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11 Perforated Diverticulitis: Laparoscopic Lavage andDrainage
127
Despite the initial enthusiasm regarding the use of LLD as a less invasive and
morbid alternative to HP, more recent studies have challenged its presumed superiority relative to other surgical approaches. Nevertheless in our experience at Texas
Endosurgery Institute, in carefully selected patients, LLD has proven to be a safe
alternative, decreasing morbidity and mortality, avoiding stoma formation, and
improving patient’s health immediately. The overall costs are decreased, and the
diseased colon segment can be laparoscopically resected in a non-emergent fashion.
Surgical therapy tailored to the patient appears appropriate.
References
1. Parks TG.Natural history of diverticular disease of colon. Clin Gastroenterol. 1975;4:53–69.
2. Morris CR, Harvey IM, Stebbings WS, Hart AR.Incidence of perforated diverticulitis and risk
factors for death in a UK population. Br JSurg. 2008;95:876–81.
3. Vermeulen J, Gosselink MP, Hop WCJ, Lange JF, Coene PPLO, Van de Harst E, Weidema WF,
Mannaerts GHH.Hospital mortality after emergency surgery for perforated diverticulitis. Ned
Tijdschr Geneeskd. 2009;153:1209–14.
4. Mayo WJ, Wilson LB, Grifn HZ.Acquired diverticulitis of the large intestine. Surg Gynecol
Obstet. 1907;5:8–15.
5. Judd ES, Pollack LW.Diverticulitis of the colon. Ann Surg. 1924;80:425–38.
6. Lockhart Mummery JP.Late results of diverticulitis. Lancet. 1938;2:1401–4.
7. Smithwick RH. Experiences with the surgical management of diverticulitis of the sigmoid.
Ann Surg. 1942;115:969–83.
8. Jacobson MA, Young LS.New developments in the treatment of gram-negative bacteremia.
West JMed. 1986;144:185–94.
9. Stawicki SP, Brooks A, Bilski T, Scaff D, Gupta R, Schwab CW.The concept of damage con-
trol: extending the paradigm to emergency general surgery. Injury. 2008;39(1):93–101.
10. Miller PR, Chang MC, Hoth JJ, Holmes JH, Meredith JW.Colonic resection in the setting of
damage control laparotomy: is delayed anastomosis safe? Am Surg. 2007;73(6):606–9.
11. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, De Calan L.Emergency laparoscopic
management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. JAm Coll Surg. 2008;2006:654–7.
12. Liang S, Russek K, Franklin ME Jr. Damage control strategy for management of perforated
diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic
Hartmann’s procedure. Surg Endosc. 2012;26:2835–42.
13. Cirocchi R, Trastulli S, Vettoretto N, Milani D, Cavaliere D, Renzi C, Adamenko O, Desiderio
J, Burattini MF, Parisi A, Arezzo A, Fingerhut A.Laparoscopic peritoneal lavage: a denitive
treatment for diverticular peritonitis or a “bridge” to elective laparoscopic sigmoidectomy? A
systematic review. Medicine. 2015;94(1):e334.
14. Angenete E, Thornell A, Burcharth J, Pommergaard H-C, Skullman S, Bisgaard T, Jess P,
Läckberg Z, Matthiessen P, Heath J, Rosenberg J, Haglind E.Laparoscopic lavage is feasible
and safe for the treatment of perforated diverticulitis with purulent peritonitis the rst results
from the randomized controlled trial DILALA.Ann Surg. 2016;263(1):117.
15. Galbraith N, Carter JV, Netz U, Yang D, Fry DE, McCafferty M, Galandiuk S.Laparoscopic
lavage in the management of perforated diverticulitis: a contemporary meta-analysis.
JGastrointest Surg. 2017;21:1491.
16. Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA,
Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW,
Boermeester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA.Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicenter, parallel-group, randomized, open-label trail. Lancet. 2015;386:1289–77.
128
17. Agresta F, etal. Laparoscopic approach to acute abdomen from the Consensus Development
Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE),
Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC),
Società Italiana di Chirurgia d’Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia
nell’Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery
(EAES). Surg Endosc. 2012;26(8):2134–64.
18. Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K, AVOD Study Group. Randomized
clinical trial of antibiotics in acute uncomplicated diverticulitis. Br JSurg. 2012;99:532–9.
19. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF.Practice param-
eters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284–94.
20. Mahmoud NN, Riddle EW. Minimally invasive surgery for complicated diverticulitis.
JGastrointest Surg. 2017;21:731–8.
M.E. Franklin Jr. and M.A. Hernández
Perforated Diverticulitis: What Are
theOptions forResection?
FrançoisLetarte andCarlJ.Brown
Introduction
Diverticulosis typically involves the sigmoid colon and occurs in 50% of people
aged over 50years and up to 80% in those aged over 80 [1]. The vast majority of
patients with colonic diverticulosis are asymptomatic, whereas 10–25% will develop
at least a single episode of diverticulitis [2–4]. In these patients, 10–33% will eventually need surgical intervention [2, 5, 6] and only 1% of patients with diverticulosis
will require surgery [7]. Of all admitted patients with a diagnosis of acute diverticulitis, 10–20% will require surgical treatment [8]. Urgent indications for surgery in
patients with diverticulitis include obstruction, hemorrhage, failure of medical management, and free perforation. In this chapter, we will only consider options and
issues related to the last two.
In essence, all presentations of diverticulitis are secondary to perforation of
diverticula. However, most are microperforations that are walled off by adjacent
organs or omentum. Free perforation necessitating urgent surgery is uncommon and
is the indication to undergo emergent surgery in less than 25% of patients with acute
complicated diverticulitis [7]. Rodkey and Welch [8] reviewed the indications for
surgery in a series of 688 patients with acute diverticulitis: perforation with local
peritonitis or pelvic abscess in 32.3%, generalized peritonitis in 14.6%, pain in
13.4%, obstruction in 10.9%, pericolic abscess in 10.9%, stula in 9.7%, and bleeding in 8.2%. Free perforation following diverticulitis is especially common and
lethal in immunosuppressed patients [9, 10].
12
F. Letarte • C.J. Brown (*)
Department of Surgery, St. Paul’s Hospital, University of British Columbia,
Vancouver, BC, Canada
e-mail: etarte@gmail.com; cbrown@providencehealth.bc.ca
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_12
129
130
F. Letarte and C.J. Brown
Classification
Hughes was the rst to present a practical clinical classication of diverticulitis
based on the operative ndings [11]. He divided patients according to the severity
of their peritoneal contamination. Hinchey rened this classication into the widely
adopted four-stage classication of presentations of diverticulitis [12]. In this classication, most patients treated by surgery for acute perforation are stage III or IV,
representing generalized purulent and fecal peritonitis, respectively (Table 12.1).
More recently, Killingback proposed a more complicated classication that differentiates abscess, perforation, and peritonitis into subclassications [10].
Most cases of perforated diverticulitis will be walled off by adjacent structures
preventing free perforation and generalized peritonitis (Hinchey I/II) and resolve
with antibiotics and bowel rest. Rarely, purulent peritonitis may arise following a
progressive leak from a diverticulum or presumed rupture of a previously contained
perforation. In rare cases, patients initially presenting with early-stage diverticulitis
will develop free perforation and generalized fecal peritonitis. This scenario is associated with a very high mortality rate [13–16].
The Hinchey classication system is used to determine both treatment and prognosis. Haglund etal. [5] conrmed the impact of free perforation on outcomes; in
their series, patients experienced 33% surgical mortality in the presence of free
perforation compared to a 3% mortality rate when only acute inammation was
present. Other reports have also shown that both localized peritonitis and abscess
are associated with lower mortality when compared to diffuse fecal or purulent
peritonitis [12, 17, 18].
Table 12.1 Clinical classication of complicated diverticulitis based on operative ndings
Classication
Hughes [11] Stage I Local peritonitis
Hinchey [12] Stage I Pericolic abscess or phlegmon
Killingback [10] Stage I Abscess
Stage
Stage II Local pericolic or pelvic abscess
Stage III General peritonitis due to ruptured pericolic or pelvic abscess
Stage IV General peritonitis due to free perforation of the colon
Stage II Pelvic, intraabdominal, or retroperitoneal abscess
Stage III Generalized purulent peritonitis
Stage IV Generalized fecal peritonitis
a Peridiverticular
b Mesenteric
c Pericolic (pelvic)
Stage II Perforation
a Free
b Concealed
Stage III Gangrenous sigmoiditis
Stage IV Peritonitis
a Serous, purulent or fecal
b Local, pelvic or generalized
Description
12 Perforated Diverticulitis: What Are theOptions forResection?
131
Indications forSurgery
As previously described, we consider two scenarios that require surgery for perforated diverticulitis. The rst indication includes patients who present with generalized peritonitis due to free perforation. Typically, these patients present with diffuse
peritonitis, tachycardia, hypotension, and free air on x-ray and/or CT scan. The
decision to operate is not usually difcult. The second indication includes patients
who fail to respond to non-operative management. Most will be patients with a
phlegmon or abscess with persistent fevers, leukocytosis, tachycardia, pain and tenderness on examination despite intravenous antibiotics, bowel rest, and uid resuscitation. It is important to note that most patients with evidence of “perforation” on
CT imaging may present with localized peritonitis and non-operative management
can safely be attempted. Free air will often result from the initial microperforation
that is quickly contained by the adjacent structures, preventing free perforation and
generalized peritonitis in most cases.
Surgical Management ofPerforated Diverticulitis
The main objective of surgical resection for perforated diverticulitis is to eliminate
the source of ongoing sepsis as quickly and safely as possible. Laparoscopic lavage
has been proposed as an alternative to resection, and this option is discussed in
detail in a different chapter.
Limitations oftheAvailable Evidence
The current literature on the management of perforated diverticulitis consists mostly of
case series and retrospective reports increasing the risk for bias. Another concern is the
lack of consistent classication of diverticular disease that can lead to comparison of
patients with different severity of disease. Most studies do not specify precisely the
extent of peritonitis (i.e., localized vs. purulent vs. feculent peritonitis). The authors
also compare series from different eras where there are numerous confounding factors
inuencing patient outcomes (e.g., antibiotic use, improvements in perioperative care).
Hence, their conclusions and recommendations should be interpreted with caution.
Historic Management
In the early-mid twentieth century, the recommendation for patients presenting with
perforated diverticulitis was a three-stage procedure: an initial transverse loop
colostomy and drainage, followed 3 to 6months later by a subsequent resection, and
nally, closure of the loop colostomy [19, 20]. This procedure has largely been
abandoned in favor of either the Hartmann’s procedure or resection with primary
anastomosis with or without proximal diversion. In 1984, Krukowski and Matheson
132
F. Letarte and C.J. Brown
reviewed the world literature on emergency surgery for diverticular disease complicated by generalized peritonitis [14]. They demonstrated a clear advantage in terms
of mortality and morbidity after resection of the diseased segment rather than performing an operation where the colon was retained. Their review included 1282
patients from 57 publications. The mortality rates in operations where the colon was
resected ranged 6.1–12.2%. When the diseased segment was diverted but not
resected, mortality was 25.7–28.1%. The authors recommended that segmental
resection should be performed. While the three-stage procedure has been abandoned, there continues to be debate on which surgical procedure to choose when
facing perforated diverticulitis. We will review the controversies and highlight the
circumstances when each may be applied.
Technical Considerations
The extent of resection is determined intraoperatively based on the quality of the tissues and should include the entire thickened contracted segment, including the
inammatory process. Proximal and distal margins should be healthy colon and rectum. The most important factor to prevent recurrence of diverticulitis is to extend the
distal margin of resection to the proximal rectum to create a colorectal anastomosis.
Thaler etal. examined the impact of surgery-related variables on recurrence rate
after sigmoid resection for diverticulitis [21]. The level of the anastomosis was the
only predictor of recurrence; patients with colosigmoid anastomosis had a recurrence rate fourfold higher than patients with colorectal anastomosis (2.8% vs.
12.5%, p=0.033). Similarly, Benn etal. in a series of 501 patients reported a diverticulitis recurrence rate that was doubled in patients whom the distal margin used in
the anastomosis was the sigmoid colon rather than the rectum (6.7% vs. 12.5%)
[22]. In both series, the segment harboring diverticulitis was in the sigmoid colon.
In cases where the diseased colonic segment is proximal to a healthy sigmoid, it
is likely safe to proceed with a colo-colonic anastomosis as long as the entire thickened segment is removed. While there are no comparative studies supporting this
approach, it is clear that removing all colonic diverticula en bloc is not advisable in
patients with diverticulitis. While it is not necessary to remove all diverticulabearing colon, efforts should be made to avoid including diverticula in the anastomosis to decrease the risk of leak.
It is not clear whether effort should be made to preserve the inferior mesenteric
artery and its branches. The rationale behind preserving this artery is that it may
improve blood supply to the distal aspect of the anastomosis and, hence, reduce the
risk of anastomotic leakage. A retrospective review of 130 patients with diverticulitis who underwent elective resection, where the primary outcome was to evaluate
the impact of inferior mesenteric artery (IMA) or superior rectal artery (SRA) preservation with respect to anastomotic leak rates, showed that preservation of the
major vascular pedicle was not associated with improved outcomes [23]. However,
a randomized controlled study looking at 86 patients undergoing sigmoidectomy for
complicated diverticular disease observed a lower clinical leak rate when preserving
the SRA (2% vs. 7%, p=0.03) [24]. Of note, the authors used liberal denitions of
12 Perforated Diverticulitis: What Are theOptions forResection?
133
leak that may not represent actual or clinically signicant anastomotic leaks and
may have inuenced the results.
While the evidence is marginal, it appears that preservation of the IMA may be
benecial. However, the diagnosis of diverticulitis is often in doubt at the time of
emergency surgery, as there is a possibility of undiagnosed cancer. Bacon etal. [25]
found an underlying carcinoma in 7.7% of 351 patients undergoing elective resection for diverticulitis. In cases of emergent colectomy for presumed diverticulitis,
two series report 20–25% rates of unexpected underlying carcinoma [26, 27]. While
our experience more closely reects cancer incidence similar to those reported by
Bacon etal., we believe that patients having emergency surgery where endoscopic
exclusion of a malignancy is not possible should undergo an oncologic resection
including high ligation of the IMA.
Hartmann’s Vs. Primary Anastomosis
Hartmann’s procedure, consisting of sigmoid resection, terminal colostomy, and
closure of the rectal stump, is the easiest, fastest, and safest operation to clear the
sepsis-inducing segment of the colon and avoid the risk of anastomotic leak. The
disadvantages of interval colostomy include rectal stump leak, stoma complications, and long hospital stay. Most importantly, intestinal reconstruction can be
quite challenging and is associated with a signicant risk of complications, with
observed morbidity of up to 40% [28]. Data from large administrative database
studies show that more than a third of patients never undergo Hartmann reversal and
that the number increases up to 70% when patients are aged over 77years [29, 30].
These factors make a primary colorectal anastomosis an enticing alternative.
The available comparative data are mostly observational studies suggesting primary anastomosis (PRA), and Hartmann’s procedure (HP) is associated with similar
outcomes in terms of morbidity and mortality. However, these studies are marred by
considerable selection bias, where younger, healthier patients tend to be managed
with a restorative approach. Abbas etal. reviewed this literature comparing the safety
and feasibility of PRA compared to HP for patients with acute complicated diverticulitis [31]. Eighteen studies including 884 patients were included in the review, none of
which were randomized controlled trials. When compared to HP, PRA was associated
with lower mortality rate (9% vs. 19%) and similar postoperative morbidity rates
(29% vs. 33.4%). He found an anastomotic leak rate of 5.5% in the PRA patients
compared to 8% in the HP patients. Constantinides et al. conducted a prospective
study to assess adverse events following PRA versus HP for complicated diverticular
disease [32]. Over a 12-month period across 42 centers in Great Britain, data were
collected for 248 patients who underwent PRA and 167 patients who underwent
HP.After adjusting for risk factors for selection of patients for a non-restorative procedure, HP was found to be associated with similar 30-day mortality (OR 1.76,
p = 0.223), increased surgical complications (OR 1.90, p = 0.025), and increased
overall medical complications (OR 2.08, p = 0.026) when compared to
PRA.Constantinides also published a second systematic review comparing PRA and
HP [33]. It included 963 patients (57% PRA and 43% HP) from 15 studies. Overall
134
F. Letarte and C.J. Brown
mortality was signicantly reduced with PRA (4.9% vs. 15.1%; OR 0.41). Subgroup
analyses were performed, and PRA was associated with decreased mortality when
trials were matched for emergency operations (6.4% vs. 15.6%; OR 0.44). However,
when trials were matched for severity of peritonitis of Hinchey III or IV, there was no
signicant difference in mortality (14.1% vs. 14.4%, OR= 0.85) (see Table12.2).
Salem etal. also conducted a systematic review on the topic. Their paper included
1051 patients undergoing HP and 569 patients undergoing PRA.Mortality rates were,
respectively, 19.6% for HP and 9.9% for PRA.However, no subgroup analyses were
performed. A study by Aydin, one of the largest single institution retrospective
reviews, aimed to assess the likelihood of Hartmann versus primary anastomosis in
patients with perforated diverticulitis. They described a diverticulitis disease propensity score which showed that the strongest predictors of Hartmann’s procedure were
urgent or emergent cases, BMI over 30, Manheim peritonitis index of 10 and over,
immunosuppression, and Hinchey grade III or IV [36]. These factors have also been
recognized in other studies as predictors of end- colostomy formation, including a prospective study showing an association between higher Manheim peritonitis index and
likelihood of end colostomy [34, 35, 37]. A more recent systematic review and metaanalysis addressing the treatment of Hinchey III and IV diverticulitis found comparable mortality between patients undergoing primary anastomosis versus Hartmann’s
procedure [38]. Marked heterogeneity and potential for selection bias once again limit
the interpretation of the results as well as the possibility to draw any conclusion.
A single small randomized trial has tried to address the issue of selection bias [39].
Oberkoer etal. randomized 64 patients with Hinchey III and IV diverticulitis to HP
or PRA.The study was discontinued early as an interim safety analysis showed HP to
be associated with signicantly more serious complications when compared to ileostomy reversal. The majority of patients included were Hinchey stage III diverticulitis.
There was no signicant difference in terms of mortality and morbidity between the
two groups, but stoma reversal was signicantly higher in the primary anastomosis
group. PRA was also associated with shorter hospital stay and lower in-hospital costs.
The Dutch Diverticular Disease (3D) Collaborative Study group started the
Ladies trial in 2010in an effort to answer two important questions. The rst, comparing laparoscopic lavage with sigmoidectomy for purulent perforated diverticulitis, was stopped early by the data safety monitoring committee and is discussed in
another chapter. In the DIVA arm (perforated DIVerticulitis: sigmoid resection with
or without Anastomosis), patients randomized to resection were then randomized to
either HP or PRA [40]. The results of this trial are still pending, but this will provide
more clarity for surgeons.
Since no strong evidence is available to allow for general guidelines, surgeons
must weigh the benets of primary anastomosis versus the risks linked to anastomotic failure and longer operating times. In clinical practice, the decision to perform primary anastomosis should be individualized to each patient, and surgeons
should ask themselves if the patient could withstand and survive an anastomotic
leak. Presence of any one of the parameters including hemodynamic instability,
acidosis, acute organ failure, and any signicant comorbidity such as diabetes, malnutrition, chronic end-stage organ failure, or immunosuppression should prompt the
OutcomeMortality comperison in diverticular disease
Stud
or
02 Mortality - diverticular diseas
Drumm [24]
Gregg [26]
]1
U
52
K
Alenis [21]
]1
Hold [27]
]1
Peoples [30]
]1
Medina [29]
Sarin [33]
83
Saccomani [32]
74
]1
Wedel [35]
19
G
Schiling [36]
Blair [22]
41
]2
Regenet [31]
]2
Subtot
Total events: 27 (PRA), 63 (Hartman’s procedure)
Test
Test
03 Mortality - diverticular disease and emergency operations only
Hold [27]
]1
Saccomani [32]
77
]1
G
]2
Schiling [36]
]2
Blair [22]
]2
Regenet [31]
]2
Subtot
Total events: 17 (PRA), 39 (Hartman’s procedure)
Test
Test
05 Mo
Drumm [24]
Medina [29]
]1
G
Schiling [36]
]2
Regenet [31]
]2
Subtot
Total events: 11 (PRA), 16 (Hartman’s procedure)
Test
Test
07 Mortality - diverticular disease and abscess/peritonitis
Drumm [24]
U
53
Alanis [21]
]1
Hold [27]
Peoples [30]
]1
Medina [29]
Wedel [35]
11
]1
G
]2
Schiling [36]
]2
Blair [22]
41
]2
Regenet [31]
]2
Subtot
Total events: 23 (PRA), 58 (Hartman’s procedure)
Test for heterogeneity: Ch
Test
Modified from Constantinides et al. systematic review [33]
12 Perforated Diverticulitis: What Are theOptions forResection?
Table 12.2 Mortality comparing PRA vs. HP
135
y
sub category
nderwood [34] 0/61/1
ourtesis [28] 1/23 0/10 2.80 1.40 [0.05, 37.33] 1988
oozsen [25] 5/32 6/28 12.880.68 [0.18, 2.53] 2001
al (95% Cl)547 416100.000.41 [0.22, 0.77]
for heterogeneity: Chi2 = 20.10, df = 14 (P = 0.13), I2 = 30.4%
for overall effect: Z = 2.77 (P = 0.006)
oozsen [25] 5/32 6/28 21.660.69 [0.18, 2.53
al (95% Cl)230 250 100.00 0.44 [0.24, 0.83]
for heterogeneity: Chi2 = 4.53, df = 5 (P = 0.48), I2 = 0%
for overall effect: Z = 2.55 (P = 0.01)
rtality - diverticular disease and Hinchey >2
oozsen [25] 5/32 6/28 38.770.68 [0.18, 2.53] 2001
al (95% Cl)78111 100.00 0.85 [0.36, 2.01]
for heterogeneity: Chi2 = 2.43, df = 4 (P = 0.66), I2 = 0%
for overall effect: Z = 0.38 (P = 0.71)
nderwood [34] 0/61/1
oozsen [25] 5/32 6/28 14.910.68 [0.18, 2.53
al (95% Cl)444 366100.000.43 [0.21, 0.85]
for overall effect: Z = 2.41 (P = 0.02)
PRA
n/N
e
2/31/5 2.85 8.00 [0.31, 206.37] 1984
0/35 2/25 3.15 0.13 [0.01, 2.88
1/34 4/26 5.50 0.17 [0.02, 1.59
4/99 9/76 14.25 0.31 [0.09, 1.06
2/11 8/43 8.69 0.97 [0.18, 5.40
0/31/3 2.37 0.24 [0.01, 8.62] 1991
2/19 0/
1/26 3/
2/1837/3
1/13 4/42 5.38 0.79 [0.08, 7.78] 2001
3/33 13/6
3/27 4/33 9.75 0.91 [0.18, 4.45
4/99 9/76 23.950.31 [0.09, 1.06
1/26 3/
1/13 4/42 9.05 0.79 [0.08, 7.78
3/33 13/64 21.200.39 [0.10, 1.49
3/27 4/33 16.390.91 [0.18, 4.45
2/31/5 8.58 8.00 [0.31, 206.37] 1984
0/31/3 7.12 0.24 [0.01, 8.62
1/13 4/42 16.200.79 [0.08, 7.78
3/27 4/33 29.330.91 [0.18, 4.45
2/31/5 3.30 8.00 [0.31, 206.37] 1984
1/34 4/26 6.37 0.17 [0.02, 1.59
4/99 9/76 16.490.31 [0.09, 1.06] 1990
2/11 8/43 10.050.97 [0.18, 5.40
0/31/3 2.74 0.24 [0.01, 8.62] 1991
2/1837/3
1/13 4/42 6.23 0.79 [0.08, 7.78
3/33 13/6
3/27 4/33 11.280.91 [0.18, 4.45
i2 = 15.26, df = 10 (P = 0.12), I 2 = 34.5%
Hartmann’s
Procedure
n/N
OR (random)
95% Cl
Weight%OR (random)
.720.74 [0.03, 20.81] 1984
.032.43 [0.10, 56.39] 1991
.610.05 [0.00, 0.65
.410.04 [0.01, 0.19] 1997
2.61 0.39 [0.10, 1.49
.750.05 [0.00, 0.65
.150.74 [0.03, 20.81] 1984
0.89 0.04 [0.01, 0.19
4.59 0.39 [0.10, 1.49
95% Cl Year
984
989
990
990
993
002
003
990
993
001
001
002
003
991
001
003
989
990
997
001
001
002
003
136
F. Letarte and C.J. Brown
operating surgeon to strongly consider end colostomy. Diffuse peritonitis, either
purulent or feculent, is often considered as a strong contraindication for primary
anastomosis. However, it is our opinion that select young patients, hemodynamically stable with healthy tissues and without any signicant comorbidities, could
undergo safely primary anastomosis even in the presence of diffuse peritonitis.
Diverting loop ileostomy should be strongly considered in any of the cases.
Damage Control Surgery forPerforated Diverticulitis
Initially described for patients with major abdominal injuries, indications for damage
control surgery (DCS) have expanded to include patients with severe peritonitis and
instability [41–43]. DCS for perforated diverticulitis has been reported as an alternative treatment strategy by several authors [7, 44–49]. DCS for perforated diverticulitis involves a three-stage approach: stage I, an abbreviated initial operative procedure
with temporary abdominal closure; stage II, continued resuscitation and management of physiologic and acid–base derangements; and stage III, denitive treatment
and closure. This alternative approach allows for rapid source control and patient
resuscitation in the intensive care, postponing the decision on the denitive surgical
resolution to a semi-elective setting in a hemodynamically stable patient. In a series
by Kafka-Ritsch et al. [46], they achieved a low mortality rate (9.8%), and most
patients were discharged with their colon reconstructed (77% overall, 50% for fecal
peritonitis). All of this despite a median Manheim peritonitis index of 26 and a high
rate of severe comorbidities (Table12.3). This alternative concept should be taken
into consideration before choosing to perform a Hartmann’s procedure in patients
presenting with extensive peritonitis from perforated diverticulitis.
Table 12.3 Outcomes of damage control surgery for complicated diverticulitis
Study
Sohn etal. [42] N 18 19
Kafka-Ritsch
etal. [46]
Finlay etal. [43] N Not applicable 14
Outcomes
Postoperative complication
rate
Mortality 11% 10.5%
Primary anastomosis 22.2% 78.9%
N Not applicable 51
Postoperative complication
rate
Mortality 9.8%
Primary anastomosis 76%
Postoperative complication
rate
Mortality 7.1%
Primary anastomosis 85.7%
Primary denitive
surgery
39% 32%
Damage control
surgery
Not available
Not available