Skip to main content
SpringerLink
Log in

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O2 therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94–5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal 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
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The data used for this study can be obtained by direct request to the corresponding author.

Abbreviations

PDD:

Perforated diverticular disease

CT:

Contrast enhanced computed tomography

EDDLT:

Early delayed definitive laparoscopic treatment

SEDDLT:

Successful EDDLT

UEDDLT:

Unsuccessful EDDLT

BMI:

Body mass index

ASA score:

American Society of Anesthesiologists score

EBL:

Estimated intra-operative blood loss

LOS:

Length of hospital stay

CD:

Clavien–Dindo

SD:

Standard deviation

IQR:

Interquartile range

RPA:

Resection and primary anastomosis

DCS:

Damage control surgery

HP:

Hartmann procedure

References

  1. Lumpkin ST, Chaumont N (2019) Management of freely perforated diverticulitis. Dis Colon Rectum. Author manuscript; available in PMC 2020 Mar 20. Published in final edited form as: Dis Colon Rectum.; 62(10):1153–1156

  2. Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V et al (2020) Diverticulitis: an update from the age old paradigm. Curr Probl Surg 57(10):100862. https://doi.org/10.1016/j.cpsurg.2020.100862

    Article  PubMed  PubMed Central  Google Scholar 

  3. Sohn M, Agha A, Iesalnieks I, Tiefes A, Hochrein A, Friess H, Wilhelm D, Schorn S (2020) Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis. BMJ Open 10(12):e042350. https://doi.org/10.1136/bmjopen-2020-042350

    Article  PubMed  PubMed Central  Google Scholar 

  4. Heywood N, Parmar KL, Stott M, Sodde P, Doherty DT, Lim J, Sharma A, LEGS Study Group* and the North West Research Collaborative (2021) The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice. Ann R Coll Surg Engl 103(2):120–129. https://doi.org/10.1308/rcsann.2020.7005

    Article  CAS  PubMed  Google Scholar 

  5. Tartaglia D, Di Saverio S, Stupalkowska W, Giannessi S, Robustelli V, Coccolini F, Ioannidis O et al (2019) Laparoscopic peritoneal lavage versus laparoscopic sigmoidectomy in complicated acute diverticulitis: a multicenter prospective observational study. Int J Colorectal Dis 34(12):2111–2120. https://doi.org/10.1007/s00384-019-03429-5

    Article  PubMed  Google Scholar 

  6. Sartelli M, Weber DG, Kluger Y, Ansaloni L, Coccolini F, Abu-Zidan F, Augustin G et al (2020) 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 15:32. https://doi.org/10.1186/s13017-020-00313-4

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sallinen VJ, Mentula PJ, Leppäniemi AK (2014) Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients. Dis Colon Rectum 57(7):875–881. https://doi.org/10.1097/DCR.0000000000000083

    Article  PubMed  Google Scholar 

  8. Khan RMA, Hajibandeh S, Hajibandeh S (2017) Early elective versus delayed elective surgery in acuterecurrent diverticulitis: a systematic review and meta-analysis. Int J Surg 46:92–101. https://doi.org/10.1016/j.ijsu.2017.08.583 (Epub 2017 Sep 4)

    Article  PubMed  Google Scholar 

  9. Lock JF, Galata C, Reißfelder C, Ritz JP, Schiedeck T, Germer CT (2020) The indications for and timing of surgery for diverticular disease. Dtsch Arztebl Int 117(35–36):591–596. https://doi.org/10.3238/arztebl.2020.0591

    Article  PubMed  Google Scholar 

  10. Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F, Griffiths EA et al (2015) A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg 10:3. https://doi.org/10.1186/1749-7922-10-3

    Article  PubMed  PubMed Central  Google Scholar 

  11. Barat M, Dohan A, Pautrat K, Boudiaf M, Dautry R, Guerrache Y, Pocard M, Hoeffel C, Eveno C, Soyer P (2016) Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation. Abdom Radiol (N Y) 41(9):1842–1850. https://doi.org/10.1007/s00261-016-0764-1

    Article  Google Scholar 

  12. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  Google Scholar 

  13. Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, Steele SR, Feingold DL, Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons (2020) The American Society of colon and rectal surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum 63(6):728–747. https://doi.org/10.1097/DCR.0000000000001679

    Article  PubMed  Google Scholar 

  14. Lambrichts DPV, Vennix S, Musters GD, Mulder IM, Swank HA, Hoofwijk AGM et al (2019) LADIES trial collaborators. Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol. 4(8):599–610. https://doi.org/10.1016/S2468-1253(19)30174-8

    Article  PubMed  Google Scholar 

  15. Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E et al (2017) Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am Coll Surg 225(6):798–805

    Article  Google Scholar 

  16. Zizzo M, Castro Ruiz C, Zanelli M, Bassi MC, Sanguedolce F, Ascani S, Annessi V (2020) Damage control surgery for the treatment of perforated acute colonic diverticulitis: a systematic review. Medicine (Baltimore) 99(48):e23323. https://doi.org/10.1097/MD.0000000000023323

    Article  Google Scholar 

  17. Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L et al (2012) Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis 14(11):1403–1410. https://doi.org/10.1111/j.1463-1318.2012.03117.x

    Article  CAS  PubMed  Google Scholar 

  18. Sohn M, Agha A, Iesalnieks I, Gundling F, Presl J, Hochrein A, Tartaglia D, Brillantino A, Perathoner A, Pratschke J, Aigner F, Ritschl P (2021) Damage control strategy in perforated diverticulitis with generalized peritonitis. BMC Surg 21(1):135. https://doi.org/10.1186/s12893-021-01130-5

    Article  PubMed  PubMed Central  Google Scholar 

  19. Acuna SA, Wood T, Chesney TR, Dossa F, Wexner SD, Quereshy FA, Chadi SA, Baxter NN (2018) Operative strategies for perforated diverticulitis: a systematic review and meta-analysis. Dis Colon Rectum 61(12):1442–1453

    Article  Google Scholar 

  20. Van Dijk ST, Doelare SAN, van Geloven AAW, Boermeester MA (2018) A systematic review of pericolic extraluminal air in left-sided acute colonic diverticulitis. Surg Infect 19:362–368. https://doi.org/10.1089/sur.2017.236

    Article  Google Scholar 

  21. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG (2011) The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 54:663–671

    Article  Google Scholar 

  22. Costi R, Cauchy F, Le Bian A, Honart J-F, Creuze N, Smadja C (2012) Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment. Surg Endosc 26(7):2061–2071

    Article  Google Scholar 

  23. Garfinkle R, Almalki T, Pelsser V, Bonaffini P, Reinhold C, Morin N, Vasilevsky CA, Liberman AS, Boutros M (2020) Conditional risk of diverticulitis after non-operative management. Br J Surg 107(13):1838–1845. https://doi.org/10.1002/bjs.11836 (Epub 2020 Sep 2)

    Article  CAS  PubMed  Google Scholar 

  24. Thorisson A, Nikberg M, Andreasson K, Smedh K, Chabok A (2018) Non-operative management of perforated diverticulitis with extraluminal or free air a retrospective single center cohort study. Scand J Gastroenterol 53(10–11):1298–1303

    Article  CAS  Google Scholar 

  25. Pellino G, Podda M, Wheeler J, Davies J, Di Saverio S (2020) Laparoscopy and resection with primary anastomosis for perforated diverticulitis: challenging old dogmas. Updates Surg 72(1):21–28 (Epub 2020 Jan 28)

    Article  Google Scholar 

  26. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C et al (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 (discussion 826–7)

    Article  Google Scholar 

  27. Chua TC, Jeyakumar A, Ip JCY, Yuide PJ, Burstow MJ (2020) Conservative management of acute perforated diverticulitis: a systematic review. J Dig Dis 21(2):63–68. https://doi.org/10.1111/1751-2980.12838

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Di fratta E. and Mari G conceived the study, Crippa J. and Siracusa C. wrote the manuscript. Sassun R. did the statistical analysis, Maggioni D. and Costanzi A. revised the diagnostic work up. Fingerhut A. critically appraised and revised the paper.

Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

  1. General Surgery Unit, Hospital of Desio, ASST Brianza, Desio, MB, Italy

    Emanuele Di Fratta, Giulio Mari, Richard Sassun & Dario Maggioni

  2. IRCCS Humanitas Research Hospital, ASST Melegnano-Martesana, Rozzano, Milan, Italy

    Jacopo Crippa

  3. Laboratory of Clinical Chemistry, Hospital of Desio, ASST-Brianza, Desio, MB, Italy

    Claudia Siracusa

  4. General Surgery Unit, Merate Hospital, ASST Lecco, Merate, LC, Italy

    Andrea Costanzi

  5. AIMS Academy Clinical Research Network, ASST Grande Ospedale Metropolitano Niguarda, Milan, MI, Italy

    Abe Fingerhut

Authors
  1. Emanuele Di Fratta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Giulio Mari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jacopo Crippa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Claudia Siracusa
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andrea Costanzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Richard Sassun
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dario Maggioni
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Abe Fingerhut
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

AIMS Academy Clinical Research Network

  • Giulio Mari

Contributions

EDF and GM conceived the study, JC and CS wrote the manuscript. RS did the statistical analysis, DM and AC revised the diagnostic work up. AF critically appraised and revised the paper.

Corresponding author

Correspondence to Richard Sassun.

Ethics declarations

Conflict of interest

All authors declare they have nothing to disclose.

Ethical statement

The study was approved by a central ethical committee.

Informed consent

Written inform consent was obtained from all patients. No animals were involved in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Di Fratta, E., Mari, G., Crippa, J. et al. Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience. Updates Surg 74, 1665–1673 (2022). https://doi.org/10.1007/s13304-022-01324-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-022-01324-3

Keywords

Search

Navigation