Damage control strategy in perforated diverticulitis with generalized peritonitis

Abstract

Background The best treatment for perforated colonic diverticulitis with generalized peritonitis is still under debate. Concurrent strategies are resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann’s procedure (HP), laparoscopic lavage (LL) and damage control surgery (DCS). This review intends to systematically analyze the current literature on DCS. Methods DCS consists of two stages. Emergency surgery: limited resection of the diseased colon, oral and aboral closure, lavage, vacuum-assisted abdominal closure. Second look surgery after 24–48 h: definite reconstruction with colorectal anastomosis (−/ + DI) or HP after adequate resuscitation. The review was conducted in accordance to the PRISMA-P Statement. PubMed/MEDLINE, Cochrane central register of controlled trials (CENTRAL) and EMBASE were searched using the following term: (Damage control surgery) AND (Diverticulitis OR Diverticulum OR Peritonitis). Results Eight retrospective studies including 256 patients met the inclusion criteria. No randomized trial was available. 67% of the included patients had purulent, 30% feculent peritonitis. In 3% Hinchey stage II diverticulitis was found. In 49% the Mannheim peritonitis index (MPI) was greater than 26. Colorectal anastomosis was constructed during the course of the second surgery in 73%. In 15% of the latter DI was applied. The remaining 27% received HP. Postoperative mortality was 9%, morbidity 31% respectively. The anastomotic leak rate was 13%. 55% of patients were discharged without a stoma. Conclusion DCS is a safe technique for the treatment of acute perforated diverticulitis with generalized peritonitis, allowing a high rate of colorectal anastomosis and stoma-free hospital discharge in more than half of the patients.

Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial

“…Moreover, it also correlates to a more cost-effective therapy as was concluded earlier by Lambrichts et al [20] Furthermore no differences in outcome were found between patients being diagnosed with Hinchey III or IV. Other surgical strategies such as damage control surgery with blind closure of both colonic ends after sigmoid resection [21], postponing the decision on definitive reconstruction are interesting alternatives, however confirmation from literature is warranted. Especially in the case of hemodynamic or instable patients this therapy could be further assessed.…”

S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV)

“…Uni- und multizentrische Beobachtungsstudien konnten nachweisen, dass mit dem damage control Konzept die Rate an Hartmann Situationen sowie permanenten Stomata deutlich reduziert werden konnten 561 562 563 564 565 566 567 . Damage control bedeutet im Fall der frei perforierten Sigmadivertikulitis mit eitriger oder fäkulenter Peritonitis Entfernen des perforierten Darmsegmentes als erster rasch durchzuführender Schritt mit sparsamer Resektion und Belassen blinder Enden mit Anlage einer Vakuumversiegelung des Abdomens zur Unterdruckbehandlung der Peritonitis.…”

“…Im zweiten Schritt nach klinischer Stabilisierung des meist septischen Patienten wird nach frühestens 48 Stunden ein second look mit Vervollständigung der Sigmaresektion und Anlage einer Anastomose oder einer Hartmannsituation mit oder ohne neuerlicher Anwendung eines Unterdrucksystems je nach Lokalbefund durchgeführt. Der Vorteil dieses Konzeptes ist zweierlei: zum einen muss die primäre Operation (Sigmaresektion mit Blindverschluss der Kolonenden und Anlage eines abdominellen Vakuumsystems) nicht zwingend von einem kolorektal erfahrenen Viszeralchirurgen durchgeführt werden; zum anderen kann die Entscheidung zur Kontinuitätswiederherstellung (73 % in einem systematischen Review von Sohn et al 567 ) oder Hartmann Situation vertagt und diese Operation dann unter frühelektiven Bedingungen vom Spezialisten durchgeführt werden. Dadurch konnte die Rate an permanenten Stomata relativ niedrig gehalten werden (ca.…”

Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review

“…First, urgent surgical operation focuses on restricted sigmoidectomy including the affected segment, closure of both stumps, enough peritoneal washing, and VAC use. After elapse of 24 to 48 hours and appropriate resuscitation follows the second surgery either for definite reconstruction of colorectal continuity (accompanied by defunctioning ileostomy or not) or Hartmann's operation [ 44 ].…”