Evidence - Sigma resection, laparoscopic

  1. Summary of the literature

    Diverticulitis is an acute, primary inflammation of pseudodiverticula of the colon and the surrounding soft tissue structures, which can lead to severe abdominal and septic complications.

    If there is clinical suspicion of acute diverticulitis, the aim of diagnostics is to classify the disease in order to provide appropriate therapy recommendations. This is necessary because treatment options for sigmoid diverticulitis range from mere observation to immediate emergency surgery.

    The indication for surgical intervention depends on the severity of the diverticulitis, the likelihood of recurrence, the subjective impairment of the patients, as well as comorbidities and medication. The response to a conservative treatment attempt must also be considered.

    Acute Uncomplicated Diverticulitis

    In the presence of typical signs of diverticulitis, including changes in laboratory values but without evidence of complications (phlegmon, abscess, fistulas, or perforation) in imaging diagnostics, acute uncomplicated diverticulitis is present. It should be primarily treated conservatively under close clinical monitoring, as the majority of patients treated this way become symptom-free within a short time [13, 14, 29, 45], and the risk of recurrence is generally low. Therefore, there is no indication for elective interval surgery in such cases [13, 36, 43].

    If symptoms persist or the clinical picture progresses despite adequate therapy for uncomplicated diverticulitis, it is advisable to repeat the initial diagnostics, including imaging, promptly to detect undetected or newly developed complications and adjust the treatment to the recommendations for complicated diverticulitis.

    Antibiotic treatment for acute uncomplicated diverticulitis is not mandatory but is recommended according to the current S2k guideline for diverticular disease/diverticulitis [34] for patients with risk indicators for recurrences and complications:

    • arterial hypertension
    • chronic kidney disease
    • immunosuppression
    • allergic predisposition
    • collagenoses
    • vasculitides

    In this patient group, depending on the risk profile, an indication for surgery may exist even with successful conservative treatment [2, 9, 10, 19, 49], as diverticulitis after transplantation or in otherwise immunosuppressed individuals has a significantly higher mortality rate of up to 25% compared to the general population. The risk of perforation is also increased by 2.7 times [8].

    The surgical therapy for phlegmonous diverticulitis (Type 1b) is controversially discussed. Although a microperforation is assumed pathophysiologically in these cases [17], only a few patients develop a recurrence after successful conservative therapy [29]. Therefore, no general surgical recommendation can be made for this patient group. This approach is fixed in the current German guideline as well as in the Anglo-American and Dutch guidelines [5, 6, 34, 38].

    Acute uncomplicated diverticulitis without fever, leukocytosis, guarding, and bowel obstruction, as well as without evidence of perforation or complicated diverticulitis and only slightly elevated CRP, can indeed be treated on an outpatient basis. However, adequate compliance, sufficient oral fluid and food intake, and close medical monitoring are prerequisites [20, 40]. It remains critical to note that all patients included in the aforementioned studies were treated with antibiotics.

    Acute Complicated Diverticulitis

    Signs of acute complicated diverticulitis include paracolic abscess formation and free perforation. In the presence of free perforation with the clinical picture of an acute abdomen, it is an emergency situation requiring immediate surgery [28, 29, 34, 47].

    Even if a perforation is excluded and clinically there is no acute abdomen, patients with complicated diverticulitis should be treated as inpatients, with the therapy initially being conservative as in the uncomplicated form [6, 11]. If the desired clinical success is not achieved within 72 hours, this indicates the persistence of the inflammatory focus, and the indication for sigmoid resection with deferred urgency must be discussed (interval surgery early-elective – within 48 hours [34]).

    Paracolic Abscesses, Fistulas, Stenoses

    Around 15% of patients with acute complicated diverticulitis show paracolic abscess formation in imaging [20]. For abscesses > 5 cm, percutaneous interventional drainage plus antibiotic therapy can be performed to avoid emergency surgery [12, 17, 44].

    Regarding whether elective interval surgery is justified after successful conservative therapy of acute complicated diverticulitis, the data is incomplete. However, histopathological examinations show that persistent structural changes are to be expected after paracolic abscesses [26]. Furthermore, nearly 50% of those affected develop secondary complications and about 40% recurrences [3, 4]. Risk factors for these sequelae after paracolic abscesses include [24]

    • positive family history of diverticulitis
    • length of the affected bowel segment > 5 cm
    • presence of a retroperitoneal abscess

    In these constellations, elective interval surgery should be considered.

    If fistulas or clinically relevant colonic stenoses develop after successful conservative therapy, elective interval surgery is also an option. In particular, fistulas to the urogenital tract pose a significant risk due to the danger of urosepsis and should be addressed electively [21, 46].

    Chronic Recurrent Diverticulitis

    The recommendation for elective sigmoid resection in chronic recurrent diverticulitis was made in past decades depending on the number of disease episodes experienced: resection after the second episode [33]. This recommendation comes from T. G. Parks in 1969 [37]. He mistakenly assumed an increasing risk of complications and a decreasing success of conservative therapy after the second episode. Parks considered over 40-year-old data on the spontaneous course of diverticulitis under the clinical conditions of that time.

    Current data show that with increasing frequency of disease episodes, an increase in septic complications is not to be expected [34]. Perforations requiring emergency intervention also occur predominantly as a primary event of diverticulitis or after the first episode. A prophylactic operation after the second episode, as was common until a few years ago, is therefore no longer justified.

    The indication for surgery in chronic recurrent diverticulitis should be made individually, taking into account

    • symptomatology
    • risk factors
    • age
    • severity of the disease
    • life circumstances and comorbidities

    [32, 34].

    The main goal of surgery in chronic recurrent diverticulitis is to eliminate disease-related symptoms. Therefore, benefits and risks must be carefully weighed, and the surgical goals clearly defined, as neither septic complications, emergency interventions, or colostomies can be avoided, nor can morbidity or mortality be reduced by the intervention.

    Diverticular Bleeding

    In the management of gastrointestinal bleeding, the possibilities of endoscopic diagnostics and therapy are initially exhausted [1, 16, 27, 30, 35]. Emergency endoscopy is the first-choice measure [23].

    In the case of repeated or persistent bleeding without an endoscopically clearly identifiable source, angiography (possibly also CT angiography) should be performed for localization diagnostics at the time of suspected active bleeding.

    The indication for surgery arises in the case of persistent bleeding that cannot be controlled endoscopically or interventionally. The urgency is determined by the circulatory situation, the intensity of the bleeding, and the pre-existing risk profile.

    It is essential to strive for localization of the bleeding to proceed surgically in a targeted manner. If localization of the bleeding source is not successful, it cannot be assumed that the bleeding originates from the sigmoid. In these very rare cases of non-localizable bleeding, a subtotal colectomy with ileorectostomy must be discussed. "Blind" colon segment resections have a high risk of persistent or recurrent bleeding and should not be performed [42]. In cases of uncertain localization, subtotal colon resection is the procedure of choice [15].

    Recurrent, clinically relevant diverticular bleeding (e.g., Hb drop >2 g/dl, shock) without the option of conservative risk reduction for another recurrence should be operated on early electively after individual benefit-risk assessment [34].

    Patients with self-limiting or interventionally successfully treated previous diverticular bleeding should not be operated on [34].

    Timing of Surgery

    The American Society of Colon and Rectal Surgeons recommends elective resection 6 – 8 weeks after the onset of symptoms [38]. The Danish and Dutch guidelines do not specify the optimal timing of surgery [5, 6]. Resections in the inflammation-free interval after 6 – 8 weeks show lower rates of anastomotic insufficiencies, wound healing disorders, and conversions to open procedures than so-called "early-elective" operations [39].

    Technical Aspects of Sigmoid Resection

    The goal of elective surgery for sigmoid diverticulitis is the complete removal of the entire sigmoid colon and the creation of a tension-free anastomosis in the upper rectum.

    There is no correlation between the number of residual diverticula in the remaining colon and the risk of a diverticulitis recurrence, so an extension of the resection is not indicated [48]. The location of the distal resection plane has a decisive influence on the recurrence rate: If the resection plane is in the distal rectum, the risk of recurrence can be significantly reduced [7].

    The mobilization of the left colonic flexure is not mandatory if the descending colon is of sufficient length. To minimize the risk of anastomotic insufficiencies and sexual dysfunctions, some authors favor preserving the inferior mesenteric artery [25].

    Laparoscopic or laparoscopic-assisted surgery is preferred over open resection unless there are compelling reasons against it (e.g., patient preference, lack of surgeon expertise) [2]. This also applies to complicated and recurrent sigmoid diverticulitis [25].

    In direct comparison with open sigmoid resection in the postoperative short-term course, laparoscopic sigmoid resection is associated with less blood loss, faster recovery, shorter hospital stay, quicker return of bowel motility, overall lower morbidity, and lower total costs [18, 22]. However, in terms of quality of life and complications 6 months after surgery, the laparoscopic procedure is not superior [31].

  2. Current studies on this topic

  3. Literature on this topic

    1: Adams JB, Margolin DA. Management of diverticular hemorrhage. Clin Colon Rectal Surg. 2009 Aug;22(3):181-5.

    2: Al-Khamis A, Abou Khalil J, Demian M, Morin N, Vasilevsky CA, Gordon PH, Boutros M. Sigmoid Colectomy for Acute Diverticulitis in Immunosuppressed vs Immunocompetent Patients: Outcomes From the ACS-NSQIP Database. Dis Colon Rectum. 2016 Feb;59(2):101-9.

    3: Ambrosetti P. Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg. 2008 Aug;12(8):1318-20.

    4: Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum. 2005 Apr;48(4):787-91.

    5: Andersen JC, Bundgaard L, Elbrond H, Laurberg S, Walker LR. Danish Surgical Society. Danish national guidelines for treatment of diverticular disease. Dan Med J. 2012 May;59(5):C4453.

    6: Andeweg CS, Mulder IM, Felt-Bersma RJ, Verbon A, van der Wilt GJ, van Goor H, Lange JF, Stoker J, Boermeester MA, Bleichrodt RP; Netherlands Society of Surgery.; Working group from Netherlands Societies of Internal Medicine, Gastroenterologists, Radiology, Health Technology Assessment and Dieticians. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg. 2013;30(4-6):278-92.

    7: Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg. 1986 Feb;151(2):269-71.

    8: Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis. 2012 Jan;14(1):e1-e11.

    9: Biondo S. Age and immunocompromised status in acute diverticulitis. Colorectal Dis. 2012 Dec;14(12):1553-4; author reply 1554-5.

    10: Biondo S, Borao JL, Kreisler E, Golda T, Millan M, Frago R, Fraccalvieri D, Guardiola J, Jaurrieta E. Recurrence and virulence of colonic diverticulitis in immunocompromised patients. Am J Surg. 2012 Aug;204(2):172-9.

    11: Boostrom SY, Wolff BG, Cima RR, Merchea A, Dozois EJ, Larson DW. Uncomplicated diverticulitis, more complicated than we thought. J Gastrointest Surg. 2012 Sep;16(9):1744-9.

    12: Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA. Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum. 2006 Oct;49(10):1533-8.

    13: Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C. Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum. 2002 Jul;45(7):962-6.

    14: Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg. 2008 Nov;32(11):2429-33.

    15: Czymek R, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg. 2008 Dec;12(12):2212-20.

    16: Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA, Qureshi W, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO; Standards of Practice Committee.. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc. 2005 Nov;62(5):656-60. 17: Durmishi Y, Gervaz P, Brandt D, Bucher P, Platon A, Morel P, Poletti PA. Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan. Surg Endosc. 2006 Jul;20(7):1129-33.

    18: Dwivedi A, Chahin F, Agrawal S, Chau WY, Tootla A, Tootla F, Silva YJ. Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease. Dis Colon Rectum. 2002 Oct;45(10):1309-14; discussion 1314-5.

    19: Floch CL; NDSG.. Emergent and elective surgery for diverticulitis. J Clin Gastroenterol. 2008 Nov-Dec;42(10):1152-3.

    20: Friend K, Mills AM. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann Emerg Med. 2011 Jun;57(6):600-2.

    21: Garcea G, Majid I, Sutton CD, Pattenden CJ, Thomas WM. Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases. Colorectal Dis. 2006 May;8(4):347-52.

    22: Gonzalez R, Smith CD, Mattar SG, Venkatesh KR, Mason E, Duncan T, Wilson R, Miller J, Ramshaw BJ. Laparoscopic vs open resection for the treatment of diverticular disease. Surg Endosc. 2004 Feb;18(2):276-80.

    23: Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, Leung J, Jowell P. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005 Nov;100(11):2395-402.

    24: Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011 Mar;54(3):283-8.

    25: Holmer C, Kreis ME. Diverticular disease – choice of surgical procedure. Chirurg. 2014 Apr;85(4):308-13.

    26: Holmer C, Lehmann KS, Engelmann S, Frericks B, Loddenkemper C, Buhr HJ, Ritz JP. Microscopic findings in sigmoid diverticulitis–changes after conservative therapy. J Gastrointest Surg. 2010 May;14(5):812-7.

    27: Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000 Jan 13;342(2):78-82.

    28: Jurowich CF, Jellouschek S, Adamus R, Loose R, Kaiser A, Isbert C, Germer CT, von Rahden BH. How complicated is complicated diverticulitis?–phlegmonous diverticulitis revisited. Int J Colorectal Dis. 2011 Dec;26(12):1609-17.

    29: Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW Jr. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005 Apr;100(4):910-7.

    30: Kaltenbach T, Watson R, Shah J, Friedland S, Sato T, Shergill A, McQuaid K, Soetikno R. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol. 2012 Feb;10(2):131-7.

    31: Klarenbeek BR, Bergamaschi R, Veenhof AA, van der Peet DL, van den Broek WT, de Lange ES, Bemelman WA, Heres P, Lacy AM, Cuesta MA. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc. 2011 Apr;25(4):1121-6.

    32: Kruis W, Germer CT, Leifeld L; German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion. 2014;90(3):190-207.

    33: 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 Apr;13(4):430-6.

    34: Leifeld L, Germer CT, Böhm S, Dumoulin FL, Häuser W, Kreis M, Labenz J, Lembcke B, Post S, Reinshagen M, Ritz JP, Sauerbruch T, Wedel T, von Rahden B, Kruis W. S2k guidelines diverticular disease/diverticulitis. Z Gastroenterol. 2014 Jul;52(7):663-710.

    35: Lewis M; NDSG.. Bleeding colonic diverticula. J Clin Gastroenterol. 2008 Nov-Dec;42(10):1156-8.

    36: Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005 Jun;17(6):649-54.

    37: Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J. 1969 Dec 13;4(5684):639-42.

    38: Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal Surgeons.. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44.

    39: Reissfelder C, Buhr HJ, Ritz JP. What is the optimal time of surgical intervention after an acute attack of sigmoid diverticulitis: early or late elective laparoscopic resection? Dis Colon Rectum. 2006 Dec;49(12):1842-8.

    40: Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, O’Mahony JB, Mealy K. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis. 2009 Nov;11(9):941-6.

    41: Ritz JP, Lehmann KS, Frericks B, Stroux A, Buhr HJ, Holmer C. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery. 2011 May;149(5):606-13.

    42: Schuetz A, Jauch KW. Lower gastrointestinal bleeding: therapeutic strategies, surgical techniques and results. Langenbecks Arch Surg. 2001 Feb;386(1):17-25.

    43: Shaikh S, Krukowski ZH. Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg. 2007 Jul;94(7):876-9.

    44: Siewert B, Tye G, Kruskal J, Sosna J, Opelka F, Raptopoulos V, Goldberg SN. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol. 2006 Mar;186(3):680-6. Erratum in: AJR Am J Roentgenol. 2007 Sep;189(3):512. Raptopoulos, Vassilios [added]; Goldberg, S Nahum [added].

    45: Simianu VV, Strate LL, Billingham RP, Fichera A, Steele SR, Thirlby RC, Flum DR. The Impact of Elective Colon Resection on Rates of Emergency Surgery for Diverticulitis. Ann Surg. 2016 Jan;263(1):123-9.

    46: Solkar MH, Forshaw MJ, Sankararajah D, Stewart M, Parker MC. Colovesical fistula–is a surgical approach always justified? Colorectal Dis. 2005 Sep;7(5):467-71.

    47: von Rahden BH, Germer CT. Pathogenesis of colonic diverticular disease. Langenbecks Arch Surg. 2012 Oct;397(7):1025-33.

    48: Wolff BG, Ready RL, MacCarty RL, Dozois RR, Beart RW Jr. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis Colon Rectum. 1984 Oct;27(10):645-7.

    49: Yoo PS, Garg R, Salamone LF, Floch MH, Rosenthal R, Longo WE. Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg. 2008 Nov;196(5):710-4.

Reviews

Ahmed AM, Moahammed AT, Mattar OM, Mohamed EM, Faraag EA, AlSafadi AM, Hirayama K, Huy NT. Surgical

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