The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis

Cirocchi, Roberto; Fearnhead, Nicola; Vettoretto, Nereo; Cassini, Diletta; Popivanov, Georgi; Henry, Brandon Michael; Tomaszewski, Krzysztof A.; D’Andrea, Vito; Davies, Justin; Saverio, Salomone Di

doi:10.1016/j.surge.2018.08.010

Cited by 37 publications

(22 citation statements)

References 69 publications

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“…On the other hand, a significantly higher rate of conversion in the IMA preservation group was found. Another aspect that is not addressed in the available literature is the role of laparoscopic IMA preservation/ligation in the emergency setting and during Hartmann's procedure . With this in mind, the influence of IMA preservation on the operating time and on anastomotic leakage after Hartmann's reversal deserves further exploration.…”

Section: Discussionmentioning

confidence: 99%

Sigmoid resection for diverticular disease – to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta‐analysis

et al. 2019

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Aim In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta‐analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage. Method A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta‐analysis software Review Manager 5.3. Results Eight studies met the inclusion criteria and were included in the meta‐analysis: two randomized controlled trials (RCTs) and six non‐RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26–1.33, I2 = 55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14–2.65, I2 = 0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed. Conclusion This meta‐analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA‐preserving technique as mandatory in resection for left‐sided colonic diverticular disease.

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Section: Discussionmentioning

confidence: 99%

Sigmoid resection for diverticular disease – to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta‐analysis

et al. 2019

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“…[ 27 – 35 ] The management of retroperitoneal abscess from visceral perforation in complicated diverticular disease is still a challenge during the common surgical treatment of colonic diverticulitis. [ 36 – 39 ]…”

Section: Discussionmentioning

confidence: 99%

Clinical signs of retroperitoneal abscess from colonic perforation

Ruscelli

Renzi²,

Polistena

et al. 2018

Medicine

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Rationale:Retroperitoneal colonic perforation is a rare cause of retroperitoneal abscess. It presents, more frequently in frail elderly patients, with heterogeneous signs and symptoms which hamper the clinical diagnosis. Subcutaneous emphysema with pneumomediastinum and iliopsoas muscle abscess are unusual signs. Colonic retroperitoneal perforation may be consequent to diverticulitis or locally advanced colon cancer. Due to the anatomy of the retroperitoneal space and different physiopathology, diverticular perforation may present with air and pus collection; on the other hand perforated colon cancer may cause groin mass and psoas abscess. We reported 2 cases of colonic retroperitoneal perforation from diverticulitis and locally advanced colon cancer, respectively. Aim of this report is to improve differential diagnosis based on clinical signs.Patients’ concerns:A 71-year-old man presented with pain in his left side, fatigue, fever, nausea, massive subcutaneous emphysema of the neck, and Blumberg sign in the left iliac fossa. A 67-year-old man presented with abdominal pain, sub-occlusion, left groin mass, left groin, and lower limb pain during walking, negative Blumberg sign.Diagnosis:In the first patient the computerized tomography revealed pneumoperitoneum, gas in the mesosigma, pneumomediastinum, wall thickening of the descending colon, and retroperitoneal collection from diverticular perforation. In the second patient abdominal CT scan found thickening of the sigmoid colon adherent to the iliopsoas and fluid collection.Interventions:In the first patient, a left hemicolectomy extending to the transverse colon, followed by a toilette and debridement of the retroperitoneum were performed. In the second patient, tumor of descending colon perforated in the retroperitoneum with iliopsoas abscess was treated with left hemicolectomy and a drainage of the abscess.Outcomes:The first patient underwent right colectomy with ileostomy in the 7th postoperative day for large bowel necrosis. He died of sepsis 2 days after. The second patient had regular postoperative and he is still alive.Lessons:The spread of retroperitoneal abscess in complicated colonic diverticulitis is different from that in advanced colonic cancer. The former can present with a subcutaneous emphysema, the latter with a groin mass. Hence a thorough clinical examination and radiological studies are needed to diagnose these conditions.

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“…A few favourable outcomes of emergency laparoscopic resection for perforated diverticulitis have emerged. A metaanalysis [42] of experimental/observational studies comparing laparoscopic and open sigmoidectomy in acute settings showed reduced morbidity after a laparoscopic approach, although differences between the two groups in the rate of Hartmann's procedure (HP) vs primary resection and anastomosis (PRA), operating time, reoperation rate and postoperative 30-day mortality were not detected. Caution is advised when considering these data since lack of hemodynamic data and reasons for operative approach suggests a potential selection bias.…”

Section: Considerationsmentioning

confidence: 99%

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

et al. 2020

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Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

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The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis

Cited by 37 publications

References 69 publications

Sigmoid resection for diverticular disease – to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta‐analysis

Sigmoid resection for diverticular disease – to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta‐analysis

Clinical signs of retroperitoneal abscess from colonic perforation

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

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