Hinchey Classification Research Articles

Laparoscopic Peritoneal Lavage or Primary Anastomosis With Defunctioning Stoma for Hinchey 3 Complicated Diverticulitis

This study was designed to compare postoperative outcomes of laparoscopic peritoneal lavage and open primary anastomosis with defunctioning stoma in the management of Hinchey 3 diverticulitis. From 1994 to 2006, 35 patients underwent laparoscopic peritoneal lavage for Hinchey 3 diverticulitis in three institutions. Data prospectively collected were compared with those of a retrospective series of 24 patients matched for Hinchey's classification and who underwent primary anastomosis with defunctioning stoma. There was no postoperative death. Postoperative morbidity was not different between the two groups. One patient in the laparoscopic peritoneal lavage group required a Hartmann's procedure because of a colonic fistula. One patient in the primary anastomosis with defunctioning stoma group underwent a reoperation for incisional dehiscence. The median hospital stay was lower in patients treated by laparoscopic peritoneal lavage (8 vs. 17 days, P < 0.0001). Twenty-five patients in the laparoscopic peritoneal lavage group underwent elective laparoscopic resection. One of them required conversion to laparotomy. All patients in the primary anastomosis with defunctioning stoma group have had their ileostomy closed. Cumulative surgical morbidity (16 vs. 37.5 percent, P = 0.0507) and hospital stay (14 vs. 23 days, P < 0.0001) were lower in the laparoscopic peritoneal lavage group. In the management of Hinchey 3 diverticulitis, laparoscopic peritoneal lavage does not result in excess morbidity or mortality, it reduces the length of hospital stay and avoids a stoma in most patients, and it is, therefore, a reasonable alternative to primary anastomosis with defunctioning stoma.

Surgical treatment of sigmoid diverticulitis—analysis of predictive risk factors for postoperative infections, surgical complications, and mortality

Sigmoid diverticular disease has great clinical importance due to its increasing incidence in the Western world and a broad spectrum of clinical features with potential fatal complications after surgery. The definition of risk factors associated with postoperative infections, surgical complications and mortality could be helpful in clinical decision-making and optimizing perioperative treatment. Based on a prospective database, 168 consecutive patients undergoing surgery for sigmoid diverticulitis were included in this study. The association of different potential risk factors such as age, Hinchey classification, type and duration of operation, surgeons' experience, blood loss, comorbidities, and hospital course with perioperative complications and mortality were tested by univariate and multivariate analysis. Of the 168 patients enrolled in this study, there were 84 male and 84 female. A third of patients were operated as emergency cases (within 24 h after surgical evaluation); 62% underwent open surgery, 35% were treated laparoscopically with a conversion rate of 3%. A blood transfusion received 14% of patients, a surgical infection occurred in 20%, surgical complications appeared in 24% with a necessity for re-exploration in 9.5%. Leakage of the primary anastomosis was seen in 3.3%, whereas a leakage of the Hartmann's stump occurred in 4.3%. Overall in-hospital mortality was 4.1%. Multivariate analysis demonstrated Hinchey classification and intraoperative blood transfusion to be independently associated with postoperative infections, complications and mortality. Hinchey classification and intraoperative blood transfusion are independently associated with a worse perioperative outcome in patients undergoing surgery for sigmoid diverticular disease. While Hinchey classification cannot be influenced per se by the surgeon, outcome might be influenced by reducing the need for intraoperative blood transfusion.

Image-guided conservative management of right colonic diverticulitis.

To study the clinical outcomes of medical therapy in patients with right colonic diverticulitis. The records of 189 patients with right colonic diverticulitis which was finally diagnosed by computed tomography, ultrasonography, or operative findings were retrospectively reviewed. Of the 189 patients hospitalized for right colonic diverticulitis, the stages of diverticulitis by a modified Hinchey classification were 26 patients (13.8%) in stage 0, 139 patients (73.5%) in stage Ia, 23 patients (12.2%) in stage Ib, and 1 patient (0.5%) in stage III. Medical therapy was undertaken in 185 of 189 patients (97.9%). One hundred and eighty three of 185 patients were successfully treated with bowel rest and antibiotics. Two patients in stage Ib required a resection or surgical drainage because of an inadequate response to conservative treatment. Recurrent diverticulitis developed in 15 of 183 patients (8.2%) who responded to medical therapy. All 15 patients who suffered a second attack had uncomplicated diverticulitis, and were successfully treated with medical therapy. Our results indicate that right colonic diverticulitis is essentially benign and image-guided conservative treatment is primarily required.

CT in acute perforated sigmoid diverticulitis

Background: To assess the value of computed tomography (CT) in patients with acute perforated sigmoid diverticulitis in correlation with the Hinchey classification of perforated diverticular disease. Methods: Thirty patients with acute perforated sigmoid diverticulitis underwent computed tomography prior to surgery. Computed tomography scans were compared with the surgical and histopathological reports, utilizing the Hinchey classification. Results: In 28 of the 30 (93%) patients examined, the Hinchey stage was correctly determined by means of computed tomography. One patient with Hinchey stage IV was falsely classified as Hinchey stage III, and one patient with Hinchey stage III as Hinchey stage II. Computed tomography revealed 12 out of 14 (86%) patients with perforation sites and 3 out of 3 (100%) patients with contained perforation. In one of 17 (6%) patients with surgically or histopathologically proven perforation or contained perforation, a bowel wall discontinuity was revealed by computed tomography. In 6 of the 17 (35%) patients with surgical or histopathological perforation or contained perforation, extraluminal contrast material was detected by computed tomography. Conclusions: Computed tomography is a valuable imaging tool for determining the degree of acute perforated sigmoid diverticulitis, by means of which patients can be stratified according to the severity of the disease; furthermore, this tool is of assistance in surgical planning.

Large bowel perforation: morbidity and mortality.

Perforations of large bowel are rare but severe complications, mainly of colorectal cancer and colonic diverticulitis. The choice of the surgical procedure is still debated. We retrospectively studied peritonitis caused by large bowel perforation to assess predictors of mortality and safety of primary resection and anastomosis. We investigated 59 patients with large bowel perforation treated surgically as emergency cases: 18 patients underwent primary resection and anastomosis, 36 had primary resection of the diseased part of bowel without anastomosis, and 5 patients had non-resective procedures. The severity of peritonitis was assessed using Hinchey's classification and the Mannheim peritonitis index (MPI). Overall mortality was 16.9%. MPI score was significantly lower for survivors vs. non-survivors, and for patients with resection and anastomosis vs. those who underwent resection without anastomosis (p<0.001). The mortality rate was 11.1% for primary resection with anastomosis, and 22.2% for primary resection without anastomosis. No patient with MPI less than 25 died, while 10 (38.5%) of the patients with MPI of 26-36 died. In conclusion, a radical aggressive approach is recommended for most patients with large bowel perforation. Mortality and morbidity are closely related to the extent of intraperitoneal infection and the incidence of postoperative complications is higher in patients with perforation due to non-malignant causes.

Prognostic factors in perforating diverticulitis of the large intestine

Morbidity and mortality after emergency procedures in 105 patients with perforated colonic diverticulitis were evaluated in a retrospective study. In different stages of diverticulitis (Hinchey classification: I, 8.6%; II, 14.3%; III, 57.1%; IV, 20.0%) mortality was 12.4%. Preoperative sepsis syndrome with leucopenia and disturbed liver function, cardiac risk factors and obesity were independent prognostic factors in multiple logistic regression. Accompanied by immunosuppression the mortality rate remarkably increased to 33%. The stage of peritonitis showed no influence on the prognosis. In multivariate analysis, surgical procedure (primary resection 12.4%. Hartmann's procedure 61.9%, non-resection procedures 25.7%) showed influence only on increased general complications.

Intraoperative colonic lavage in nonelective surgery for diverticular disease.

Staged resection of the sigmoid colon has been the traditional strategy for treating patients who require nonelective surgery to manage complications of diverticular disease. Resection and primary anastomosis has not generally been recommended when the clinical setting is compromised by contiguous inflammation or inadequate mechanical cleansing of the colon because of concerns regarding the potential risk of anastomotic dehiscence. Although many reports have confirmed that intraoperative colonic lavage (ICL) is a safe method for relieving fecal loading of the colon to facilitate primary intestinal anastomosis in patients with mechanical obstruction of the distal colon, there is very limited experience with the use of this technique in treating acute inflammatory disorders of the colon. In this report, we present our results with ICL in the nonelective treatment of patients with complications of diverticulitis. Records of all patients undergoing urgent operations at the Lahey Clinic to treat complications of diverticular disease from July 1987 to January 1996 were reviewed. Of 62 patients who required nonelective operations, 33 underwent ICL in an attempt to perform primary anastomosis. In five patients, the operation included creation of a colostomy. The indication for surgery was obstruction in 13 patients (39 percent), persistent abscess or phlegmon in 13 (39 percent), perforation in 6 patients (18 percent), and hemorrhage in 1 patient (3 percent). According to Hinchey's classification system, 18 patients had Stage I disease, 10 had Stage II, and 5 patients had Stage III disease. There were no patients with Stage IV disease. The single anastomotic complication in the series was responsible for the sole operative mortality. The morbidity rate of 42 percent, included three intraoperative complications (2 splenic injuries and 1 ureteral laceration), two intra-abdominal abscesses (6 percent), and six wound infections (18 percent). In our experience, ICL has proven to be a safe method for accomplishing single-stage resection of the colon in selected patients with diverticulitis who require an urgent operation. When there is no evidence of diffuse purulent or feculent peritonitis, we believe this is the preferred method for treating patients who are hemodynamically stable.

Laparoscopic surgery for diverticulitis.

Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p = NS). Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment.