Laparoscopic Resection of Chronic Sigmoid Diverticulitis with Fistula.

2013·0.07 MB·English

by  Abbass, Mohammad A.

S P
CIENTIFIC APER
Laparoscopic Resection of Chronic Sigmoid
Diverticulitis with Fistula
Mohammad A. Abbass, MD, Anna T. Tsay, NP, Maher A. Abbas, MD
ABSTRACT Key Words: Laparoscopic resection, Sigmoid diverticuli-
tis, Colonic fistula.
Background and Objectives: A growing number of op-
erations for sigmoid diverticulitis are being done laparo-
scopically. There is a paucity of data on the outcome of
laparoscopy for sigmoid diverticulitis complicated by co-
lonic fistula. The aim of this study was to compare the INTRODUCTION
results of laparoscopic resection of sigmoid diverticulitis
The incidence of diverticulitis is rising in the United
with and without colonic fistula.
States.1,2 Operative intervention is warranted in patients
Methods: A retrospective review was conducted of all who present with acute perforation with peritonitis or
patients who underwent laparoscopic resection of sig- recurrent disease with multiple episodes, or in patients
moid diverticulitis complicated by fistula at a single ter- with complicated diverticulitis.3–5 Colonic fistula is a rare
tiarycareinstitutionovera7-yearperiod.Comparisonwas complication of chronic diverticulitis with a reported in-
made with a group of patients who underwent resection cidenceof6%to16%ofsurgicallytreatedpatients.4–8The
for diverticulitis without fistula during the same study symptoms of diverticular fistulas can vary depending on
period. whether the fistula is colovesical, colovaginal, colocuta-
neous, or a combination of two or more types.
Results: Forty-two patients were analyzed (group 1: di-
verticularfistula,group2:nofistula).Themedianagewas Most patients with colonic fistula from diverticulitis re-
similar (49 vs. 50 years, P (cid:1) .68). A chronic abscess was quire operative intervention for resolution of their symp-
presentin24%ofpatientsingroup1and10%ingroup2 toms. Various surgeries are available to treat this condi-
(P (cid:1) .40). Fistula types were colovesical (71%), colovagi- tion, including single-stage procedures such as resection
nal (19%), and colocutaneous (10%). Operation types with primary anastomosis or end colostomy versus two-
weresigmoidectomy(57%vs.81%)andanteriorresection stage procedures such as resection and temporary stoma
(43% vs. 19%) in groups 1 and 2, respectively (P (cid:1) .18). ordivertingcolostomywithsubsequentresection.Several
Ureteral catheters were used more frequently in group 1 studies have reported the technical feasibility and short-
(67% vs. 33% [P (cid:1) .06]). No difference was noted in term recovery benefits of laparoscopic resection for sig-
operativetime,bloodloss,conversionrate,lengthofstay, moid diverticulitis.9–14 Although a laparoscopic approach
overall complications, wound infection rate, readmission can offer several advantages compared with the open
rate, reoperation rate, and mortality. All patients healed technique, it can be technically challenging, especially in
without fistula recurrence. the setting of extensive inflammation, chronic abscess,
disease extending down into the pelvis or engulfing the
Conclusions:Patientswithsigmoiddiverticulitiswithfis-
ureters, and prior pelvic surgery such as hysterectomy.
tula can be successfully treated with laparoscopic exci-
Because of such factors, some surgeons advocate ap-
sion, with similar outcomes for patients without fistula.
proaching complicated cases, including those associated
with a colonic fistula, with the open technique.15 The
DepartmentofSurgery,KaiserPermanente,LosAngeles,CA,USA(Drs.Abbass, purpose of this study was to compare the outcome of
Tsay). laparoscopic resection in patients with chronic sigmoid
MinimallyInvasiveandRoboticSurgery,KaiserPermanente,LosAngeles,CA(Dr. diverticulitis with and without colonic fistula.
Abbas).
Addresscorrespondenceto:MaherA.Abbas,MD,Chair,MinimallyInvasiveand
Robotic Surgery, 4760 Sunset Boulevard, Third Floor, Los Angeles, CA 90027. PATIENTS AND METHODS
Telephone:[phone],Fax:[phone],E-mail:[email protected]
Thestudywasapprovedbytheinstitutionalreviewboard
DOI:10.4293/108680813X13693422520512
ofKaiserPermanenteSouthernCalifornia.Aretrospective
©2013byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. review was conducted of all consecutive patients who
636 JSLS(2013)17:636–640
underwent laparoscopic excision for chronic sigmoid di- laparoscopicresectionduringthesameperiodforchronic
verticulitis with fistula over a 7-year period (2006–2012). diverticulitis without fistula (group 2). Table 1 summa-
Thispatientcohort(group1)wasmatchedwithagroupof rizesthecharacteristicsofbothgroups.Nodifferencewas
consecutive patients who underwent laparoscopic resec- noted in median age, gender distributions, body mass
tion for chronic sigmoid diverticulitis without fistula dur- index, and American Society of Anesthesiologists class
ing the same study period (group 2). All operations were betweenthegroups.Achronicpelvicabscesswaspresent
performed at Kaiser Permanente, Los Angeles Medical in24%ofpatientsingroup1andin10%ingroup2(P(cid:1)
Center, a regional center that receives referrals from 13 .40). Fifty-two percent of patients in group 1 had prior
hospitals that serve a population of approximately 3.4 abdominopelvic operations compared with 38% in group
million patients in southern California. The operations 2 (P (cid:1) .53). Nineteen percent of patients in both groups
were conducted electively by one colorectal surgeon were malnourished. Most fistulas in group 1 were
trainedinminimallyinvasivesurgeryandwhosestandard colovesical (71%), followed by colovaginal (19%), and
practice was to offer a laparoscopic approach to all pa- colocutaneous (10%).
tients with sigmoid diverticulitis regardless of its severity
Table 2 highlights intraoperative findings. A higher pro-
or complexity. The diagnosis of diverticulitis was con-
portion of patients in group 1 compared with group 2
firmed by the clinical history and computed tomography
underwent laparoscopic anterior resection (43% vs. 19%)
findings. All patients underwent mechanical bowel prep-
and the majority of patients in group 2 underwent lapa-
aration. All operations were conducted with patients in
roscopic sigmoidectomy (81% vs. 57%, P (cid:1) .18). Splenic
the lithotomy position and a 4-trocar technique (two
12-mm trocars and two 5-mm trocars). The anastomosis
was performed intracorporeally using a circular stapler. Table1.
All specimens were extracted through a transverse left CharacteristicsofPatientswithChronicDiverticulitiswith
Fistula(Group1)orWithoutFistula(Group2)
lower quadrant incision using a wound protector.
Group1 Group2 PValue
The outpatient and inpatient electronic records were re- (N(cid:1)21) (N(cid:1)21)
viewed, and the abstracted data included demographics,
medical comorbidities (malnutrition [albumin level (cid:2)3.3 Medianage, 49[56,25–79] 50[53,26–83] .68
g/dL], diabetes, anemia [hemoglobin level: male (cid:2)42, fe- y(mean,range)
male (cid:2)37], smoking), American Society of Anesthesiolo- GenderM/F,n(%) 9/12(43%/57%) 11/10(52%/48%) .75
gistsclass,bodymassindex(kg/m2),pastsurgicalhistory, MedianBMIa(kg/ 31[31,19–47] 31[31,20–50] .96
type of fistula, and the presence of a chronic pelvic ab- m2)(mean,range)
scess. Outcome measures included intraoperative data ASAclass
(type of operation, splenic flexure mobilization, ureteral I 1(5%) 1(5%) .38
catheterusage,divertingstoma,conversionrate,operative
II 12(57%) 13(62%)
time in minutes, blood loss in milliliters, transfusion, in-
III 8(38%) 7(33%)
traoperative complications) and postoperative outcome
Anemia 14(67%) 17(81%) .48
(admissiontointensivecareunit,hospitallengthofstayin
days, complications, transfusion, readmission rate, reop- Priorabdominal 11(52%) 8(38%) .53
operation
eration, mortality, and anastomotic/fistula healing).
Chronicpelvic 5(24%) 2(10%) .40
Statistical analysis for group comparison was performed abscess
usinganunpaired2-tailedttestanda(cid:1)2test.APvalue(cid:2) Diabetes 5(24%) 4(19%) 1.0
.05 was considered statistically significant. All statistical
Smoking 3(14%) 5(24%) .69
analysis was performed using GraphPad software (La
Malnutrition 4(19%) 4(19%) 1.0
Jolla, California, USA).
Fistulatype
RESULTS Colovesical 15(71%) 0
Colovaginal 4(19%) 0
During the study period, 21 patients underwent laparo-
Colocutaneous 2(10%) 0
scopic resection for chronic diverticulitis complicated by
colonic fistula (group 1). The patients with fistula were aBMI (cid:1) body mass index; ASA (cid:1) American Society of
Anesthesiologists.
compared with 21 consecutive patients who underwent
JSLS(2013)17:636–640 637
LaparoscopicResectionofChronicSigmoidDiverticulitiswithFistula,AbbassMAetal.
Table2. Table3.
IntraoperativeOutcomeofPatientswithChronicDiverticulitis PostoperativeOutcomeofPatientswithChronicDiverticulitis
withFistula(Group1)orWithoutFistula(Group2) withFistula(Group1)orWithoutFistula(Group2)
Group1 Group2 PValue Group1 Group2 PValue
(N(cid:1)21) (N(cid:1)21) (N(cid:1)21) (N(cid:1)21)
Operationtype Medianhospitalization, 4(4,2–9) 4(8,1– .17
d(mean,range) 55)
Sigmoidectomy 12(57%) 17(81%) .18
Intensivecareadmission 0 3(17%) .23
Anteriorresection 9(43%) 4(19%)
Overallcomplications 8(38%) 7(33%)a 1.0
Splenicflexure 14(67%) 10(48%) .34
mobilization Woundinfection 4(19%) 3(14%)
Ureteralcatheters 14(67%) 7(33%) .06 Abscess 2(10%) 0
Divertingstoma 1(5%) 1(5%) 1.0 Gastrointestinalbleeding 1(5%) 2(10%)
Conversiontoopen 0 2(10%) .48 Woundhematoma 0 1(5%)
Medianoperative 240 260 .36 Anastomoticleak 0 1(5%)
time(min)
Urinarytractinfection 0 1(5%)
Mean(range) 254(168–360) 281(127–641)
Smallbowelobstruction/ 1(5%) 0
Medianblood 150 150 .94 trocarsitehernia
loss(mL)
Postoperativetransfusion 1(5%) 4(19%) .34
Mean(range) 216(50–800) 221(30–1200)
Readmission 2(10%) 1(5%) 1.0
Intraoperative 0 1(5%) 1.0
Reoperation 2(10%) 2(10%) 1.0
transfusion
Recurrenceoffistula 0 0
Intraoperative
complication Mortality 0 0
Ureterallaceration 0 1(5%) 1.0 aSomepatientshadmorethanonecomplication.
flexuremobilizationwasperformedin67%ofthepatients DISCUSSION
in group 1 compared with 48% in group 2 (P (cid:1) .34).
The field of minimally invasive surgery has evolved rap-
Ureteral catheter placement was used more frequently in
idly in the past 2 decades. Laparoscopic resection of
group 1 (67% vs. 33%, P (cid:1) .06). No difference in conver-
chronicsigmoiddiverticulitishasbeenwidelyreportedas
sion rate was noted between the groups (0 vs. 10%, P (cid:1)
asafealternativetoopenresectionandisbeingusedwith
.48).Medianoperativetimeandbloodlossweresimilarin
increasing frequency because of patient-related bene-
both groups. One patient in group 2 sustained ureteral
fits.9–17Variousfactorscanaddtothetechnicalchallenges
laceration, which was repaired intraoperatively.
of laparoscopic resection of chronic sigmoid diverticulitis
Medianlengthofstaywas4daysinbothgroups(Table3).No including prior abdominopelvic surgery, the presence of
difference in overall complications was noted between chronic pelvic abscess, extensive inflammation surround-
the groups (38 vs. 33%, P (cid:1) 1.0). Only one anastomotic ingtheleftureter,orinvolvementofadjacentorganssuch
leak(5%)wasnotedingroup2.Mortalitywas0%inboth as the bladder and vagina. Because of such factors, some
groups.Readmissionratewas10%and5%ingroups1and surgeonsrecommendtheopenapproachforcomplicated
2, respectively (P (cid:1) 1.0). Two patients (10%) in group 1 cases. However because of the potential patient-related
requiredreoperation(onesmallbowelobstructionfroma benefits, the standard practice of the senior author at a
trocar site hernia and one for incisional ventral hernia), tertiary center has been to offer all patients with chronic
and one patient had percutaneous drainage of a pelvic diverticulitis the laparoscopic approach regardless of the
abscess. In group 2, two patients (10%) had reoperation extent of disease seen on imaging findings and/or the
(one anastomotic leak and one to evaluate for possibility presence of colonic fistula. In this study, we wanted to
of ischemic small intestine). Mean follow-up was 15 review the results of such an approach by investigating
months (range, 1–72). All patients in group 1 had fistula theoutcomeofpatientswithchronicdiverticulitiscompli-
healing without recurrence. cated by the presence of a colonic fistula and compare
638 JSLS(2013)17:636–640
them with a group of patients without fistula who were extensive disease (patients with more limited disease were
operated on during the same period. All patients elected treated at local hospitals). Another potential explanation may
to have surgery. Patients either presented with spontane- havebeenthehigheruseofureteralcathetersinpatientswith
ously draining fistula or with a history of a previous fistula,whichaidsinidentificationoftheureters.
diverticulitis attack with or without a previously drained
abscess.Inthecaseofthelattergroup,sufficienttimewas A review of the literature revealed only a few retrospective
given(aminimumof8weeks)toallowfortheinflamma- studies that have investigated the outcome of laparoscopic
tion to subside before elective operative intervention. resectionforchronicsigmoiddiverticulitiswithfistula.15,18–22
Table4summarizesthefindingsofthesepublications.None
Overall, no differences were noted between patients with of the studies except for the current one has compared the
fistula and those without fistula with respect to conversion outcome of patients with diverticular fistula with that of
rate,bloodloss,needfortransfusion,intraoperativeorpost- patientswithoutfistula.Thenumberofreportedsubjectshas
operative complications, length of hospitalization, readmis- ranged from 7 to 31 patients. A colovesical fistula was the
sionrate,andreoperationrate.Allstudypatientswithfistula mostcommontypeoffistulatreatedlaparoscopically.Except
healed and there were no deaths. Although no statistically for the present study, the conversion rate has ranged from
significantdifferenceswerefound,afewtrendswerenoted. 18.7% to 50%, highlighting the technical challenges of ap-
Mostpatientswithoutfistulaunderwentastandardsigmoid- proachingsuchaconditionlaparoscopically.Indicationsfor
ectomy,but43%ofpatientswithfistularequiredananterior conversion include an intraoperative complication such as
resection. In addition, the splenic flexure was mobilized bleedingorureterallaceration,failuretoprogress,difficulty
morefrequentlyinpatientswithfistulacomparedwiththose withrectosigmoiddivisioninthepelvis,orinabilitytosafely
withoutfistula.Similarly,ahigherproportionofpatientswith performtheanastomosis.However,allstudieshavereported
fistula had ureteral catheter placement to safely identify the 100%healingwithoutrecurrence.
left ureter. An interesting finding was the operative time.
Although a higher percentage of patients with fistula had Wewouldliketoacknowledgethelimitationsofthisstudy.
anteriorresection,splenicflexuremobilization,andureteral It was retrospective in nature with a small number of pa-
catheter placement, no significant difference was noted in tients.Thelimitednumberofpatientscouldhavepotentially
the operative time. Although we do not have a definitive introduced a type II error during statistical group compari-
explanationforthis,wespeculatethatthereferralpatternto son.Thepatientswerereferredtoatertiarycenterandwere
atertiarycentermayhaveplayedarole.Althoughthecases operated on by a single surgeon with much experience in
offistulawereconsideredcomplicatedandthepatientswere advanced laparoscopic surgery and expertise in complex
referred for a higher level of care, some had limited areas of pelvicoperations.Furthermore,thepurposeofthestudywas
inflammation,andthemainindicationforreferralwasthepres- to determine the outcome of the laparoscopic technique in
enceofthefistula.Thisiscontrarytothepatientswithdivertic- patients with diverticular colonic fistula compared with pa-
ulitis without fistula. Typically, the indication for referral was tients with chronic diverticulitis without fistula. A priori as-
Table4.
LiteratureReviewofStudiesofLaparoscopicResectionofDiverticularColonicFistula
Authors Year N FistulaType EBLa ORT Conversion LOS Morbidity Mortality Recurrence
Vesical Vaginal Cutaneous Other
HewettandStitz18 1995 7 6 1 0 0 — 220 — 4.7 0 0 0
Vargasetal15 1999 8 — — — — — — 50% — — — —
Bartusetal19 2005 36 34 2 0 0 — 220 25% 6.2 8% — —
Laurentetal20 2005 16 11 4 — 1 — 172 18.7% 5.7 12.5% 0 0
Nguyenetal21 2006 14 8 3 1 5 326 209 36% 6 14% 0 0
Engeldowetal22 2007 31 22 9 0 0 — 150 29% 7 6% 6% 0
Abbassetalb 2013 21 15 4 2 — 150 240 0 4 38% 0 0
aEBL(cid:1)estimatedbloodloss(inmilliliters);ORT(cid:1)operatingroomtime(inminutes);LOS(cid:1)lengthofstay(indays).
JSLS(2013)17:636–640 639
LaparoscopicResectionofChronicSigmoidDiverticulitiswithFistula,AbbassMAetal.
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