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THE ELECTIVE MANAGEMENT OF COMPLICATED VS UNCOMPLICATED DIVERTICULAR DISEASE IN THE MIS ERA: ARE THE MIS APPROACHES APPROPRIATE FOR COMPLEX DISEASE?
Abhinit Shah*1,2, Erica Pettke1, Vesna Cekic1, Chandana Herath Mudiyanselage1, Xiaohong Yan1, Daniel Feingold3, Tracey D. Arnell3, Nipa D. Gandhi1, Richard L. Whelan1
1Surgery, Mount Sinai Roosevelt Hospital, New York, NY; 2Topiwala National Medical College, Mumbai, Maharashtra, India; 3Surgery, NewYork-Presbyterian/Columbia, New York, NY
Introduction: Laparoscopic-assisted methods are the gold standard for elective colorectal resection (CRR) for diverticulitis, however, patients (pts) with complex disease (fistula, abscess, adjacent organ involvement, and sizable phlegmon with dense adhesions) can be quite challenging. This retrospective review was undertaken to assess the surgical management of complex diverticulitis vs simple disease in the MIS era.
Methods: A review of elective diverticulitis CRR cases done for between 2000 and 2016 at 2 hospitals was carried out. Data concerning co-morbidities, disease complexity, operation performed, surgical technique, intra- and postoperative complications, and short term outcome was obtained from an IRB-approved prospective database as well as operative notes and hospital/office charts. The complicated (C) and uncomplicated (UC) patient groups were compared. The Students T and Chi-Square tests were used where appropriate.
Results: A total of 324 Diverticulitis CRR patients (pts) were identified: 186(57.4%) had UC disease and 138(42.6%) had C disease. The findings in the C group were: fistulas, 34 pts (24.6%) (vesical, 36; vaginal 7; enteric, 7; colonic 5; multiple, 5); abscess, 40 (29%); phlegmon, 39 (28.2%), adjacent organ involvement requiring resection, 19 pts (13.8%)(SB, 12; GYN, 8); phlegmon/abscess, 4.3%. As regards co-morbitidies, the groups were similar except that the C group was 4.5 yrs elder, and 10% more patients had DM. In the C group, 41.3% were started as LAP (vs 64% for UC), 44.2% were started as HAL (vs 31.7% for UC) and 14.5% were started as Open (vs 4.3% for UC). The C group (vs the UC group) had a higher Conversion rate to Open (28.8% vs 10.6%), greater diversion rate (20.3% vs 3.76%), longer mean incision length (10.5 vs 7.5) and had a longer LOS (7.7 vs 5.9 days). The C group also had higher rates of transfusion (6.7% vs 2.2%), ileus (17.4% vs 7.6%), SSIs (15.2% vs 8.1%). The success rates of MIS in UC and C disease were 89.3% and 71.1% respectively. Of note, when the C patients who were converted from MIS to Open (34)are compared to the Open C pts the converted pts had a significant shorter incision (5.8cm) but a higher sSSI rate (10 vs 35%, p=ns) and ileus rate (26 vs 5%, p=ns).
Conclusion: MIS methods were used for 84.5% of complex pts (vs 87% for UC pts); of note, over half the MIS cases were done with HAL’s methods. The completion rate of LA methods in patients with other organ involvement was only 43%. Although MIS methods were successful in 70 % of C patients, the rates of diversion, conversion, and SSI’s as well as the IL and LOS were notably greater for the C group. The value and logic of using MIS methods in C patients is less clear. Further study is warranted to determine the patient and disease attributes associated with conversion so as to better select pts for MIS methods.
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