Transcript Impact of Laparoscopy on the Management of Right

Impact of Laparoscopy on the
Management of Right-sided Diverticulitis
Dr. CHAN chun-yin, Oliver
Department of Surgery, Pamela Youde Nethersole Eastern Hospital
17th September 2005
Right sided diverticulitis
 Acute diverticulitis of the
right colon is relatively
uncommon
 Reported frequency of
disease varies
 1 in 300 to 1 in 34
appendectomies
Oudenhoven et al. Radiology .1998
 Prevalence in Western
literature
 0.9 % - 5% of all diverticulitis
Diverticulosis in Asia
HK
Singapore Japan
Taiwan
Patient
number
858
524
625
106
Prevalence
of
diverticulosis
25.1%
20%
13.3%
N/A
Only Right
colon
involvement
55%
70%
68.8%
60%
Oudenhoven et al. Radiology .1998
Chia JG et al. Diseases of the Colon & Rectum. 1991
Sugihara et al. Annals of the Academy of Medicine, Singapore. 1987
Chiu et al. J Surg Asso. 1987
Right sided diverticulitis in Asia
 Prevalence
 10 to 17% of all diverticulitis
Sugihara et al. Annals of the Academy of Medicine, Singapore. 1987
Lo et al. The Ameriacan Journal of Surgery 1996
Diagnostic dilemma
 Clinical features mimic acute appendicitis
 Almost always misdiagnosis as acute
appendicitis
Markham et al. Gut 1992
Lo et al. The Ameriacan Journal of Surgery 1996
Chiu et al. ANZ J Surg. 2001
Treatment strategy
 Antibiotics alone
 Appendicectomy with antibiotics
 Diverticulectomy +/- appendicectomy with
antibiotics
 Ileocolic resection with primary anastomosis
with antibiotics
 Formal right hemicolectomy with antibiotics
Complicated: resection + antibiotics
Uncomplicated: Huge controversies !
Greaney and Snyder classification
Grade I
Acute inflammation
UNCOMPLICATED
Grade II
Inflammatory mass
Grade III
Localized perforation
over diverticulitis
Grade IV
Pus collection over whole
abdominal cavity
COMPLICATED
Background
 Ileocolic resection or right hemicolectomy
with primary anastomosis was commonly
practiced in the era of open surgery for right
sided diverticulitis
 Via midline laparotomy wound
 Claimed low morbidity and mortality
Background
 In the era of laparoscopic surgery
 Changing management pattern
Objective
 To evaluate the impact of laparoscopy on
the management of right-sided diverticulitis
 In terms of
 Surgical resection rate
 Safety of conservative treatment after
laparoscopic examination
 Hospital stay
 Chance of missing a carcinoma
Setting
 A general community hospital
Design
 Retrospective evaluation study
Patients and method
 All patients who discharged with coding of




acute appendicitis, diverticulits or
diverticulosis
From August 1993 - August 2005
Through hospital computer data
Review of case notes
Telephone interview
 Open era
 From 1993 to 1998
 Laparoscopic era
 Routine laparoscopic appendicectomy started
since 1999 in our hospital
Result
 Total number of cases with preoperative diagnosis
of appendicitis
 2569 cases
 Number of right sided diverticulitis
 135 cases underwent operation
 41 cases without operation were excluded
 Already underwent appendicectomy before
 Previous investigation confirmed presence of right colon
diverticulae
2569 patients with preoperative diagnosis of acute appendicitis
41 patients
diagnosed by
CT without
operation were
excluded
135 patients with intraop findings of right diverticulitis
Open era
Laparoscopic era
38 cases
97 cases
Right
hemicolectomy
28 cases
2434 appendicitis
Appendicectomy
10 cases
Right
hemicolectomy
Appendicectomy
56 cases
-open: 14 case
-Lap: 2 case
Laparoscopy
only
25 cases
Result
 Open era: 38 cases
 Right hemicolectomy: 28 (73.6%)
 Appendicectomy alone: 10 (26.4%)
 Laparoscopic era: 97 cases
 Laparoscopy  open right hemicolectomy: 14
(16.5%)
 Laparoscopic right hemicolectomy  2
 Laparoscopy only: 25
 Laparoscopic incidental appendicectomy: 56
(83.5%)
Open era vs lap era
60
50
40
Right hemicolectomy
30
Appendicectomy
20
Laparoscopy only
83.5%
73.6%
10
0
26.4%
Open era
16.5%
Lap era
Result
 Right side diverticulitis : 135 cases
 Surgical resection: 44 (32.6%)
 Open era no…. 28 (63.6%)
 Lap era no…. 16 (36.4%)
 Without resection: 91 (67.4%)
 Open era no… 10 (11%)
 Lap era no… 81 (89%)
Result
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Without resection
Surgical resection
Open era
Lap era
overall
surgical
resection
without
surgical
resection
Result
Open group
Laparoscopic group
Age, mean
49
44.8
Sex (M:F)
2:1
1:1.17
Length of stay (days),
median
7
5
Mortality
0
0
Wound infection
3
0
Intra-abdominal
collection
1
0
0
0
Morbidity
Readmission
Reasons for resection
Open group
Perforation
Inflammatory
mass
Suspected
tumor
Total no.
Lap group
8
12
18
-
2
4
28
16
Result
 Non resection group after laparoscopy
 Further colonic investigations arranged 4 weeks
later
Single 9
+ve for diverticuli 33
Colonoscopy
Multiple 24
-ve for diverticuli 15
Caecal tumor 1
Single 3
+ve for diverticuli 11
Multiple 8
Ba enema
-ve for diverticuli 5
Virtual
colonoscopy
Defaulted
investigation
+ve for diverticuli 1
13
Result

Missed carcinoma: 3 cases
1.
71 year old lady, detected on colonoscopy 4 weeks’
postop, right hemicolectomy performed 1 week later
2.
45 year old gentleman, “prolong ileus” postop, CT
revealed caecal tumor, right hemicolectomy performed
on Day 10
3.
52 year old gentleman, persistent pain at 2 weeks’
postop, CT revealed caecal tumor, right
hemicolectomy at 3 weeks’ postop
Discussion
 Incidence quite high
 1 case every 18 cases of appendicitis
 Increased use of laparoscopy
 Minimally invasive and safe as diagnostic tool
 Increased detection of diverticulitis
 More conservative trend in laparoscopic era
 Decreased resection rate
 Early detection of uncomplicated diverticulitis
 Better assessment by means of laparoscopy
Discussion
 Conservative treatment
 Low morbidity
 Shorter hospital stay
 No readmission for second attack
 Routine follow up colonic investigation
 Default rate 16%
 Missing carcinoma
 Early pickup
Discussion
 Potential advantages
 Avoid unnecessary surgical resection and their
potential complication
 Shorter hospital stay
 However,
 Low resection rate really due to laparoscopy or
 Changing attitude of surgeon towards the
management of right-sided diverticulitis
Conclusion
 Laparoscopy is a safe procedure in the
management of right-sided diverticulitis
 Increasing trend of adopting conservative
treatment
 Rate of missing a carcinoma by
laparoscopic examination were low in the
present study
Thank you!