Clin Colon Rectal Surg 2021; 34(02): 113-120
DOI: 10.1055/s-0040-1716703
Review Article

Minimally Invasive Management of Diverticular Disease

Andrea Madiedo
1   Department of Surgery, Boston Medical Center, Boston, Massachusetts
,
Jason Hall
1   Department of Surgery, Boston Medical Center, Boston, Massachusetts
› Institutsangaben

Abstract

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy.

While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective.

Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion.

In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.



Publikationsverlauf

Artikel online veröffentlicht:
24. Februar 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Feo L, Schaffzin DM. Colonic stents: the modern treatment of colonic obstruction. Adv Ther 2011; 28 (02) 73-86
  • 2 Currie A, Christmas C, Aldean H, Mobasheri M, Bloom ITM. Systematic review of self-expanding stents in the management of benign colorectal obstruction. Colorectal Dis 2014; 16 (04) 239-245
  • 3 Anjum N, Ren J, Wang G. et al. A randomized control trial of preoperative oral antibiotics as adjunct therapy to systemic antibiotics for preventing surgical site infection in clean contaminated, contaminated, and dirty type of colorectal surgeries. Dis Colon Rectum 2017; 60 (12) 1291-1298
  • 4 Kiran RP, Murray ACA, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 2015; 262 (03) 416-425 , discussion 423–425
  • 5 Klinger AL, Green H, Monlezun DJ. et al. The role of bowel preparation in colorectal surgery. Ann Surg 2017; DOI: 10.1097/SLA.0000000000002568.
  • 6 Garfinkle R, Abou-Khalil J, Morin N. et al. Is there a role for oral antibiotic preparation alone before colorectal surgery? ACS-NSQIP analysis by coarsened exact matching. Dis Colon Rectum 2017; 60 (07) 729-737
  • 7 Coakley KM, Kasten KR, Sims SM, Prasad T, Heniford BT, Davis BR. Prophylactic ureteral catheters for colectomy: a national surgical quality improvement program-based analysis. Dis Colon Rectum 2018; 61 (01) 84-88
  • 8 Boyan Jr WPJ, Lavy D, Dinallo A. et al. Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience. Ann Transl Med 2017; 5 (03) 44-44
  • 9 Chiu AS, Jean RA, Gorecka J, Davis KA, Pei KY. Trends of ureteral stent usage in surgery for diverticulitis. J Surg Res 2018; 222: 203-211.e3
  • 10 Leff EI, Groff W, Rubin RJ, Eisenstat TE, Salvati EP. Use of ureteral catheters in colonic and rectal surgery. Dis Colon Rectum 1982; 25 (05) 457-460
  • 11 Masoomi H, Buchberg B, Nguyen B, Tung V, Stamos MJ, Mills S. Outcomes of laparoscopic versus open colectomy in elective surgery for diverticulitis. World J Surg 2011; 35 (09) 2143-2148
  • 12 Ragupathi M, Ramos-Valadez DI, Patel CB, Haas EM. Robotic-assisted laparoscopic surgery for recurrent diverticulitis: experience in consecutive cases and a review of the literature. Surg Endosc 2011; 25 (01) 199-206
  • 13 Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151 (02) 269-271
  • 14 Gachabayov M, Oberkofler CE, Tuech JJ, Hahnloser D, Bergamaschi R. Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis 2018; 20 (09) 753-770
  • 15 Windsor A, Wexner S, Heald RJ. et al. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Color Dis 2016; 19 (01) O1-O12
  • 16 Tadlock MD, Karamanos E, Skiada D. et al. Emergency surgery for acute diverticulitis: which operation? A National Surgical Quality Improvement Program study. J Trauma Acute Care Surg 2013; 74 (06) 1385-1391 , quiz 1610
  • 17 Bridoux V, Regimbeau JM, Ouaissi M. et al. Hartmann's procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am Coll Surg 2017; 225 (06) 798-805
  • 18 Cirocchi R, Fearnhead N, Vettoretto N. et al. The role of emergency laparoscopic colectomy for complicated sigmoid diverticulitis: a systematic review and meta-analysis. Surgeon 2018; 1-10 DOI: 10.1016/j.surge.2018.08.010.
  • 19 Cassini D, Miccini M, Manoochehri F, Gregori M, Baldazzi G. Emergency Hartmann's procedure and its reversal: a totally laparoscopic 2-step surgery for the treatment of Hinchey III and IV diverticulitis. Surg Innov 2017; 24 (06) 557-565
  • 20 Turley RS, Barbas AS, Lidsky ME, Mantyh CR, Migaly J, Scarborough JE. Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis. Dis Colon Rectum 2013; 56 (01) 72-82
  • 21 Vennix S, Musters GD, Mulder IM. et al; Ladies trial colloborators. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015; 386 (10000): 1269-1277
  • 22 Schultz JK, Yaqub S, Wallon C. et al; SCANDIV Study Group. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA 2015; 314 (13) 1364-1375
  • 23 Shaikh FM, Stewart PM, Walsh SR, Davies RJ. Laparoscopic peritoneal lavage or surgical resection for acute perforated sigmoid diverticulitis: a systematic review and meta-analysis. Int J Surg 2017; 38: 130-137
  • 24 Feingold D, Steele SR, Lee S. et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57 (03) 284-294
  • 25 Klarenbeek BR, Veenhof AAFA, de Lange ESM. et al. The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. BMC Surg 2007; 7: 16 DOI: 10.1186/1471-2482-7-16.
  • 26 Klarenbeek BR, Veenhof AA, Bergamaschi R. et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009; 249 (01) 39-44
  • 27 Klarenbeek BR, Bergamaschi R, Veenhof AA. et al. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc 2011; 25 (04) 1121-1126
  • 28 Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW. Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences. Dis Colon Rectum 2002; 45 (04) 485-490
  • 29 Delaney CP, Chang E, Senagore AJ, Broder M. Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg 2008; 247 (05) 819-824
  • 30 Gervaz P, Mugnier-Konrad B, Morel P, Huber O, Inan I. Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial. Surg Endosc 2011; 25 (10) 3373-3378
  • 31 Raue W, Paolucci V, Asperger W, Albrecht R, Büchler MW, Schwenk W. LAPDIV-CAMIC Trial Group. Laparoscopic sigmoid resection for diverticular disease has no advantages over open approach: midterm results of a randomized controlled trial. Langenbecks Arch Surg 2011; 396 (07) 973-980
  • 32 Klarenbeek BR, Coupé VMH, van der Peet DL, Cuesta MA. The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial. Surg Endosc 2011; 25 (03) 776-783
  • 33 Keller DS, Delaney CP, Hashemi L, Haas EM. A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery. Surg Endosc 2016; 30 (10) 4220-4228
  • 34 Cassini D, Depalma N, Grieco M, Cirocchi R, Manoochehri F, Baldazzi G. Robotic pelvic dissection as surgical treatment of complicated diverticulitis in elective settings: a comparative study with fully laparoscopic procedure. Surg Endosc 2019; 33 (08) 2583-2590
  • 35 Raskin ER, Keller DS, Gorrepati ML, Akiel-Fu S, Mehendale S, Cleary RK. Propensity-matched analysis of sigmoidectomies for diverticular disease. JSLS 2019; 23 (01) e2018.00073
  • 36 Harr JN, Haskins IN, Amdur RL, Agarwal S, Obias V. The effect of obesity on laparoscopic and robotic-assisted colorectal surgery outcomes: an ACS-NSQIP database analysis. J Robot Surg 2018; 12 (02) 317-323
  • 37 Salman M, Bell T, Martin J, Bhuva K, Grim R, Ahuja V. Use, cost, complications, and mortality of robotic versus nonrobotic general surgery procedures based on a nationwide database. Am Surg 2013; 79 (06) 553-560
  • 38 Vasudevan V, Reusche R, Wallace H, Kaza S. Clinical outcomes and cost-benefit analysis comparing laparoscopic and robotic colorectal surgeries. Surg Endosc 2016; 30 (12) 5490-5493
  • 39 Ke T-W, Geniales CR, Chen WT-L. The role of splenic flexure mobilization in laparoscopic rectal surgery for rectal cancer. Mini-invasive Surg 2018; 2 (10) 35 DOI: 10.20517/2574-1225.2018.46.
  • 40 Kye BH, Kim HJ, Kim HS, Kim JG, Cho HM. How much colonic redundancy could be obtained by splenic flexure mobilization in laparoscopic anterior or low anterior resection?. Int J Med Sci 2014; 11 (09) 857-862
  • 41 Schlussel AT, Wiseman JT, Kelly JF. et al. Location is everything: The role of splenic flexure mobilization during colon resection for diverticulitis. Int J Surg 2017; 40: 124-129
  • 42 Isik O, Sapci I, Aytac E. et al. Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery. Tech Coloproctol 2018; 22 (10) 767-771
  • 43 Isik O, Benlice C, Gorgun E. A novel approach for robotic mobilization of the splenic flexure. Tech Coloproctol 2017; 21 (01) 53-57
  • 44 Tocchi A, Mazzoni G, Fornasari V, Miccini M, Daddi G, Tagliacozzo S. Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease. Am J Surg 2001; 182 (02) 162-167
  • 45 Lehmann RK, Brounts LR, Johnson EK, Rizzo JA, Steele SR. Does sacrifice of the inferior mesenteric artery or superior rectal artery affect anastomotic leak following sigmoidectomy for diverticulitis? A retrospective review. Am J Surg 2011; 201 (05) 623-627
  • 46 Cirocchi R, Trastulli S, Farinella E. et al. Is inferior mesenteric artery ligation during sigmoid colectomy for diverticular disease associated with increased anastomotic leakage? A meta-analysis of randomized and non-randomized clinical trials. Colorectal Dis 2012; 14 (09) e521-e529
  • 47 Masoni L, Mari FS, Nigri G. et al. Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial. Surg Endosc 2013; 27 (01) 199-206
  • 48 Dobrowolski S, Hać S, Kobiela J, Sledziński Z. Should we preserve the inferior mesenteric artery during sigmoid colectomy?. Neurogastroenterol Motil 2009; 21 (12) 1288-e123
  • 49 Keller DS, Ishizawa T, Cohen R. et al. Elsevier Editorial System(tm) for The Lancet Gastroenterology & Hepatology Manuscript Draft Indocyanine Green Fluorescence Imaging in Colorectal Surgery: Reviewing the Current Literature, Applications, and Future Direction. Lancet. 2017 http://discovery.ucl.ac.uk/10045273/1/THELANCETGASTROHEP-D-17-00224R1.pdf . Accessed July 15, 2020
  • 50 Jafari MD, Wexner SD, Martz JE. et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 2015; 220 (01) 82-92.e1
  • 51 Degett TH, Andersen HS, Gögenur I. Indocyanine green fluorescence angiography for intraoperative assessment of gastrointestinal anastomotic perfusion: a systematic review of clinical trials. Langenbecks Arch Surg 2016; 401 (06) 767-775
  • 52 Bae SU, Min BS, Kim NK. Robotic low ligation of the inferior mesenteric artery for rectal cancer using the firefly technique. Yonsei Med J 2015; 56 (04) 1028-1035
  • 53 Ryu S, Yoshida M, Hironori O. et al. Intraoperative ICG fluorescence contrast imaging of the main artery watershed area in colorectal cancer surgery: report of a case. Int J Surg Case Rep 2016; 26: 176-178
  • 54 Sherwinter DA, Gallagher J, Donkar T. Intra-operative transanal near infrared imaging of colorectal anastomotic perfusion: a feasibility study. Colorectal Dis 2013; 15 (01) 91-96
  • 55 Blanco-Colino R, Espin-Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol 2018; 22 (01) 15-23
  • 56 Hellan M, Spinoglio G, Pigazzi A, Lagares-Garcia JA. The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc 2014; 28 (05) 1695-1702