Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy

Abstract

Introduction Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS. Methods All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011–2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study. Results There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m 2 (SD ± 3.33). Thirteen cases (38%) were Wasvary’s modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann’s procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender ( p = 0.010) and MPI ( p = 0.034) correlated with a high percentage of Hartmann’s procedures. Conclusion DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis

“…One ongoing study (NCT04220840, first posted at January 7, 2020, with the title "The Damage Control Strategy for the Treatment of Perforated Diverticulitis of the Sigmoid Colon With Diffuse Peritonitis") [18] and thirteen studies were excluded based on reasons listed in the SDC 2 [19][20][21][22][23][24][25][26][27][28][29][30][31]. Nine studies were included in this systematic review and meta-analysis [32][33][34][35][36][37][38][39][40]. The NCT04220840 is an ongoing study, first posted at January 7, 2020, with the title "The Damage Control Strategy for the Treatment of Perforated Diverticulitis of the Sigmoid Colon With Diffuse Peritonitis."…”

“…One RCT [32], three prospective observational studies [36][37][38], and five retrospective observational studies [33-35, 39, 40]. All studies were performed in Central Europe [33,34,[37][38][39][40]/Italy [35,36] and published between 2008 and 2020.…”

Damage control surgery for the treatment of perforated acute colonic diverticulitis

“…In a perforated ACD setting, initial emergency operation (first-look) was as short as possible and focused on source control, with limited resection of perforated colon segment, proximal and distal colon closure, leaving stapled colon without in situ reconstruction, peritoneal lavage, and temporary abdominal closure by use of NPWT during initial surgery. [ 11 – 18 ] In selected cases, closure of perforation site was carried out through interrupted sutures, instead of performing colon resection. [ 12 ]…”

Perforated descending colon adenocarcinoma manifesting as necrotizing fasciitis

“…A Hartmann's procedure was deemed the safest and most suitable option in light of these conditions. Damage control surgery is preferable for severely septic patients with hostile abdominal compartments not amenable to colonic anastomosis 7. Post‐operative adjuvant chemotherapy has been shown to improve outcome in advanced cancers such as T4.…”