Diverticulitis Abscess

1
Diverticulitis Abscess

• Tryggvi Stefánsson
• Centrallasarettet in Västerås
• and
• Landspitali University Hospital
• Reykjavík/Iceland

2
Perforation

• Abscess
• Purulent peritonitis
• Faecal peritonitis
• Incidence
• Hart Cambridge UK 1995-1997 4/100000/year
• Mäkelä Oulu, Finland 1986-2000 3,8/100000/year

3
Abscess

• Diverticulitis abscesses are rare.
• Individual experience not enough.
• Incidence
• Ambrosetti Geneva 1986-1997 1/100000/year

4
Risk factors for perforated diverticulitis

• Industrialized countries with high prevalence of
  diverticulosis
• Increases with advanced age
• Men gt Women
• Immune suppression
• Corticosteroids
• NSAID
• Opioids, smoking, alcoholism, red meat, fiber
  deficiency (??)
• Morris, Postgrad Med J, 2002
• obesity
• Dobbins, Colorectal dis, 2005
• Renal failure

5
Location

• Paracolic or Pelvic
• Retroperitoneal, Retrorectal, Psoas muscle, Hip,
  Buttock, Flank, Leg, Inguinal region, Scrotum
• Stabile, Am J Surg, 1990
• Neff, Radiology, 1987
• Ravo, Am J Gastroenterol, 1985

6
Bacterias

• 19 patients
• Polymicrobial (E-coli, Bacteroides, Enterococcus,
  Klebsiella) in 17
• E-coli in 1
• B Fragilis in 1
• Stabile Am J Surg 1990

7
Abscess
8
Abscess
9
Abscess
10
Treatment Options

• Bowel Rest
• Antibiotics
• PAD (Percutaneous Abscess Drainage)
• SD (Surgical Drainage)
• One Stage (Res ana /- ostomy)
• Two Stages (Hartmanns procedure)
• Three Stages (Drainageostomy)

11
Results of operations

• Lahey clinic 1967-1982
• Mortality
• Res and ana 1
• Res, ana with stoma 0
• Hartmann 16
• Three Stages 14
• Hackford AW, Dis Colon Rectum, 1985

12
Results of operations

• Of 37 patients operated with a
• 2-stage operation for an abscess
• 13 patient could have been operated in a single
  stage operation if they had undergone PAD
• Mueller PR, Radiology, 1987

13
Goal of Drainage

• Downstage-Single stage
• Patient can recover, Bowel Prep, Clean op field
• Bacteria culture.
• Only treatment.

14
How to drain

• CT guided Transabdominal, trans sacral (PAD)
• US guided transabdominal (PAD), transvaginal,
  transrectal
• EUS guided through the sigmoid wall
• Surgical drainage
• Blind transrectal or transvaginal

15
Contraindications to PAD

• Abscess not localized
• Access not safe
• Generalized peritonitis
• Pneumoperitoneum
• Obstruction
• Blood dyscrasias/Bleeding diathesis
• Persistent symptoms after drainage
• Faeculent Drainage
• (Immunocompromized and high mortality score)
• Diverticular disease.
• Management of the difficult surgical case
• Williams and Wilkins 1998

16
Published Results of PAD

• Neff CC Radiology 1987
• 16 patients, 13 pelvic, 2 paracolic and 1 psoas,
  size 5-15cm
• 11 single stage op in 10d-6w
• 3 inop, drainage only.
• 1 sigm fistula 3 stage
• 1 resp insuff-died

17
Published Results of PAD

• Mueller PR, Radiology 1987
• 24 patients, pelvic abscesses
• 14 single stage op within 10 days
• 5 two-stage op because of inflammation
• 2 no initial op but res within 8 months
• 1 just drain
• Stabile BE, Am J Surg, 1990
• 19 patients with parac or pelvic abscesses
  (8,9cm)
• 14 (74) single stage operation after PAD.
• 3 Urgent colostomy and surgical drainage.
• 2 refused operation (one died).

18
Drainage

• Drainage
• Infected part of the colon is left behind.
• Risk for complications like persistent fistula,
  DVT, Atelectasis, pneumonia and other infections.
  
• If the patient deteriorate in spite of drainage
  the op risk will be higher.
• Hartmann op
• The patient is drained and deviated

19
Choice of Treatment

• 1 The Abscess
• Size
• Location
• Bacterias
• 2 The Patient
• Morbidity, mortality scoring systems.
• Anastomose healing
• 3 The Surgeon
• Training
• Hospital
• Emergency/Elective

20
Size of Abscess

• lt 3-5 cm? Bowel rest and Antibiotics
• gt 5 cm? Bowel rest, Antibiotics and Drainage
• Ambrosetti Dis Colon Rectum 2005
• Siewert AJR 2006

21
Location

• Abscesses gt5cm
• Pelvic Drainage.
• Resected when the acute inflammation has
  faded.
• Paracolic
• Drainage.
• Conservative treatment. Resection only if
  symptoms persist.
• Ambrosetti, Dis Colon Rectum, 2005

22
Antibiotics

• Broadspectrum antibiotics (G neg and anaerobes)
• Cefuroxim, Metronidazol
• Ciprofloxacin, Metronidazol
• Tienam
• Meronem
• Tacozin

23
Patient

• Mortality and Morbidity score
• ASA, APACHE, POSSUM
• Anastomose healing
• Normal Young and healthy
• Impaired Old, Malnourished, Renal failure,
  AIDS, Steroid dependent, Chemotherapy, Diabetes,
  Chronic alcoholics, High BMI, Transplant
  patients

24
Surgeon

• Training In training, General Surgeon,
  Colorectal Surgeon
• Hospital Radiology equipment, Radiologist, ICU,
  Assistance
• Emergency/Elective Rate of complications higher
  in emergency operations

25
Team decision

• Colorectal Surgeon
• Radiologist
• Cardiologist
• Anaesthetist
• ......

26
Abscess treatment

• Normal healing of anastomosis and a favorable
  mortality score
• lt5 cm Bowel rest and Broadspectrum antibiotics
• Those who dont respond Drainage
• Persist after drainage Res and Ana
• gt5cm in pelvis Drainage with a later res and
  ana
• gt5cm above the pelvis Drainage
• Persist after drainage Res and Ana
• Impaired healing of anastomosis
• 1) Bowel rest, Broadspectrum antibiotics and
  Drainage
• 2) Res and Ana loop Ileost or Hartmanns op
• Impaired healing of anastomosis and unfavorable
  mortality score
• Hartmann operation directly

27
Summary

• Young and healthy patients tolerate conservative
  treatment.
• Immunocompromized with unfavorable mortality
  score may not tolerate conservative
  treatment-need more active surgical treatment.