Il ruolo della laparoscopia nella terapia chirurgica della diverticolite.

2. Laparoscopia e peritonite
Malattia diverticolare
Marco Azzola Guicciardi
&
Andrea Favara
U.O. Chirurgia Generale e mininvasiva
Ospedale Sant’ Antonio Abate
Cantù (Co)
A.O. Sant Anna Como

3. Diverticolosi -malattia diverticolare
Diverticolite
10 -20% pazienti con diverticolosi

4. CLASSIFICAZIONE HINCHEY (1978)
Stadio I Flemmone o ascesso
pericolico
Stadio II a Ascesso pelvico
Stadio II b Ascesso pelvico
complesso
Stadio III Peritonite purulenta
Stadio IV Peritonite stercoracea

5. In elezione
* indicazioni alla resezione ridotte
* resezione indicata dopo due episodi dogma
superato
* se resezione meglio laparoscopia

7. L' indicazione al ricovero nelle diverticoliti
non complicate da trattare con
antibioticoterapia non è assoluta
Il ruolo stesso dell' antibioticoterapia è in
discussione

8. Outpatient versus hospitalization management for uncomplicated
diverticulitis: a prospective, multicenter randomized clinical trial
(DIVER Trial)
Biondo S et al.
Conclusions: Outpatient treatment is safe and effective in selected
patients with uncomplicated acute diverticulitis.Outpatient
treatment allows important costs saving to the health systems
without negative influence on the quality of life of patients with
uncomplicated diverticulitis.
Ann Surg. 2014 Jan;259(1):38-44

9. Indicazioni in urgenza
Emorragia
stenosiocclusione
PERFORAZIONE

14. •

15. Indicazioni
Hinchey 1 e 2a
Terapia medica ,drenaggio percutaneo o
laparoscopico

16. Diverticolite acuta
Terapia antibiotica
1) Ampicillina sulbactam
2) Cefalosporina 3 + metronidazolo
3) Chinolone + metronidazaolo
4) carbapenemi

17. Indicazioni
Hinchey 2b e 3
Lavaggio drenaggio laparoscopico

18. Indicazioni
Hinchey (3) e 4
Resezione colica con o senza anastomosi
laparoscopica o laparotomica

19. Hartmann

21. Laparoscopic peritoneal lavage for generalized peritonitis due to
perforated diverticulitis
Authors
E. Myers,M. Hurley,G. C. O'Sullivan,D. Kavanagh,I. Wilson,D.
C. Winter
First published: 12 December 2007
Methods:
A prospective multi-institutional study of 100 patients was
undertaken
Conclusion:
Laparoscopic management of perforated diverticulitis with generalized
peritonitis is feasible, with a low recurrence risk in the short term

22. Lavaggio laparoscopico

24. Determinants of outcome following laparoscopic peritoneal lavage for perforated
diverticulitis
Authors
F. Radé,F. Bretagnol,M. Auguste,C. Di Guisto,N. Huten,L. de Calan 9
September 2014
Presented to the 114th French Congress of Surgery, Paris, France, October 2013 Abstract
Background
Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perforated
diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to
establish determinants of failure to enable improved selection of patients for this approach.
Results
For patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per
cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent
respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more,
American Society of Anesthesiologists grade III or above, and immunosuppression were associated with
reintervention.
Conclusion
Elderly patients and those with immunosuppression or severe systemic co-morbidity are
at risk of reintervention after laparoscopic lavage.

27. *QUATTRO studi randomizzati multicentrici
*lavaggio laparoscopico vs resezione colica
- LAPLAND (Irlandese)
- LADIES (Olandese)
- SCANDIV
- DILALA (Scandinavo).

29. Treatment of acute diverticulitis laparoscopic
lavage vs. resection (DILALA): study protocol for
a randomised controlled trial
Anders Thornell1*, Eva Angenete2, Elisabeth Gonzales2, Jane Heath2, Per Jess3, Zoltan Läckberg4, Henrik
Ovesen3,
Jacob Rosenberg5, Stefan Skullman6 and Eva Haglind2, for the Scandinavian Surgical Outcomes Research
Group, SSORG
Abstract
Background: Perforated diverticulitis is a condition associated with substantial morbidity. Recently published
reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no
randomised
study has published any results.
Methods: DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional
Hartmann’s Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary
endpoints
consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma.
Patients
are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the
patient is
included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally,
placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12
months.
A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40).
Discussion: HP is associated with a high rate of complication. Not only does the primary operation entail
complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of
treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe,
minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer
reoperations,
decreased morbidity, mortality, costs and increased quality of life.
Trial registration: British registry (ISRCTN) for clinical trials ISRCTN82208287 http://www.controlled-trials.com/

31. Conclusion
Perforated acute diverticulitis is treated by surgical intervention.
Worldwide, Hartmann’s procedure remains the gold standard and the
primary choice for acute diverticulitis with fecal peritonitis. Peritoneal
lavage is a more conservative and bowel-preserving approach compared to
resection in purulent diverticulitis. Peritoneal lavage has currently been
added to certain official treatment guidelines. The lack of level 1 evidence
does, however, keep peritoneal lavage from being implemented as a
routine treatment. Current ongoing randomized trials on surgical
treatments for perforated diverticulitis are awaited to determine if
peritoneal lavage can be recommended as a routine approach. When data
from these are available, guidelines may be adjusted. In the meantime,
treatment must be decided on an individual basis when treating acute
perforated, colonic diverticulitis.

32. Esperienza personale
122012 – 92014
• 93 pazienti ricoverati per diverticolite
• 21 operati (13f 8m)
• 1621 pazienti eta’ superiore a 65
anni
• Hinchey 2 7 casi
• Hinchey 3 9 casi
• Hinchey 4 5 casi

33. CASISTICA 12.2011~9.2014
21 PAZIENTI OPERATI
F 90 H3 laparoscopia laparotomia
Hartmann
Infez ferita 27 gta dim
F74 H4 laparoscopia laparotomia
Hartmann
Vers pleur, epa 41 gta dim
F65 H2 Laparoscopia drenaggio 7 gta dim
F73 H3 laparoscopia laparotomia
Hartmann
Infez ferita 20 gta dim (5m ricanalizzata)
M33 H3 Laparoscopia drenaggio 10 gta dim
F76 H4 laparoscopia laparotomia
Hartmann
Infez/ ematoma ferita 47 gta dim
M66 H3 Laparoscopia drenaggio Perforaz ileo reintervento I
gta sutura
9 gta dim

34. F 84 H4 laparoscopia laparotomia Hartmann polmonite dim 23 gta
F88 H3 laparotomia Hartmann - dim 28 gta
F66 H2 laparoscopia drenaggio - Dim 7gta
resez anastomosi 2mesi dopo
F67 H2 laparoscopia drenaggio - 8 gta dim
M58 H2 laparoscopia drenaggio 6 gta dim 4 mesi dopo
colon: k, attende resez
F66 H3 laparotomia Hartmann Infez ferita 17 gta dimessa
ricanalizzata 5mesi dopo
M55 H2 Laparoscopia laparotomia drenaggio Infez ferita 11gta dimesso
M67 H2 Laparoscopia drenaggio - dim 9
F82 H4 Laparotomia Hartmann Infez ferita dim 26
F85 H3
laparoscopia laparotomia resez
anastomosi
fa – tvp
(filtro cavale)
dim 40 gta

35. Intervento 42014
Colonscopia 82014

36. Interventi eseguiti
• 8 laparoscopia drenaggio
• 1 laparoscopia conversione e
drenaggio
• 9 laparoscopia conversione
Hartmann
• 3 laparotomia ed Hartmann

37. Interventi in base allo stadio
Hinchey 2:
6 laparoscopia drenaggio
(1 resezanastomosi laparotomica in 4 gta ,
1 k colon alla colonscopia)

38. Interventi in base allo stadio
Hinchey 3 :
5 laparoscopia, conversione ed
Hartmann
2 laparoscopia e drenaggio (1 reint 1
gta perforaz ileale)
2 laparotomia ed Hartmann

39. Interventi in base allo stadio
Hinchey 4:
4 laparoscopia conversione ed
Hartmann
1 laparotomia ed Hartmann
1 laparoscopia e drenaggio

40. Casistica complessiva
• Mortalita’ 0
• Morbilita’ 80% Hartmann
• Infezione ferita
• Polmonite
• versamento pleurico
• Ep
• raccolta ascessuale
30% lavaggio
perforaz ileale
cancro non riconosciuto

41. Lavaggio drenaggio laparoscopico
tecnica
• Verres in ipocondrio sinistro
• Trocar ottico ombelicale
• Due trocar da 5 mm accessori
• Minima mobilizzazione dei visceri
• Lavaggio con fisiologica e betadine
• Sutura della perforazione se piccola e visibile
• Due drenaggi , nel Douglas e nella doccia
parietocolica sinistra.

42. CONCLUSIONI I
• indicazioni in elezione ridotte e
personalizzate
• terapia urgenza conservativa
laparoscopica
• Età avanzata e comorbidità:Hartmann

43. CONCLUSIONI II
La resezione laparoscopica con o senza anastomosi
in urgenza è un intervento complesso che richiede
competenze non comuni a tutta l’ equipe, rendendo
la conversione laparotomica frequente in questi
casi
Surgeon, Not Disease Severity, often Determines
the Operation for Acute Complicated
Diverticulitis
Presented at the New England Surgical Society
94th Annual Meeting, Hartford, CT, September
2013.
Mohammad S. Jafferji, MD, Neil Hyman, MD,
FACSemail

44. Grazie
Settembre in Valtellina