (21) 12 (33) MPI > 21 ( %) 39 (31) 36 (25) p<0.001 p<0.001 Reoperations (early) 11 2 # total operations Permanent stoma 2 5 Zeitoun FASR Br J Surg 2000

19 Resection+primary anastomosis despite peritonitis? Author n n MPI Hinchey 95%CI III/IV Belmonte ? 1 - Wedell ? Schwesinger 89 6?? - Biondo ?? 0-20 Goozsen Schilling

20 Proposed RCT Resection+primary anastomosis vs Hartmann Inclusion 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

21 3 Laparoscopic management of generalized peritonitis due to perforated colonic diverticula Lavage Glue Suture Omentoplasty +/- Drainage

22 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 16 fecal 12 2 Organ failure 7 none mean MPI score 18

23 Laparoscopic management of generalized peritonitis due to perforated colonic diverticula «Don t trythisathome!». ME Arregui «The procedure of choice is immediate segmental resection with colostomy». ASCRS Selection bias for laparoscopy? n 95% Confidence Interval Krukowski Kronborg FASR O Sullivan Faranda ////////

24 The influence of Lavage on Peritonitis Platell J Am Coll Surg 2000 «Removing obvious peritoneal contamination is not under question» «There is little evidence that supports routine peritoneal lavage in the management of patients with peitonitis» «May just be a ritual»

25 Thank you for your attention Abe Fingerhut Centre Hospitalier Intercommunal Poissy, France