With the above in mind,

SAPBC will be sending you

bimonthly newsletters

informing you of the latest

treatment modalities

available to your patients

for various surgical

conditions. Our goal is to

keep you informed so that

you can make the most

intelligent

recommendation to your

patients, and most of all,

feel comfortable referring

them to our group.

We appreciate the trust

you have given us to care

for your patient’s surgical

problems and will

endeavor to provide them

with the highest quality

surgical care. When your

patient needs surgery, you

need to know that they

are getting experienced,

fully capable care

performed to the highest

standards.

As always, thank you for

your continued support.

INTRODUCTION

Surgical Associates of

Palm Beach County

(SAPBC) is a Multi-

Specialty Surgical group

practice with over 200

years of combined

surgical experience.

SAPBC has a reputation

for leadership and

innovation in the surgical

community, and has built

a reputation for

excellence in surgical care

over the past four

decades.

Our mission is to provide

the highest quality, state

of the art, and

personalized care possible

for our patients. We take

pride in our individual

specialties and work hard

to maintain our expertise.

Our surgeons are

proficient in the latest

minimally invasive

surgical techniques,

including Laparoscopy,

solid organs,

Thoracoscopy and

Endovascular surgery.

SAPBC is capable of

providing skilled care for

most General Surgical,

Colon and Rectal,

Vascular, Thoracic,

Breast and Surgical

Oncologic conditions. The

combined training,

experience and technical

skill of our surgeons has

made our practice a true

Center of Excellence.

However, if any of us

believe a patient would

be better served with

treatment elsewhere, we

will gladly and honestly

make that referral and

help get a timely

appointment.

Because of all the recent

advances occurring in

Medicine, especially

within the field of

Surgery, we feel that it is

important for our

referring physicians to

have an understanding of

the latest treatment

modalities available to

their patients and what

we as a group have to

offer.

Surgical

Associates

of Palm

Beach

County is

the oldest

and largest

Multi-

Specialty

Surgical

group

practice in

South Palm

Beach

County

Gerald N.

Newsletter

Frederick B. Jonathan Matthew A. Joseph A. Angela Manuel A.

Liebler. M.D. Wideroff, M.D. Klein, M.D. Colletta, M.D. Jones, M.D. Molina M.D.

David L. John C. Andrew S. James R. Jonathan Jose F.

Wulkan, M.D. Motta, M.D. Ross, M.D. Barron, M.D. Waxman, M.D. Yeguez, M.D.

Robinson, M.D.

August 2009 Volume 1, Issue 3

1 www.sapbc.net

CEO

For more information please visit our website

(Sigmoid resection, closure of the rectum and

end colostomy. (Fig.1).

In experienced hands, laparoscopic surgery (LS) is as good or better than open colectomy. LS is associated with less pain, less scaring, less use of narcotic and shorter

hospitalization (Fig.2,3,4).

Complicated acute diverticulitis has been a challenge for surgeons for years. It accounts for 25 % of all acute diverticulitis. Severe disease includes: Abscesses, fistula, obstruction, or peritonitis. Ct-Scans have helped us to determine the severity of disease and the necessity of surgery, by showing evidence of localized sigmoid wall thickening, inflammation of pericolic fat, abscess formation (extraluminal gas and/or contrast), and fistula or perforation.

Surgical therapy is indicated for: Recurrent diverticulitis, inability to rule out cancer, medical intractability and complications (obstruction, bleeding, fistula, perforation).

Emergency surgery is basically indicated in two scenarios: 1. When patient presents with severe or diffuse peritonitis (Fig.2). 2. If

sepsis does not improve with inpatient conservative treatment or after percutaneous drainage (Fig.3).

The most challenging situation for the surgeon is the timing of performing resection in patients who failed medical therapy. Waiting a few weeks makes the surgery easier after the anatomy goes back to normal. Waiting too long could be deleterious for some patients with pericolic collections or multiple medical problems. Our tendency is to take patients for surgery sooner if the patient does not get well with a conservative approach. That way the patient has a greater possibility of having a successful surgical outcome and may avoid a colostomy.

The gold standard for acute or emergent cases has been the Hartman’s procedure

670 Glades Rd, Ste 300 - Boca Raton, FL 33431 Ph: 561.395.2626 http://www.sapbc.net

2

Acute Diverticulitis in the Era of Laparoscopic Surgery

August 2009 Volume 1, Issue 3

Fig.1.

Fig.3 & 4. Morbid obese

female. COPD, diabetes,

sleep apnea. Failure CT-

guided drainage. Laparoscopic

Hartman’s. BRCH

Fig.2. Acute abdomen.

Sigmoid perforation/large

pelvis abscess. BRCH

Newsletter

670 Glades Rd, Ste 300 - Boca Raton, FL 33431 Ph: 561.395.2626 http://www.sapbc.net

3

Management of diverticular

disease had been

changing, especially with the

advent of better

antibiotics and

laparoscopic

surgery

August 2009

abscess greater than

5 cm.

After percutaneous drainage of a diverticular abscess: A later elective colectomy usually should be planned. However, 41 % of patients will otherwise develop severe recurrent sepsis.

Low pelvic abscess, not able to be drained by CT-scan, can be treated by transrectal or transvaginal drainage. Most of these require a laparotomy and resection. Laparotomy and drainage only has been associated with high morbid-mortality. Actually, laparoscopic drainage alone could be performed in selected patients, without colectomy.

Hartman’s procedure main disadvantage is that the second-stage colostomy closure is technically difficult. Furthermore, such temporary colostomies often are never closed (35-50%). An alternative to a Hartman’s procedure is resection with primary anastomosis with, or without, a diverting

ostomy (Fig.5).

This surgery depends on patient comorbidities and intraabdominal conditions.

The applicability of laparoscopic colonic

resection will remain directly dependent upon the individual surgeon’s laparoscopic skills. The learning curve is significant. Actually, only 18 % of all the colectomies in US are done by Minimally Invasive Surgery (MIS). In our group around 72 % are done this way. That decreases to 62 % in diverticulitis cases.

Most of the pericolonic abscess can be treated with percutaneous drainage. In that way a colostomy could be avoided. Multiple abscess or inability to perform the drainage may necessitate emergency surgery.

(Fig.6-8)

Most abscesses less than 5 cm will regress with antibiotic treatment alone. CT-guided drainage with antibiotics should be tried for

Fig.5

65 y/o female patient with multiple pericolonic abscess by Ct-Scan (5). Laparoscopic

assisted sigmoid resection and anastomosis. Specimen (6) . Patient in POD #1 (7)

Fig.5 Fig.6 Fig.7

Volume 1, Issue 3

best option if feasible.

SAPBC has the largest experience doing Minimally Invasive Colon Surgery in our area. We have a vast experience in Minimally Invasive Surgery for cancer, inflammatory bowel disease as well as diverticular disease. We have done well over 2,000 cases of laparoscopic colon resection.

The literature showed that this approach should be done for patients with high risk for surgery, in high volume centers, by surgeons with high laparoscopic skills. Decision to perform resection or non-resectional surgery seems to be influenced by surgical findings and patient conditions. Laparoscopic lavage(without resection or stoma), is an obvious

extension of such conservational approaches. The use of colostomy is avoided, patient improved immediately, and this procedure could be done with acceptable mortality and morbidity.

Our experience with lavage and drainage has been limited to a few well selected patients (Fig. 8-10). We believe resection is the

670 Glades Rd, Ste 300 - Boca Raton, FL 33431 Ph: 561.395.2626 http://www.sapbc.net

4

August 2009 Volume 1, Issue 3

Fig.8 Fig.9 Fig.10

Large diverticulitis pelvis

abscess. No window for CT-

Scan guided drainage (8).

Laparoscopic drainage (9).

Jakson-Prat drain in place (10)

Laparoscopic surgical treatment for acute complicated diverticulitis needs to be individualized depending on the clinical situation and patient selection.

The Gold standard has been the Hartman’s Procedure. However, there is good evidence that primary anastomosis can be accomplished safely in many situations.

Other options such as laparoscopic drainage of abscess, colorraphy and lavage may be applicable. There is good evidence that Minimally Invasive techniques can be performed safely in most situations with excellent results.

Summary

Jose F. Yeguez, M.D. Andrew S. Ross, M.D. James Barron, M.D.

In

experienced

hands,

laparoscopic

surgery is

as good or

better than

open

colectomy

Newsletter

SAPBC’s colorectal surgeons have the largest experience doing Minimally Invasive colon resection in Palm Beach County.

We have special interest in laparocopic surgery for colorectal cancer, IBD, stoma creation and closure, and Single Incision Laparoscopic Surgery (SILS)

ACS, ASCRS,SLS ACS, ASCRS ACS, ASCRS