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Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure

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Abstract

Background

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann’s procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

Methods

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study.

Results

A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann’s for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %.

Conclusions

Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

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References

  1. Parks TG (1975) Natural history of diverticular disease of the colon. Clin Gastroenterol 4:53–69

    PubMed  CAS  Google Scholar 

  2. Krukowski ZH, Matheson NA (1984) Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 71:921–927

    Article  PubMed  CAS  Google Scholar 

  3. Berry AR, Turner WH, Mortensen NJ, Kettlewell MG (1989) Emergency surgery for complicated diverticular disease: a five-year experience. Dis Colon Rectum 32:849–854

    Article  PubMed  CAS  Google Scholar 

  4. Salem L, Anaya DA, Flum DR (2005) Temporal changes in the management of diverticulitis. J Surg Res 124(2):318–323

    Article  PubMed  Google Scholar 

  5. Kronborg O (1993) Treatment of perforated sigmoid diverticulitis: a prospective randomized trial. Br J Surg 80:505–507

    Article  PubMed  CAS  Google Scholar 

  6. Khan AL, Ah-See AK, Crofts TJ, Heys SD, Eremin O (1995) Surgical management of the septic complications of diverticular disease. Ann R Coll Surg Engl 77:16–20

    PubMed  CAS  Google Scholar 

  7. Köhler L, Sauerland S, Neuebauer E (1999) Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 13:430–436

    Article  PubMed  Google Scholar 

  8. Stollman NH, Raskin JB (1999) Diagnosis and management of diverticular disease of the colon in adults: Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 94:3110–3121

    Article  PubMed  CAS  Google Scholar 

  9. Salem L, Anaya DA, Roberts KE, Flum DR (2005) Hartmann’s colectomy and reversal in diverticulitis: a population-level assessment. Dis Colon Rectum 48:988–995

    Article  PubMed  Google Scholar 

  10. Seah DW, Ibrahim S, Tay KH (2005) Hartmann procedure: is it still relevant today? ANZ J Surg 75:436–440

    Article  PubMed  Google Scholar 

  11. Stawicki SP, Brooks A, Bilski T, Scaff D, Gupta R, Schwab CW, Gracias VH (2008) The concept of damage control: extending the paradigm to emergency general surgery. Injury 39(1):93–101

    Article  PubMed  Google Scholar 

  12. Parra-Blanco A (2006) Colonic diverticular disease: pathophysiology and clinical picture. Digestion 73(Suppl 1):47–57

    Article  PubMed  Google Scholar 

  13. Rotondo M, Schwab CW, McGonigal M, Phillips G, Fruchterman T, Kauder D, Latenser B, Angood P (1993) Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 35:373–383

    Google Scholar 

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

    Article  PubMed  Google Scholar 

  15. Stocchi L (2010) Current indications and role of surgery in the management of sigmoid diverticulitis. World J Surg 16(7):804–817

    Google Scholar 

  16. 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 95:97–101

    Article  PubMed  CAS  Google Scholar 

  17. Santaniello M, Bergamaschi R (2006) Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis 9:494–495

    Article  Google Scholar 

  18. Murphy T, Hunt RH, Fried M, Krabshuis JH (2007) World Gastroenterology Organisation Practice Guidelines: diverticular disease. WGO guidelines@worldgastroenterology.org. Accessed 12 Dec 2011

  19. Scholefield JH, Wyman A, Rogers K (1991) Management of generalized faecal peritonitis–can we do better. J R Soc Med 84:664–666

    PubMed  CAS  Google Scholar 

  20. Schwesinger WH, Page CP, Gaskill HV 3rd, Steward RM, Chopra S, Strodel WE, Sirinek KR (2000) Operative management of diverticular emergencies. Strategies and outcomes. Arch Surg 135:558–563

    Article  PubMed  CAS  Google Scholar 

  21. Vermeulen J, Lange JF (2010) Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future. World J Surg 34(3):587–593

    Article  PubMed  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  23. Durmishi Y, Gervaz P, Brandt D, Bucher P, Platon A, Morel P, Poletti PA (2006) Results from percutaneous drainage of Hinchey II diverticulitis guided by computed tomography scan. Surg Endosc 20:1129–1133

    Article  PubMed  CAS  Google Scholar 

  24. Christou NV, Barie PS, Dellinger EP, Waymack JP, Stone HH (1993) Surgical Infection Society intra-abdominal infection study. Prospective evaluation of management techniques and outcome. Arch Surg 128:193–198

    Article  PubMed  CAS  Google Scholar 

  25. Hau T, Ohmann C, Wolmershäuser A, Wacha H, Yang Q (1995) Peritonitis Study Group of the Surgical Infection Society Europe. Planned relaparotomy vs. relaparotomy on demand in the treatment of intra-abdominal infections. Arch Surg 130:1193–1197

    Article  PubMed  CAS  Google Scholar 

  26. Wittmann DH, Schein M, Condon RE (1996) Management of secondary peritonitis. Ann Surg 224:10–18

    Article  PubMed  CAS  Google Scholar 

  27. Wittmann DH (1998) Operative and nonoperative therapy of intraabdominal infections. Infection 26:335–341

    Article  PubMed  CAS  Google Scholar 

  28. Desai DC, Brennan EJ Jr, Reilly JF, Smink RD Jr (1998) The utility of the Hartmann procedure. Am J Surg 175:152–154

    Article  PubMed  CAS  Google Scholar 

  29. Faranda C, Barrat C, Catheline JM, Champault GG (2000) Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Surg Laparosc Endosc Percutan Tech 10:135–138

    PubMed  CAS  Google Scholar 

  30. The Standards Task Force, The American Society of Colon and Rectal Surgeons (2000) Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 43:289–297

    Article  Google Scholar 

  31. 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 88:693–697

    Article  PubMed  CAS  Google Scholar 

  32. Regenet N, Tuech JJ, Pessaux P, Ziani M, Rouge C, Hennekinne S, Arnaud JP (2002) Angers CHU: intraoperative colonic lavage with primary anastomosis vs. Hartmann’s procedure for perforated diverticular disease of the colon: a consecutive study. Hepatogastroenterology 49:664–667

    PubMed  CAS  Google Scholar 

  33. Seetharam S, Paige J, Horgan PG (2003) Impact of socioeconomic deprivation and primary pathology on rate of reversal of Hartmann’s procedure. Am J Surg 186:154–157

    Article  PubMed  Google Scholar 

  34. Maggard MA, Zingmond D, O’Connell JB, Ko CY (2004) What proportion of patients with an ostomy (for diverticulitis) get reversed? Am Surg 70:928–931

    PubMed  Google Scholar 

  35. Salem L, Flum DR (2004) Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 47:1953–1964

    Article  PubMed  Google Scholar 

  36. Banerjee S, Leather AJ, Rennie JA, Samano N, Gonzalez JG, Papagrigoriadis S (2005) Feasibility and morbidity of reversal of Hartmann’s. Colorectal Dis 7:454–459

    Article  PubMed  CAS  Google Scholar 

  37. Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, Larson D (2005) Complicated diverticulitis: is it time to rethink the rules? Ann Surg 242:576–581

    PubMed  Google Scholar 

  38. Peralta R, Napolitano LM: Surgical approach to peritonitis and abdominal sepsis. In: Geibel J ed. medscape.com (http://emedicine.medscape.com/article/1952823-overview). Accessed 12 Dec 2011

  39. Franklin ME Jr, Dorman JP, Jacobs M, Plasencia G (1997) Is laparoscopic surgery applicable to complicated colonic diverticular disease? Surg Endosc 11:1021–1025

    Article  PubMed  Google Scholar 

  40. Mutter D, Bouras G, Forgione A, Vix M, Leroy J, Marescaux J (2006) Two-stage totally minimally invasive approach for acute complicated diverticulitis. Colorectal Dis 8:501–505

    Article  PubMed  CAS  Google Scholar 

  41. Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A (2007) Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis. Dis Colon Rectum 50:1157–1163

    Article  PubMed  Google Scholar 

  42. Agaba EA, Zaidi RM, Ramzy P, Aftab M, Rubach E, Gecelter G, Ravikumar TS, DeNoto G (2009) Laparoscopic Hartmann’s procedure: a viable option for treatment of acutely perforated diverticulitis. Surg Endosc 23:1483–1486

    Article  PubMed  Google Scholar 

  43. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L (2008) Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedure. J Am Coll Surg 206:654–657

    Article  PubMed  Google Scholar 

  44. Franklin ME Jr, Portillo G, Trevin˜o JM, Gonzalez JJ, Glass JL (2008) Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 32:1507–1511

    Article  PubMed  Google Scholar 

  45. Alamili M, Gogenur I, Rosenberg J (2009) Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 52:1345–1349

    Article  PubMed  Google Scholar 

  46. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA (2010) Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 12:862–867

    Article  PubMed  CAS  Google Scholar 

  47. Carrillo C, Fogler R, Shaftan G (1993) Delayed gastrointestinal reconstruction following massive abdominal trauma. J Trauma 34:233–235

    Article  PubMed  CAS  Google Scholar 

  48. Surface ship survivability. Naval War Publications 3–20.31 (1996). Department of Defense, Washington, DC

  49. Moore EE, Burch JM, Franciose RJ, Offner PJ, Biffl WL (1998) Staged physiologic restoration and damage control surgery. World J Surg 22(12):1184–1190

    Article  PubMed  CAS  Google Scholar 

  50. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF (2000) Damage control: collective review. J Trauma 49:969–978

    Article  PubMed  CAS  Google Scholar 

  51. Person B, Dorfman T, Bahouth H, Osman A, Assalia A, Kluger Y (2009) Abbreviated emergency laparotomy in the non-trauma setting. World J Emerg Surg 4:41–44

    Article  PubMed  Google Scholar 

  52. Jansen JO, Loudon MA (2007) Damage control surgery in a non-trauma setting. Br J Surg 94(7):789–790

    Article  PubMed  CAS  Google Scholar 

  53. Burch JM, Denton JR, Noble RD (1997) Physiologic rationale for abbreviated laparotomy. Surg Clin North Am 77(4):779–782

    Article  PubMed  CAS  Google Scholar 

  54. Miller PR, Chang MC, Hoth JJ, Holmes JH, Meredith JW (2007) Colonic resection in the setting of damage control laparotomy: is delayed anastomosis safe? Am Surg 73(6):606–609

    PubMed  Google Scholar 

  55. Van Goor H (2002) Interventional management of abdominal sepsis: when and how? Langenbecks Arch Surg 387(5–6):191–200

    Article  PubMed  Google Scholar 

  56. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, de Graaf PW, Lamme B, Gerhards MF, Steller EP, van Till JW, de Borgie CJ, Gouma DJ, Reitsma JB, Boermeester MA (2007) Comparison of on-demand vs. planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. Dutch Peritonitis Study Group. JAMA 298(8):865–872

    Article  PubMed  Google Scholar 

  57. Banieghbal B, Davies MR (2004) Damage control laparotomy for generalized necrotizing enterocolitis. World J Surg 28(2):183–186

    Article  PubMed  Google Scholar 

  58. Hau T, Ohmann C, Wolmershäuser A, Wacha H, Yang Q (1995) Planned relaparotomy vs. relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe. Arch Surg 130(11):1193–1196

    Article  PubMed  CAS  Google Scholar 

  59. Lamme B, Boermeester MA, Reitsma JB, Mahler CW, Obertop H, Gouma DJ (2002) Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg 89(12):1516–1524

    Article  PubMed  CAS  Google Scholar 

  60. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE (2003) Spectrum of disease and outcome of complicated diverticular disease. Am J Surg 186:696–701

    Article  PubMed  Google Scholar 

  61. Constantinides VA, Tekkis PP, Senapati A (2006) Prospective multicenter evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 93:1503–1513

    Article  PubMed  CAS  Google Scholar 

  62. Taylor CJ, Layani L, Ghusn MA, White SI (2006) Perforated diverticulitis managed by laparoscopic lavage. ANZ J Surg 76:962–965

    Article  PubMed  Google Scholar 

  63. Killingback M (1983) Management of perforative diverticulitis. Surg Clin North Am 63:97–115

    PubMed  CAS  Google Scholar 

  64. Fry RD, Mahmoud NN (2007) Segmental resection for diverticulitis. In: Fischer JE, Bland KI (eds) Mastery of surgery, 5th edn. Lippincott Williams & Wilkins, Philadelphia, pp 1516–1526

  65. Scandinavian Diverticulitis Trial (SCANDIV). http://clinicaltrials.gov/ct2/show/NCT01047462. Accessed 12 Dec 2011

  66. Constantinides VA, Heriot A, Remzi FH, 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 procedure. Ann Surg 245:94–103

    Article  PubMed  Google Scholar 

  67. Laparoscopic peritoneal lavage or resection for generalised peritonitis for perforated diverticulitis (ladies). http://clinicaltrials.gov/ct2/show/NCT01317485. Accessed 12 Dec 2011

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Disclosures

S. Liang and M. E. Franklin Jr., have no conflicts of interest or financial ties to disclose.

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  1. The Texas Endosurgery Institute, 4242 E. Southcross Blvd., Suite 1, San Antonio, TX, 78222, USA

    Song Liang, Karla Russek & Morris E. Franklin Jr.

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  1. Song Liang
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Liang, S., Russek, K. & Franklin, M.E. Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure. Surg Endosc 26, 2835–2842 (2012). https://doi.org/10.1007/s00464-012-2255-y

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