Skip to main content
SpringerLink
Log in

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”

  • Original Scientific Report
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Purpose

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: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann’s procedure) after 24–48 h.

Results

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%).

Conclusion

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Holmer C, Kreis ME (2014) Diverticular disease—choice of surgical procedure. Chir Z Für Alle Geb Oper Medizen 85(4):308–313

    Article  CAS  Google Scholar 

  2. Vermeulen J, Gosselink MP, Busschbach JJV, Lange JF (2010) Avoiding or reversing Hartmann’s procedure provides improved quality of life after perforated diverticulitis. J Gastrointest Surg Off J Soc Surg Aliment Tract 14(4):651–657

    Article  Google Scholar 

  3. Aydin HN, Remzi FH, Tekkis PP, Fazio VW (2005) Hartmann’s reversal is associated with high postoperative adverse events. Dis Colon Rectum 48(11):2117–2126

    Article  PubMed  Google Scholar 

  4. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256(5):819–826

    Article  PubMed  Google Scholar 

  5. Jurowic C, Germer C-T (2016) Leitliniengerechte Therapie der Divertikulitis. Coloproctol 38(4):267–278

    Article  Google Scholar 

  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):619–624

    CAS  Google 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):1915–1922

    Article  Google Scholar 

  8. Perathoner A, Klaus A, Mühlmann G, Oberwalder M, Margreiter R, Kafka-Ritsch R (2010) Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis–a proof of concept. Int J Colorectal Dis Juni 25(6):767–774

    Article  Google Scholar 

  9. Langenfeld SJ (2013) Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air. J Trauma Acute Care Surg Mai 74(5):1376

    Article  Google Scholar 

  10. Cirocchi R, Arezzo A, Vettoretto N, Cavaliere D, Farinella E, Renzi C (2014) Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy. Medicine (Baltimore) 93(25):e184

    Article  Google Scholar 

  11. Sohn M, Agha A, Heitland W, Gundling F, Steiner P, Iesalnieks I (2016) Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis. Tech Coloproctol 20(8):577–583

    Article  PubMed  CAS  Google Scholar 

  12. Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA (2012) Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 27(2):207–214

    Article  PubMed  Google Scholar 

  13. Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109

    PubMed  CAS  Google 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):347–352

    CAS  Google 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):297–300

    CAS  Google 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):598–601

    Google Scholar 

  17. Brunkhorst F, Hagel S (2011) Sepsis. Intensivmed 48:57–73

    Article  Google 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):1403–1410

    CAS  Google Scholar 

  19. Cirocchi R, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A (2013) Treatment of Hinchey stage III–IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 28(4):447–457

    Article  PubMed  Google Scholar 

  20. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A (1996) Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 171(4):432–434

    Article  PubMed  Google Scholar 

  21. Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC (2008) Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 95(1):97–101

    Article  PubMed  CAS  Google 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):862–867

    CAS  Google 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):117–122

    Google 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 10:29

    Article  PubMed  PubMed Central  Google Scholar 

  25. Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH (2015) Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet Lond Engl 386(10000):1269–1277

    Article  Google Scholar 

  26. Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J (2015) Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA 314(13):1364–1375

    Article  PubMed  CAS  Google 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):190–207

    Article  PubMed  Google Scholar 

  28. Leifeld L, Germer CT, Böhm S, Dumoulin FL, Häuser W, Kreis M (2014) S2k guidelines diverticular disease/diverticulitis. Z Für Gastroenterol 52(7):663–710

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral-, Endokrine- und minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Strasse 77, 81925, Munich, Germany

    Maximilian Sohn, I. Iesalnieks & A. Agha

  2. Chirurgische Klinik, Charité – Universitätsmedizin Berlin, Campus Charité Mitte|Campus Virchow-Klinikum, Berlin, Germany

    J. Pratschke, P. Ritschl & F. Aigner

  3. Klinik für Allgemein, Viszeral- und Gefäßchirurgie-, Klinikum Harlaching, Städtisches Klinikum München GmbH, Munich, Germany

    P. Steiner

  4. OCM – München, Munich, Germany

    A. Hochrein

Authors
  1. Maximilian Sohn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. I. Iesalnieks
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Agha
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. Steiner
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Hochrein
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. J. Pratschke
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. Ritschl
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. F. Aigner
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

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.

Corresponding author

Correspondence to Maximilian Sohn.

Ethics declarations

Conflict of interest

All the authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sohn, M., Iesalnieks, I., Agha, A. et al. Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”. World J Surg 42, 3189–3195 (2018). https://doi.org/10.1007/s00268-018-4585-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-018-4585-y

Search

Navigation