Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis

BACKGROUND

The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons' choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis.

METHODS

Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis.

RESULTS

Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy.

CONCLUSIONS

A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals

BACKGROUND

The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.

METHOD

The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.

RESULTS

Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.

CONCLUSION

The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.

Unusual phenomenon-“polyp” arising from a diverticulum: A case report

BACKGROUND

Sealed perforation of colonic diverticulum is a common clinical condition and may be differentiated from an underlying malignant perforation using interval endoscopy. We present an uncommon colonoscopy finding of a healed diverticular perforation, mimicking a polyp, 6 wk post-diverticulitis-something that has not been reported in literature. We aim to shed light on the likely process that resulted in the trompe l'œil after diverticulitis. This also introduces the possibility of more targeted colonic resection in the event of a similar recurrence.

CASE SUMMARY

A middle-aged Chinese female presented with a 3-d history of non-colicky left iliac fossa pain. It was associated with fever (T_max 37.6 ºC), non-bloody diarrhoea and non-bloody, non-bilious vomiting. She had a history of Type 2 diabetes mellitus, well controlled on metformin. Tenderness was noted on the left iliac fossa region with no guarding or mass. Total white cell count (11.45 × 10⁹/L) and C-reactive protein levels (213.9 mg/L) were elevated. Computed tomography imaging of the abdomen revealed pericolonic fat stranding and extraluminal air pockets fluid density with peritoneal thickening at the sigmoid colon, likely representing a sealed perforation. Six weeks after the episode, she underwent a follow-up colonoscopy. An exophytic polypoid lesion closely associated with a diverticulum was seen in the sigmoid colon. The lesion was easily “pinched” off without much effort using endoscopic forceps and sent for histology which revealed granulation tissue suggesting a healed diverticular perforation.

CONCLUSION

Granulation tissue associated with healed diverticular perforations resemble polyps. Tattooing around these sites may allow for future targeted colonic resections.

Relationship between Dynamic Changes of Microcirculation Flow, Tissue Perfusion Parameters, and Lactate Level and Mortality of Septic Shock in ICU

Background

Septic shock is a common clinical critical disease with high mortality, hemodynamic instability, and easy to be complicated with multiple organ failure. The rapid progress of the patient's condition poses a serious threat to patient's safety.

Aim

To investigate the relationship between the dynamic monitoring of microcirculation perfusion parameters and blood lactic acid level and the prognosis of patients with infection shock in ICU.

Methods

A total of 104 patients with septic shock admitted to ICU of Affiliated Hai'an Hospital of Nantong University from February 2018 to June 2021 were selected for clinical research. According to the survival situation of patients after 28 days of treatment, they were divided into the death group (n = 48) and the survival group (n = 56). The central venous-arterial carbon dioxide partial pressure difference (Pcv-aCO2), the ratio of central venous-arterial carbon dioxide partial pressure difference to arterial central venous oxygen content difference (Pcv-aCO2/Ca-cvO2), and blood lactic acid level were retrospectively analyzed and compared between the two groups on the first, third, and seventh days after admission to ICU. The odds ratio (OR) of three indexes affecting the prognosis of patients with septic shock was analyzed by univariate and multivariate mathematical models, and the value of three indexes in predicting the prognosis of patients was analyzed by receiver operating curve (ROC).

Results

Pcv-aCO2 and lactic acid in the death group were higher than those in the survival group on the 1st, 3rd, and 7th day of ICU stay (P < 0.05). The Pcv-aCO2/Ca-cvO2 of the death group was higher than that of the survival group on the 3rd and 7th day of ICU stay (P < 0.05). Logistic model results showed that age, SOFA score, APACHE II score, the number of multiple organ failure (MODS), intracranial infection, the increase of Pcv-aCO2, Pcv-aCO2/Ca-cvO2, and the increase of lactic acid were independent risk factors for death in patients with septic shock (OR values were 1.519, 1.808, 1.781, 1.912, 2.069, 1.848, 1.781, and 1.642, respectively, P < 0.05). The results showed that the AUC value of Pcv-aCO2 in predicting death was 0.943, and the sensitivity and specificity were 93.72% and 83.09%, respectively. The AUC value of Pcv-aCO2/Ca-cvO2 for predicting death was 0.887, and the sensitivity and specificity were 81.63% and 77.56%, respectively. The AUC value of lactic acid in predicting death of patients was 0.825, and the sensitivity and specificity were 71.66% and 82.09%, respectively.

Conclusion

Changes of microcirculation flow tissue perfusion parameters and blood lactic acid level changes are closely related to the prognosis of patients with septic shock, which is of great value in the evaluation of the prognosis of patients with septic shock.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

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

Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann's sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey's classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).

The Dilemma of the Level of the Inferior Mesenteric Artery Ligation in the Treatment of Diverticular Disease: A Systematic Review of the Literature

Background and aim: Although sigmoidectomy is a well-standardized procedure for diverticular disease, there are still unclear areas related to the varying morphology and vascular supply of the sigmoid colon. The level of vascular ligation could affect the functional outcomes of patients operated on for diverticular disease. The aim of this review is to primarily evaluate sexual, urinary and defecatory function outcomes, as well as postoperative results, in patients who underwent surgery for diverticular disease, with or without inferior mesenteric artery (IMA) preservation. Materials and methods: The MEDLINE/PubMed, WOS and Scopus databases were interrogated. Comparative studies including patients who underwent sigmoidectomy for diverticular diseases were considered. Bowel function, genitourinary function, anastomotic leak, operation time, conversion to open surgery, anastomotic bleeding, bowel obstruction were the main items of interest. Results: Twelve studies were included in the review, three randomized and nine comparative studies. Bowel and genitourinary function are not differently affected by the level of vascular ligation. The site of ligation of IMA did not influence the rate of functional complications, anastomotic leak and bleeding. Of note, the preservation of IMA is associated with a higher conversion rate and longer operative time. Conclusions: Despite the heterogeneity of patient groups, and although the findings should be interpreted with caution, functional and clinical outcomes after sigmoidectomy for diverticular disease do not seem to be affected by the level of vascular ligation as long as the IMA is ligated far from its origin.

The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review

Background and Objective: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. Method: We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. Results: We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. Conclusion: During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.

State-of-the-art surgery for sigmoid diverticulitis

Background

In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.

Purpose

This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.

Conclusion

Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

[Choice of operative procedure in diverticular disease : Taking the latest treatment strategies into consideration]

BACKGROUND

There are various procedures to be considered in the surgical treatment of complicated diverticulitis, which must be selected depending on the classification of diverticular disease (CDD) type and the condition of the patient.

OBJECTIVE

Comparison of surgical procedures with respect to aspects such as morbidity, mortality, reconstructive surgery and postoperative quality of life.

MATERIAL AND METHODS

Evaluation, analysis and assessment of the current literature on surgical treatment of diverticular disease.

RESULTS

Laparoscopic sigmoid resection with primary anastomosis is now considered the standard procedure for complicated sigmoid diverticulitis. It is preferable to open resection because of the better results of the minimally invasive approach with respect to the incidence of wound infections, abdominal abscesses and the occurrence of fascial dehiscence. In an emergency situation with perforation and peritonitis (CDD type 2c1/2), primary anastomosis with protective ileostomy should be favored over discontinuity resection (Hartmann's procedure). In particular, it must be taken into account that in a large proportion of patients there is no restoration of continuity after Hartmann's operation. The damage control strategy can be used in perforated sigmoid diverticulitis with generalized peritonitis (CDD type 2c1/2). In individual cases, laparoscopic lavage with insertion of a drainage may be considered as a therapeutic treatment strategy for perforated sigmoid diverticulitis with purulent peritonitis (CDD type 2c1).

CONCLUSION

Selection of the surgical procedure for complicated sigmoid diverticulitis remains challenging. Randomized controlled trials of new treatment strategies as well as robotic-assisted surgery should be considered in the choice of surgical procedure in the future.