Skip to main content

Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?

Techniques in Coloproctology volume 15, pages 199–203 (2011)Cite this article

Abstract

Background

Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe.

Methods

All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed.

Results

Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula.

Conclusion

The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Mäkelä J, Kiviniemi H, Latinen S (2002) Prevalence of perforated sigmoid diverticulitis is increasing. Dis Colon Rectum 45:955–961

    PubMed  Article  Google Scholar 

  2. Baker ME (2008) Imaging and interventional techniques in acute left-sided diverticulitis. J Gastrointest Surg 12:1314–1317

    PubMed  Article  Google Scholar 

  3. Mazza D, Chio’ F, Khoury-Helou A (2009) Conservative laparoscopic treatment of diverticular peritonitis. J Chir (Paris) 146:265–269

    CAS  Google Scholar 

  4. Böttger TC, Müller M, Terzic A, Hermeneit S, Roderhorst A (2007) Laparoscopic resection with primary anastomosis in Hinchey stages I and II without previous abscess drainage. Chirurg 78:456–460

    Article  Google Scholar 

  5. Zingg U, Pasternak I, Dietrich M, Seifert B, Oertli D, Metzger U (2010) Primary anastomosis vs. Hartmann’s procedure in patients undergoing emergency left colectomy for perforated diverticulitis. Colorectal Dis 12:54–60

    PubMed  Article  CAS  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  7. Alvarez JA, Baldonedo RF, Bear IG et al (2009) Outcome and prognostic factors of morbidity and mortality in perforative sigmoid diverticulitis. Int Surg 94:240–248

    PubMed  Google Scholar 

  8. Mueller MH, Karpitschka M, Renz B et al. (2010) Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis. Int J Colorectal Dis 2010 Jul 30 [Epub Ahead of Print]

  9. Bielecki K, Kamiński P, Klukowski M (2002) Large bowel perforation: morbidity and mortality. Tech Coloproctol 6:177–182

    PubMed  Article  CAS  Google Scholar 

  10. Antolovic D, Reissfleder C, Koch M et al (2009) Surgical treatment of sigmoid diverticulitis—analysis of predictive risk factors for postoperative infections, surgical complications and mortality. Int J Colorect Dis 24:577–584

    Article  CAS  Google Scholar 

  11. Roblick UJ, Massmann A, Schwandner O et al (2002) Quality of life assessment after surgery for diverticulitis—a follow-up study. Zentralb Chir 127:31–35

    Article  CAS  Google Scholar 

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

    PubMed  Article  CAS  Google Scholar 

  13. Naraynsingh V, Ariyanayagam D, Pooran S (1991) Primary repair of colon injuries in a developing country. Br J Surg 78:319–320

    PubMed  Article  CAS  Google Scholar 

  14. Naraynsingh V, Rampaul R, Maharaj D, Kuruvilla T, Ramcharan K, Pouchet B (1999) Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon. Br J Surg 86:1341–1343

    PubMed  Article  CAS  Google Scholar 

  15. Linder MM, Wacha H, Feldmann U, Wesch G, Streifensand RA, Gundlach E (1987) The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis. Chirurg 58:84–92

    PubMed  CAS  Google Scholar 

  16. 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 44:699–703

    PubMed  Article  CAS  Google Scholar 

  17. Hart AR, Kennedy HJ, Stebbings WS, Day NE (2000) How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. Eur J Gastroenterol Hepatol 12:661–665

    PubMed  Article  CAS  Google Scholar 

  18. Constantinides VA, Heriot A, Remzi F et al (2007) Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg 245:94–103

    PubMed  Article  Google Scholar 

  19. Pasternak I, Dietrich M, Woodman R, Metzger U, Wattchow DA, Zingg U (2010) Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis. Int J Colorectal Dis 25:463–470

    PubMed  Article  Google Scholar 

  20. 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

    PubMed  Article  CAS  Google Scholar 

  21. Franklin ME Jr, Portillo G, Treviño 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

    PubMed  Article  Google Scholar 

  22. Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA (2010) Patterns of recurrence in patients with acute diverticulitis. Br J Surg 97:952–957

    PubMed  Article  CAS  Google Scholar 

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

    PubMed  Article  CAS  Google Scholar 

  24. Zeitoun G, Laurent A, Rouffet F et al (2000) Multicentre randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg 87:1366–1374

    PubMed  Article  CAS  Google Scholar 

  25. Wasvary H, Turfah F, Kadro O, Beauregard W (1999) Same hospitalization resection for acute diverticulitis. Am Surg 65:632–635

    PubMed  CAS  Google Scholar 

  26. Vermeulen J, Gosselink MP, Hop WC et al. (2009) Long-term survival after perforated diverticulitis. Colorectal Dis Nov 6 [EPub ahead of print]

Download references

Author information

Affiliations

  1. Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies, Trinidad, West Indies

    V. Naraynsingh, R. Maharaj, D. Hassranah, S. Hariharan & D. Dan

  2. Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel Hashomer Hospital, Tel-Aviv, Israel

    A. P. Zbar

Authors
  1. V. Naraynsingh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Maharaj
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Hassranah
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. Hariharan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. D. Dan
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. A. P. Zbar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. P. Zbar.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Naraynsingh, V., Maharaj, R., Hassranah, D. et al. Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?. Tech Coloproctol 15, 199–203 (2011). https://doi.org/10.1007/s10151-011-0675-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10151-011-0675-7

Keywords

  • Perforated diverticulitis
  • Primary suture
  • Omentoplasty
  • Hinchey classification
  • Hinchey grade IV
  • Faecal peritonitis