Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”
- 8 Downloads
Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS).
Materials and methods
Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept:  limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and  definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann’s procedure) after 24–48 h.
Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).
The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.
MS, II, AA, PS, AH, JP, PR, and FA contributed significantly to the design of the study, interpretation of data, drafting of the manuscript, critical revision, and final approval of this work. All authors agree to be accountable for the accuracy and integrity of this work.
Compliance with ethical standards
Conflict of interest
All the authors declare that they have no conflict of interest.
- 6.Vermeulen J, Coene PPLO, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GHH (2009) Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one-stage procedure? Colorectal Dis Off J Assoc Coloproctol G B Irel 11(6):619–624Google Scholar
- 7.Kafka-Ritsch R, Birkfellner F, Perathoner A, Raab H, Nehoda H, Pratschke J (2012) Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV. J Gastrointest Surg Off J Soc Surg Aliment Tract 16(10):1915–1922CrossRefGoogle Scholar
- 14.Demmel N, Muth G, Maag K, Osterholzer G (1994) Prognostic scores in peritonitis: the Mannheim Peritonitis Index or APACHE II? Langenbecks Arch Für Chir 379(6):347–352Google Scholar
- 15.Rogy M, Függer R, Schemper M, Koss G, Schulz F (1990) The value of 2 distinct prognosis scores in patients with peritonitis. The Mannheim Peritonitis Index versus the Apache II score. Chir Z Für Alle Geb Oper Medizen 61(4):297–300Google Scholar
- 16.Függer R, Rogy M, Herbst F, Schemper M, Schulz F (1988) Validation study of the Mannheim Peritonitis Index. Chir Z Für Alle Geb Oper Medizen 59(9):598–601Google Scholar
- 18.Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L (2012) Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis Off J Assoc Coloproctol G B Irel 14(11):1403–1410Google Scholar
- 22.Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA (2010) Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis Off J Assoc Coloproctol G B Irel 12(9):862–867Google Scholar
- 23.Angenete E, Thornell A, Burcharth J, Pommergaard H-C, Skullman S, Bisgaard T (2016) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg 263(1):117–122Google Scholar
- 24.Swank HA, Vermeulen J, Lange JF, Mulder IM, van der Hoeven JAB, Stassen LPS (2010) The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 10:29CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Kruis W, Germer C-T, Leifeld L (2014) German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion 90(3):190–207CrossRefPubMedGoogle Scholar