Background Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization. Methods A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically. Results Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)). Conclusion Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

Objective Acute diverticulitis is a frequent clinical conditions encountered in emergency settings. Despite recent international guidelines, management of acute diverticulitis (AD) varies and is not standardized. The aim of the study was to achieve a Swiss nationwide consensus on clinical management of acute diverticulitis. Methods A three-staged consensus meeting according to the Delphi method was performed in 2020 involving 78 Swiss surgeons from 40 hospitals. A steering-group drafted the questionnaires, gathered best available evidence which was presented and discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement. Results 57 surgeons answered all the 3 rounds and 28 (53%) performed > 50 colorectal resections per year. On initial workup in the emergency setting, performing leucocytes count (87%), CRP (98%) and CT imaging (98%) reached consensus for the diagnosis, but no uniform classification system of AD was retained. Signs of generalized peritonitis (100%), requiring intravenous pain medication (98%), inability to tolerate oral intake (95%), lack of adequate social support (86%), immunosuppression (96%), and complicated AD on CT (84%) were criteria for hospitalization. Persisting symptoms (95%) and immunosuppression (89%) were criteria for elective colonic resection, while the number of AD episodes were not (27%). In case of abscess, a size ≥ 4 cm reached consensus for percutaneous drainage (88%). No consensus were reached for surgical approach and techniques in the emergency settings, apart from damage control surgery for instable patients (70%). In the follow-up, recommendation for dietary restrictions or lifestyle habits did not reach reach consensus. Conclusion Swiss colorectal surgeons reached consensus for several diagnostics, hospitalization, and elective surgery criterias. However, emergency surgical management and follow-up are less standardized. These variations should be further assessed, and particularly in the context the latest published recommendations.

Objective Anastomotic leakage (AL) is one of the most feared complications of colorectal surgery. Despite surgical improvements, AL incidence remains significant and guidance on its prevention and management is lacking. The aim of the study was to achieve a Swiss nationwide consensus on clinical prevention and management of AL. Methods A three-step Delphi consensus meeting was performed in 2020 involving 78 Swiss surgeons from 40 centers. A steering-group drafted the questions, gathered best available evidence which was discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement. Results The three consensus meetings were attended by 66, 57 and 37 surgeons, respectively. Surgeons’ median experience was 14 years, with 47% performing >50 colorectal resections yearly. Consensus was reached on routine use of preoperative nutritional screening (100%) using nutritional scores (88%) and >10% weight loss (95%). but not low BMI (63%) or low albumin (64%). Consensus was reached for no bowel preparation (BP) prior to right colectomy (RC) (76%) and for mechanical BP with oral antibiotics prior anterior resections (AR) (70%). No consensus was found on BP prior left colectomy (LC). Respondents favored a side-to-side anastomosis (76%) after RC, with extra-corporeal confection (70%), without consensus on the anastomosis being stapled or hand-sewn; an end-to-end (73%), stapled (80%) anastomosis after LC and a stapled anastomosis (86%) after AR, irrespective of the anastomosis configuration type. Anastomotic control with transanal leak-test was supported by 92%, while ICG control did not reached consensus (67%). After TME, routine diversion was favored (73%), irrespective of neoadjuvant therapy (94%) or not (70%). Consensus was reached on routine postoperative CRP monitoring (94%). CT-scan with rectal contrast enema was the preferred investigation for suspected AL after RC or LC (82%) and AR (76%). Conservative management of AL, provided appropriate clinical state, was an acceptable option after LC (72%), AR with stoma (95%), but not after RC (59%) or AR without stoma (53%). Conclusion Consensus was reached on several clinical aspects for prevention and management of AL among Swiss colorectal surgeons, providing national guidance. Further data is required on intraoperative aspects of anastomosis confection and control to ensure broader consensus.