Diverticular Disease Complicated With Colovesical Fistula: Laparoscopic Versus Robotic Management

摘要

Fistula formation is a complication of diverticulitis in 4% to 20% of cases.1,2 The left or sigmoid colon is the most commonly involved segment. The most common presenting symptom is pneumaturia and dysuria, followed by fecaluria, abdominal pain and, rarely, hematuria.3–6 Some colovesical fistulas (CVFs) are asymptomatic.4–6 CVF is more common in males and in females with a history of hysterectomy.5,6 The diagnosis is usually made clinically but can be confirmed by cystoscopy, sigmoidoscopy, barium enema, computed tomography (CT) scan, magnetic resonance imaging (MRI), or virtual colonoscopy.3,4,7 The usual management for symptomatic patients is colon resection, and there is still controversy in the approach to asymptomatic patients.4,6Left colectomy for CVF secondary to diverticular disease can be very challenging owing to the presence of acute and chronic inflammation, which makes the tissues harder and more prone to bleeding. It is also more difficult to visualize and find proper anatomic planes and to identify vital structures. Conversion rates of laparoscopic sigmoidectomy complicated with diverticulitis are double that for cancer and as high as 30%.2,8–11 In general, a colectomy for diverticulitis is considered a more difficult operation than a colectomy for cancer, whether or not a laparoscopic or open approach is chosen.2,8 Some authors have proposed laparoscopic surgery as the gold standard approach for diverticular disease2 and CVF management.7,11 The safety of robotic surgery for colorectal diseases has been previously addressed in other studies.12–18 The purpose of our study is to review and compare our experience with laparoscopic left colectomy and robotic left colectomy for diverticular disease complicated with CVF. The primary end point was conversion.This is a retrospective review of a prospective database. Robotic colorectal surgery was introduced into our practice in June 2009. A total of 251 robotic colectomies were performed from June 2009 to April 2013 in our practice. Of the 251 robotic colectomies, 112 were left colectomies and 20 of them were for CVF secondary to diverticular disease. We compared these 20 consecutive patients, who underwent robotic left colectomy for diverticular disease complicated with CVF, with 55 consecutive comparable cases performed laparoscopically from January 2001 to May 2009. All cases, laparoscopic and robotic, were performed by the same board-certified colorectal surgeons. Our standard practice for over 20 years has been to perform elective laparoscopic colectomy for diverticular disease with associated CVF.All patients were 18 years or older and did not have any contraindication for major elective surgery. Only benign CVFs secondary to diverticular disease were included; malignant and emergent cases were excluded. Variables studied were age, body mass index (BMI), comorbidities, and American Society of Anesthesiologists score (ASA). Total operative room time (TORT) was defined as “wheels-in” to “wheels-out” and operative time (OT) was defined as the time from first incision to last skin closure. Intraoperative and postoperative complications and conversion rates were also recorded. Follow-up was done by the customary office visits. Informed consents were obtained from all patients. This protocol and database were Institutional Review Board (IRB) reviewed and approved.Conversion was defined as the use of an extraction site for any part of the dissection or CVF takedown. In other words, an extraction site was only used for specimen extraction. Conversion to laparoscopic surgery was defined as undocking the robot at any time prior to performing the anastomosis and performing any part of the dissection under laparoscopic guidance with the exception of the stapled anastomosis.Two independent statisticians provided the data analysis. Mann-Whitney U tests and Fisher's exact tests were used. The results are reported as mean, median, standard deviation, and range. A P value less th