International Journal of Colorectal Disease

, Volume 26, Issue 2, pp 227–234 | Cite as

Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis

  • Mario H. Mueller
  • Martina Karpitschka
  • Bernhard Renz
  • Axel Kleespies
  • Michael S. Kasparek
  • Karl-Walter Jauch
  • Martin E. Kreis
Original Article



It was previously reported that in patients with acute perforated diverticulitis with Hinchey categories I to III sigmoidectomy with primary anastomosis (PA) is superior to Hartmann’s procedure (HP) as later closure of colostomy involves substantial morbidity. We evaluated our experience with PA for patients with perforated diverticulitis over a 10-year period and aimed to investigate whether Hinchey category or co-morbidity are more relevant for postoperative outcome.


Records of all patients treated at our institution for sigmoid diverticulitis between 1996 and 2006 were retrieved from an in-hospital database (N = 787, median age 66 years, range 30 to 94, female:male ratio 1.3:1); 73 patients who underwent immediate emergency surgery for perforated diverticulitis were included in this study. American Society of Anesthesiology (ASA) classification to gauge co-morbidity and Hinchey category for intraoperative extent of inflammation were evaluated as regards their relevance for postoperative mortality and major complications.


47 patients (64%) underwent sigmoid colectomy and PA, which was combined with loop ileostomy in 11 patients (15%). Sigmoid colectomy and HP was performed in 26 patients (36%). Major postoperative complications occurred in 26 patients (36%). In the PA group, 10 of 47 patients (21%) had anastomotic leakage. Three leakages occurred despite a loop ileostomy. Anastomotic leakage was independent of Hinchey category (Hinchey I: three patients, Hinchey II: four patients, Hinchey III: three patients, n.s.), but associated with co-morbidity (one patient ASA II, six patients ASA III, three patients ASA IV, P < 0.05). Total mortality was 12%. Seven patients died after HP and two patients after PA. No mortality was observed in PA patients with loop ileostomy.


Emergency surgery for perforated sigmoid diverticulitis is associated with high morbidity and mortality rates. Anastomotic leakage was associated with patient co-morbidity rather than with intraoperative Hinchey category, suggesting that the decision to perform PA should better be based on patient’s general condition rather than on intraoperative extent of inflammation.


Perforated diverticulitis Emergency surgery Co-morbidity Mortality 


  1. 1.
    Martel J, Raskin JB (2008) History, incidence, and epidemiology of diverticulosis. Clin Gastroenterol 42:1125–1127CrossRefGoogle Scholar
  2. 2.
    Parks NS, Burkitt DP (1975) Diverticular disease of the colon: a 20th century problem. Clin Gastroenterol 4:3–21Google Scholar
  3. 3.
    Rafferty J, Shelito P, Hyman NH et al (2006) Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 49:939–944CrossRefPubMedGoogle Scholar
  4. 4.
    Gooszen AW, Gooszen HG, Veerman W et al (2001) Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection. Eur J Surg 167:35–39CrossRefPubMedGoogle Scholar
  5. 5.
    Zeitoun G, Laurent A, Rouffet F, Hay J, Fingerhut A, Paquet J, Peillon C, Research TF (2000) Multicentre randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg 87:1366–1374CrossRefPubMedGoogle Scholar
  6. 6.
    Salem L, Anaya DA, Roberts KA et al (2005) Hartmann’s colectomy and reversal in diverticulitis. Dis Colon Rectum 48:988–995CrossRefPubMedGoogle Scholar
  7. 7.
    Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J (1997) Surgical management of complicated colonic diverticulitis. Br J Surg 84:380–383CrossRefPubMedGoogle Scholar
  8. 8.
    Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME (2005) Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 17:649–654CrossRefPubMedGoogle Scholar
  9. 9.
    Schilling MK, Maurer CA, Kollmar O, Büchler MW (2001) Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey stage III and IV). A prospective outcome and cost analysis. Dis Colon Rectum 44:699–705CrossRefPubMedGoogle Scholar
  10. 10.
    Salem L, Flum DR (2004) Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 47:1953–1964CrossRefPubMedGoogle Scholar
  11. 11.
    Constantinides VA, Heriot A, Remzi F, Darzi A, Senapati A, Fazio VW, Tekkis PP (2007) Operative strategies for diverticular peritonitis. A decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg 245:94–103CrossRefPubMedGoogle Scholar
  12. 12.
    Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109PubMedGoogle Scholar
  13. 13.
    Oomen JLT, Engel AF, Cuesta MA (2005) Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors. Colorectal Dis 8:112–119CrossRefGoogle Scholar
  14. 14.
    Zingg U, Pasterna KI, Dietrich M, Seifert B, Oertli D, Metzger U (2010) Primary anastomosis vs. Hartmann’s procedure in patients undergoing left colectomy for perforated diverticulitis. Colorectal Dis 2:54–60CrossRefGoogle Scholar
  15. 15.
    Roberts P, Abel M, Rosen L, Cirocco W, Fleshman J, Leff E, Levien D, Pritchard T, Wexner S, Hicks T (1995) Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons. Dis Colon Rectum 38:126–132CrossRefGoogle Scholar
  16. 16.
    ASA physical status classification system. American Society of Anesthesiologists, 2003. Available at Accessed on January 11, 2010
  17. 17.
    Framakis N, Tudor RG, Keighley MR (1994) The 5-year natural history of complicated diverticular disease. Br J Surg 81(5):733–735CrossRefGoogle Scholar
  18. 18.
    Gooszen AW, Tollenaar RA, Geelkerken RH, Smeets HJ, Bemelman WA, Van Schaardenburgh P, Gooszen HG (2001) Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 88:693–697CrossRefPubMedGoogle Scholar
  19. 19.
    Tang R, Chen HH, Wang YL (2001) Risk factors for surgical site infection after elective resection of the colon and rectum. Ann Surg 234:181–189CrossRefPubMedGoogle Scholar
  20. 20.
    Longo WE, Virgo KS, Johnson F (2000) Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum 43:83–91CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Mario H. Mueller
    • 1
  • Martina Karpitschka
    • 1
  • Bernhard Renz
    • 1
  • Axel Kleespies
    • 1
  • Michael S. Kasparek
    • 1
  • Karl-Walter Jauch
    • 1
  • Martin E. Kreis
    • 1
  1. 1.Department of SurgeryLudwig-Maximilians-UniversityMunichGermany

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