Diverticulitis AbscessDiverticulitis Abscess
Tryggvi StefánssonTryggvi StefánssonCentrallasarettet in Västerås Centrallasarettet in Västerås
andandLandspitali University HospitalLandspitali University Hospital
Reykjavík/IcelandReykjavík/Iceland
PerforationPerforation
Abscess Abscess Purulent peritonitisPurulent peritonitis Faecal peritonitisFaecal peritonitis
IncidenceIncidence
HartHart Cambridge UKCambridge UK 1995-19971995-1997 4/100000/year4/100000/year
MäkeläMäkelä Oulu, FinlandOulu, Finland 1986-2000 1986-2000 3,8/100000/year3,8/100000/year
AbscessAbscess
Diverticulitis abscesses are rare.Diverticulitis abscesses are rare.
Individual experience not enough.Individual experience not enough.
IncidenceIncidence
AmbrosettiAmbrosetti Geneva Geneva 1986-19971986-1997 1/100000/year1/100000/year
Risk factors for perforated Risk factors for perforated diverticulitis diverticulitis
Industrialized countries with high prevalence of diverticulosisIndustrialized countries with high prevalence of diverticulosis Increases with advanced ageIncreases with advanced age Men > WomenMen > Women Immune suppressionImmune suppression CorticosteroidsCorticosteroids NSAIDNSAID Opioids, smoking, alcoholism, red meat, fiber deficiency (??)Opioids, smoking, alcoholism, red meat, fiber deficiency (??)
Morris, Postgrad Med J, 2002 Morris, Postgrad Med J, 2002
obesityobesityDobbins, Colorectal dis, 2005Dobbins, Colorectal dis, 2005
Renal failureRenal failure
LocationLocation
Paracolic or PelvicParacolic or Pelvic
Retroperitoneal, Retrorectal, Psoas Retroperitoneal, Retrorectal, Psoas muscle, Hip, Buttock, Flank, Leg, muscle, Hip, Buttock, Flank, Leg, Inguinal region, ScrotumInguinal region, Scrotum
Stabile, Am J Surg, 1990Stabile, Am J Surg, 1990
Neff, Radiology, 1987Neff, Radiology, 1987
Ravo, Am J Gastroenterol, Ravo, Am J Gastroenterol, 19851985
BacteriasBacterias
19 patients:19 patients: Polymicrobial (E-coli, Bacteroides, Polymicrobial (E-coli, Bacteroides,
Enterococcus, Klebsiella) in 17Enterococcus, Klebsiella) in 17 E-coli in 1E-coli in 1 B Fragilis in 1B Fragilis in 1
Stabile Am J Surg 1990Stabile Am J Surg 1990
AbscessAbscess
AbscessAbscess
AbscessAbscess
Treatment OptionsTreatment Options
Bowel RestBowel Rest AntibioticsAntibiotics PAD (Percutaneous Abscess Drainage)PAD (Percutaneous Abscess Drainage) SD (Surgical Drainage)SD (Surgical Drainage) One Stage (Res+ ana +/- ostomy)One Stage (Res+ ana +/- ostomy) Two Stages (Hartmanns procedure)Two Stages (Hartmanns procedure) Three Stages (Drainage+ostomy)Three Stages (Drainage+ostomy)
Results of operationsResults of operations
Lahey clinic 1967-1982 Lahey clinic 1967-1982 MortalityMortality
Res and anaRes and ana 1%1% Res, ana with stomaRes, ana with stoma 0%0% HartmannHartmann 16%16% Three StagesThree Stages 14%14%
Hackford AW, Dis Colon Rectum, 1985Hackford AW, Dis Colon Rectum, 1985
Results of operationsResults of operations
Of 37 patients operated with a Of 37 patients operated with a
2-stage operation for an abscess 2-stage operation for an abscess
13 patient could have been operated 13 patient could have been operated in a single stage operation if they in a single stage operation if they had undergone PADhad undergone PAD
Mueller PR, Radiology, 1987Mueller PR, Radiology, 1987
Goal of DrainageGoal of Drainage
Downstage-Single stageDownstage-Single stagePatient can recover, Bowel Prep, Clean op fieldPatient can recover, Bowel Prep, Clean op field
Bacteria culture.Bacteria culture. Only treatment.Only treatment.
How to drainHow to drain
CT guided Transabdominal, trans CT guided Transabdominal, trans sacral (PAD)sacral (PAD)
US guided transabdominal (PAD), US guided transabdominal (PAD), transvaginal, transrectaltransvaginal, transrectal
EUS guided through the sigmoid wallEUS guided through the sigmoid wall Surgical drainageSurgical drainage Blind transrectal or transvaginalBlind transrectal or transvaginal
Contraindications to PADContraindications to PAD Abscess not localized Abscess not localized Access not safeAccess not safe Generalized peritonitisGeneralized peritonitis PneumoperitoneumPneumoperitoneum ObstructionObstruction Blood dyscrasias/Bleeding diathesisBlood dyscrasias/Bleeding diathesis Persistent symptoms after drainagePersistent symptoms after drainage Faeculent DrainageFaeculent Drainage (Immunocompromized and high mortality score)(Immunocompromized and high mortality score)
Diverticular disease.Diverticular disease.
Management of the difficult surgical caseManagement of the difficult surgical caseWilliams and Wilkins 1998Williams and Wilkins 1998
Published Results of PADPublished Results of PAD Neff CC Radiology 1987Neff CC Radiology 1987
16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm16 patients, 13 pelvic, 2 paracolic and 1 psoas, size: 5-15cm 11 single stage op in 10d-6w 11 single stage op in 10d-6w 3 inop, drainage only.3 inop, drainage only. 1 sigm fistula 3 stage1 sigm fistula 3 stage 1 resp insuff-died1 resp insuff-died
Published Results of PADPublished Results of PAD Mueller PR, Radiology 1987:Mueller PR, Radiology 1987:
24 patients, pelvic abscesses24 patients, pelvic abscesses14 single stage op within 10 days14 single stage op within 10 days5 two-stage op because of inflammation5 two-stage op because of inflammation2 no initial op but res within 8 months2 no initial op but res within 8 months1 just drain1 just drain
Stabile BE, Am J Surg, 1990:Stabile BE, Am J Surg, 1990:19 patients with parac or pelvic abscesses (8,9cm)19 patients with parac or pelvic abscesses (8,9cm)14 (74%) single stage operation after PAD.14 (74%) single stage operation after PAD.3 Urgent colostomy and surgical drainage.3 Urgent colostomy and surgical drainage.2 refused operation (one died).2 refused operation (one died).
Drainage Drainage
Drainage Drainage Infected part of the colon is left behind. Infected part of the colon is left behind.
Risk for complications like persistent fistula, DVT, Risk for complications like persistent fistula, DVT, Atelectasis, pneumonia and other infections. Atelectasis, pneumonia and other infections.
If the patient deteriorate in spite of drainage the op risk If the patient deteriorate in spite of drainage the op risk will be higher.will be higher.
Hartmann opHartmann op The patient is drained and deviatedThe patient is drained and deviated
Choice of TreatmentChoice of Treatment
11 The AbscessThe Abscess
* * SizeSize
**** LocationLocation
****** BacteriasBacterias
22 The PatientThe Patient
** Morbidity, mortality scoring systems.Morbidity, mortality scoring systems.
** ** Anastomose healingAnastomose healing
33 The SurgeonThe Surgeon
** TrainingTraining
**** Hospital Hospital
****** Emergency/ElectiveEmergency/Elective
Size of AbscessSize of Abscess
< 3-5 cm< 3-5 cm Bowel rest and AntibioticsBowel rest and Antibiotics
> 5 cm> 5 cm Bowel rest, Antibiotics and Bowel rest, Antibiotics and DrainageDrainage
Ambrosetti Dis Colon Rectum 2005Ambrosetti Dis Colon Rectum 2005Siewert AJR 2006Siewert AJR 2006
LocationLocation
Abscesses >5cm:Abscesses >5cm:
Pelvic: Pelvic: Drainage. Drainage.
Resected when the acute Resected when the acute inflammation inflammation has faded.has faded.
Paracolic: Paracolic:
Drainage.Drainage.
Conservative treatment. Conservative treatment. Resection only if symptoms persist.Resection only if symptoms persist.
Ambrosetti, Dis Colon Rectum, 2005Ambrosetti, Dis Colon Rectum, 2005
AntibioticsAntibiotics
Broadspectrum antibiotics (G neg Broadspectrum antibiotics (G neg and anaerobes)and anaerobes)
Cefuroxim, MetronidazolCefuroxim, Metronidazol
Ciprofloxacin, MetronidazolCiprofloxacin, Metronidazol
TienamTienam
MeronemMeronem
TacozinTacozin
PatientPatient
Mortality and Morbidity scoreMortality and Morbidity score ASA, APACHE, POSSUMASA, APACHE, POSSUM
Anastomose healingAnastomose healingNormalNormal: : Young and healthyYoung and healthy
ImpairedImpaired: : Old, Malnourished, Renal Old, Malnourished, Renal failure, AIDS, Steroid dependent, failure, AIDS, Steroid dependent, Chemotherapy, Diabetes, Chronic Chemotherapy, Diabetes, Chronic alcoholics, alcoholics, High BMI, Transplant patientsHigh BMI, Transplant patients
SurgeonSurgeon
Training:Training: In training, General Surgeon, In training, General Surgeon, Colorectal SurgeonColorectal Surgeon
Hospital:Hospital: Radiology equipment, Radiologist, ICU, Radiology equipment, Radiologist, ICU, AssistanceAssistance
Emergency/Elective: Emergency/Elective: Rate of complications Rate of complications higher in emergency operationshigher in emergency operations
Team decisionTeam decision
Colorectal SurgeonColorectal Surgeon RadiologistRadiologist CardiologistCardiologist AnaesthetistAnaesthetist ............
Abscess treatmentAbscess treatment Normal healing of anastomosis and a favorable mortality scoreNormal healing of anastomosis and a favorable mortality score <5 cm: <5 cm: Bowel rest and Broadspectrum antibioticsBowel rest and Broadspectrum antibiotics
Those who dont respond: Those who dont respond: DrainageDrainagePersist after drainage:Persist after drainage: Res and AnaRes and Ana
>5cm in pelvis: >5cm in pelvis: Drainage with a later res and anaDrainage with a later res and ana >5cm above the pelvis:>5cm above the pelvis: DrainageDrainage
Persist after drainage:Persist after drainage: Res and Res and AnaAna
Impaired healing of anastomosisImpaired healing of anastomosis1) Bowel rest, Broadspectrum antibiotics and Drainage1) Bowel rest, Broadspectrum antibiotics and Drainage2) Res and Ana + loop Ileost or Hartmanns op2) Res and Ana + loop Ileost or Hartmanns op
Impaired healing of anastomosis and unfavorable mortality scoreImpaired healing of anastomosis and unfavorable mortality score Hartmann operation directlyHartmann operation directly
SummarySummary
Young and healthy patientsYoung and healthy patients tolerate tolerate conservative treatment.conservative treatment.
Immunocompromized with unfavorable Immunocompromized with unfavorable mortality scoremortality score may not tolerate may not tolerate conservative treatment-need more active conservative treatment-need more active surgical treatment.surgical treatment.
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