Faster bowel recovery with superior haemorrhoidal artery preservation in patients undergoing sigmoidectomy for diverticular disease: A retrospective cohort study from the diverticular disease registry trial

Abstract

Introduction:

The pathogenesis of diverticular disease varies significantly and so does its clinical presentation. The procedure for left-sided diverticular disease is standardised, but there is still no consensus on the level of arterial ligation. In 2021, our group initiated the Diverticular Disease Registry (DDR) Trial, a multi-institutional registry on diverticular disease. The aim of this study is to analyse patients enrolled in the DDR who underwent elective laparoscopic sigmoidectomy to determine if different arterial ligations result in differences in bowel function.

Patients and Methods:

Patients enrolled in the DDR from June 2021 to January 2024 were reviewed. Inclusion criteria included elective sigmoidectomy for diverticular disease, reported pre-operative bowel preparation and availability of data on the level of the arterial section. Patients were grouped according to the level of artery ligation: the superior haemorrhoidal artery transection (SHA-T) group and the superior haemorrhoidal artery preservation (SHA-P) group.

Results:

A total of 242 patients were enrolled at 8 hospitals. One hundred and ten patients were included in the analysis. Hospital stay was shorter although not significantly in the SHA-P group compared to the SHA-T group (5 ± 2 vs. 6 ± 1.5; P = 0.062). The first flatus occurred earlier in the SHA-P group, approaching the level of significance (1 ± 0.5 vs. 2 ± 0.8; P = 0.057). Bowel function restored significantly earlier in the SHA-P group (2 ± 0.4 vs. 3 ± 2.1; P = 0.041).

Conclusions:

Our study reported improved bowel function in patients undergoing SHA preservation during elective sigmoidectomy for diverticular disease.

INTRODUCTION

In 2020, the World Society of Emergency Surgery published guidelines on diverticular disease recommending a tailored approach to surgery on a case-by-case basis.[1] Similarly, the American Society of Colorectal Surgery, in its latest release, advises surgery after a complicated attack and suggests individualised decisions for patients who experienced uncomplicated diverticulitis.[2] These guidelines mark a shift in practice, moving away from decision-making based solely on the number of episodes or the severity of acute diverticulitis towards a more nuanced approach for patients with diverticulitis or symptomatic diverticular disease.

The pathogenesis of diverticular disease varies significantly and so does its clinical presentation. Deciding the optimal timing for surgery and weighing the pros and cons, considering patient-related factors, can be challenging. Clinical practices and society guidelines are continually evolving.[3]

From a strictly surgical perspective, the procedure for left-sided diverticular disease has been standardised, especially in recent years.[4] The key points of the surgical technique include:

• Complete removal of the diverticula-bearing sigmoid colon, extending the resection proximally to the descending colon if acute episodes have occurred there or in the presence of extensive disease

• Extending the resection to the level of the proximal rectum to include the rectosigmoid junction

• Performing a colorectal anastomosis between a soft, pliable proximal colon and the upper rectum.[5]

Regarding the level of arterial ligation, there is still no consensus. Options include ligation at the level of the sigmoid arteries while preserving the superior haemorrhoidal artery (SHA), at the level of the SHA with preservation of the left colic artery (LCA), or less commonly, at the level of the inferior mesenteric artery (IMA).[6] The choice of arterial ligation may affect post-operative outcomes. Surgeons must balance the safety of the ligation level with the technical challenges involved. Although a distal ligation may preserve good vascularisation of the rectal and colonic stumps, it can be more challenging in case of an inflamed sigmoid. High ligation of the IMA might not be necessary for benign conditions and could harm genitourinary function. Nonetheless, it is frequently used by colorectal surgeons during sigmoidectomy for diverticular disease.

In emergency scenarios, such as colonic perforation suspected of being caused by complicated diverticulitis, the level of ligation is not questioned. High ligation of the IMA and oncologic resection are mandated to preclude persistent disease if colorectal cancer is diagnosed postoperatively.

Among the different ligation techniques, preserving the SHA during elective sigmoidectomy for diverticular disease helps maintain the nervous pathways along this artery, which innervates the colonic segments.[7,8] This preservation could limit colonic denervation to the removed section, potentially facilitating earlier return of bowel function through preserved colonic motility.[9]

In 2021, our group initiated the Diverticular Disease Registry (DDR) Trial, a prospectively collected database, to investigate the short-term postoperative and long-term quality of life outcomes in patients undergoing surgery or receiving medical treatments for diverticular disease. This trial, registered at ClinicalTrials.gov (NCT 04907383), is open to all tertiary care hospitals.[10]

The aim of this study is to analyse patients enrolled in the DDR who underwent elective laparoscopic sigmoidectomy to determine if different arterial ligation levels result in differences in return to intestinal function.

PATIENTS AND METHODS

Patients prospectively enrolled in the DDR from June 2021 to January 2024 were retrospectively reviewed. Inclusion criteria included elective sigmoidectomy for diverticular disease, reported pre-operative bowel preparation and availability of data on the level of arterial section and the post-operative day of first intestinal canalisation. Indications for surgery included symptomatic disease, symptomatic uncomplicated diverticular disease (SUDD) and complicated diverticulitis after symptom remission.

The decision for surgery was made after mandatory collegial discussions with the endoscopist and gastroenterologist. All patients were required to have undergone an abdominal computed tomography scan with intravenous contrast and a colonoscopy with biopsy.

Patients were grouped according to the level of artery ligation: the SHA transection (SHA-T) group, including high ligation of the IMA or low ligation of the IMA with the preservation of the LCA and the SHA preservation (SHA-P) group, with distal ligation of the sigmoid arteries.

Reported post-operative outcomes were intraoperative blood loss, operative time, Clavien–Dindo complication rate,[11] conversion rate and hospital stay days.

Pre-operative bowel preparation includes citric acid 2 days before surgery, metronidazole 500 mg three times a day on the day before surgery and mesalazine 800 mg three times a day on the day before surgery.

Sigmoidectomy is performed using a medial-to-lateral approach. For SHA transection, the SHA is sectioned after the LCA. For SHA preservation, the sigmoid vessels are sectioned distally within the mesosigmoid. Rectal transection is performed with a 60-mm mechanical stapler below the rectosigmoid junction. An end-to-end Knight–Griffen anastomosis is performed to restore bowel continuity using a 29-mm circular stapler. Real-time angiography with an indocyanine green test is performed to assess anastomotic perfusion.

The decision for SHA transection or preservation was based on the surgeon’s intraoperative preference.

RESULTS

A total of 242 patients were enrolled at 8 hospitals. Patients’ characteristics are reported in Table 1.

Table 1.

Pre-operative characteristics

	Total (n=242)	SHA-P (n=138)	SHA-T (n=104)	P
Female	102	46	56	0.61
Age, median (range)	53 (21–82)	52 (21–80)	54 (35–82)	0.32
BMI (mean±SD)	26.4±2.3	26.6±2.1	25.8±2.7	0.21
Recurrent diverticulitis	110	59	51	0.34
SUDD	68	38	30	0.43
Complicated diverticulitis	64	30	34	0.55
ASA
1	91	51	40	0.09
2	113	62	51	0.12
3	38	15	13	0.38

ASA: American Society of Anaesthesiologists, BMI: Body mass index, SHA-P: Superior haemorroidal artery preservation group, SHA-T: Superior Haemorroidal Artery Transection group, SD: Standard deviation, SUDD: Symptomatic uncomplicated diverticular disease

The Visual Abstract reports a visual representation of accrual and results.

There was no difference between the two groups in terms of gender, BMI, age, ASA score and types of diverticular disease. One hundred and ten patients received an indication for elective laparoscopic sigmoidectomy due to recurrent diverticulitis, 68 for SUDD and 64 following recovery from an episode of complicated diverticulitis.

Table 2 describes post-operative outcomes. There were no differences in surgery duration, blood loss, conversion rate or complication rate between the two groups.

Table 2.

Post-operative outcomes

	Tot (n=242)	SHA-P (n=138)	SHA-T (n=104)	P
Time of surgery (min)	144±29	152±19	134±25	0.62
Blood loss (mL)	33±13	38±5	32±9	0.74
Overall complication rate	36 (14.9)	22 (15.9)	14 (13.5)	0.08
CD >3	11 (4.5)	6 (4.5)	5 (4.8)	0.92
Anastomotic bleeding	17 (7.0)	10 (7.2)	7 (6.7)	0.72
Conversion rate	17 (7.0)	9 (6.5)	8 (7.7)	0.35
Anastomotic leak	8 (3.3)	4 (2.9)	4 (3.8)	0.32
Reoperation	8 (3.3)	4 (2.9)	4 (3.8)	0.21
Hospital stay (days)	5±2.9	5±2	6±1.5	0.06
First flatus (days)	2±1.2	1±0.5	2±0.8	0.06
First passage of stool (days)	3±2.2	2±0.4	3±2.1	0.04*

*Statistically significant. CD: Clavien-Dindo, SHA-P: Superior Haemorroidal Artery Preservation group, SHA-T: Superior Haemorroidal Artery Transection group

Hospital stay was shorter in the SHA-P group, although not significantly so, compared to the SHA-T group (5 ± 2 vs. 6 ± 1.5; P = 0.062). The first flatus occurred earlier in the SHA-P group compared to the SHA-T group, approaching the level of significance (1 ± 0.5 vs. 2 ± 0.8; P = 0.057). Bowel function was restored significantly earlier in the SHA-P group compared to the SHA-T group (2 ± 0.4 vs. 3 ± 2.1; P = 0.041).

DISCUSSION

In our study, we found that patients undergoing elective laparoscopic sigmoidectomy for diverticular disease, with complete preservation of the SHA, resumed bowel function earlier compared to patients in whom the SHA was transected. There were no differences in other intra- or post-operative outcomes between the two groups.

The physiological mechanism of defecation results from a complex interaction between sympathetic and parasympathetic innervation.[12] The conclusion that this nervous mechanism has been preserved by maintaining the SHA in its entirety is a reasoned assumption.[13] However, albeit in a limited way, the more rapid resumption of intestinal canalisation in patients in whom the SHA is maintained provides us with interesting insights.

The ability to empty the rectal ampulla depends on a parasympathetic innervation coming from the sacral plexuses intertwined with a sympathetic component conveyed by the SHA.[14] The more efficient vascularisation of the ampulla, provided by the SHA, certainly favours improved defecation function.[15] Furthermore, peristalsis and colonic motility could be better preserved through the maintenance of proximal nerve fibres originating from the SHA.[16] From an anatomical perspective, it is, therefore, possible to suggest that intestinal functionality may be compromised through vascular ligations proximal to the plane of the superior hypogastric plexus. Nerve lesions at that point, in fact, mostly lead to genitourinary rather than intestinal dysfunctions.[17]

In a previous study conducted by our group, we investigated the genitourinary function at 6 months in patients who were electively operated on for diverticular disease, comparing those with either preservation or transection of the SHA.[18] We did not find significant differences between the two groups. Both techniques, in fact, are able to maintain a physical distance between the dissecting plane and the inferior mesenteric plexus, the superior and inferior hypogastric plexuses and the hypogastric nerves. Conversely, preserving the SHA allows for the sparing of the nervous component that travels along the artery to innervate the descending and sigmoid colon and the upper rectum. Maintaining such innervation could aid in preserving bowel motility, thereby potentially leading to the earlier resumption of bowel function observed.

Recently, Silvestri et al. retrospectively investigated bowel function at 6 months post-surgery through a questionnaire, reporting a lower incidence of defecatory disorders – confirmed by manometry data – less incontinence and fewer lifestyle alterations in patients with SHA preservation compared with those who underwent SHA transection.[19]

Our results, although related to bowel function recovery in the immediate post-operative period, could be in line with those reported by Silvestri et al.[19] Similarly, Masoni et al. reported a lower incidence of defecation disorders at 6 months in the SHA preservation group in a randomised trial published in 2013.[20] Jolivet et al. conducted a pilot study to determine the functional impact of elective laparoscopic sigmoidectomy, performed with high ligation of the IMA, on consecutive male patients suffering from diverticulitis. This study emphasised the importance of the interaction between the nerve fibres of the hypogastric plexus and those running along with the SHA to the rectum and distal sigmoid colon. It suggested that complete preservation of the SHA could spare the parasympathetic component involved in bowel function, potentially resulting in better functional outcomes.[6]

Despite all these reported trials, a recent meta-analysis by Cirocchi et al. concluded that the site of ligation of the IMA does not influence the rate of functional complications. They also noted that complete preservation of the SHA may be associated with a higher conversion rate and longer operative time.[21]

The difficulty in achieving robust evidence regarding the efficacy of SHA preservation may depend on the fact that intestinal functional outcomes are rarely reported, and randomised controlled trials are thus far few. The use of registries such as the DDR could pave the way for a new type of prospective evidence, providing real-life data on the causes of diverticular disease, without the well-known flaws of big datasets.

Our study suffers from several limitations, besides its retrospective nature. The decision to preserve or transect the SHA was made by the surgeon during sigmoidectomy. Considering the technical challenges associated with SHA preservation, anatomical reasons and others may have impacted the results, leading to a selection bias. The DDR comprises multiple hospitals, and clinical practices may slightly differ between the centres, affecting the post-operative outcomes, including bowel recovery. Readers must bear these limitations in mind when interpreting the results.

CONCLUSIONS

Our study reported improved bowel function in patients undergoing SHA preservation during elective sigmoidectomy for diverticular disease. Reports from registries like the DDR are strongly encouraged to provide real-life evidence on diverticular disease, which is currently lacking in the literature.

Conflicts of interest

There are no conflicts of interest.

Visual Abstract

Faster bowel recovery with superior haemorrhoidal artery preservation in patients undergoing sigmoidectomy for diverticular disease: A retrospective cohort study from the DDR Trial

Funding Statement

Nil.