Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis

Emergency laparotomy preoperative risk assessment tool performance: A systematic review

Background

Preoperative assessment of risk for emergency laparotomy may enhance decision making with regards to urgency or perioperative critical care admission and promote a more informed consent process for patients. Accordingly, we aimed to assess the performance of risk assessment tools in predicting mortality after emergency laparotomy.

Methods

PubMed, Embase, the Cochrane Library and CINAHL were searched to 12 February 2022 for observational studies reporting expected mortality based on a preoperative risk assessment and actual mortality after emergency laparotomy. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, expected and actual mortality rates were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42022299227.

Results

From 10,168 records, 82 observational studies were included. 17 risk assessment tools were described, the most common of which were P-POSSUM (42 studies), POSSUM (13 studies), NELA (12 studies) and MPI (11 studies). Articles were published between 1990 and 2022 with the most common country of origin being the UK (33 studies) followed by India (11 studies). Meta-analysis was not possible. Observed mortality and expected mortality based on risk assessment is reported for each study and generally shows most studies show accurate risk prediction.

Conclusions

This review synthesises available literature to characterise the performance of various risk assessment tools in predicting mortality after emergency laparotomy. Findings from this study may benefit those undertaking emergency laparotomy and future research in risk prediction.

Comparison Between Primary Anastomosis Without Diverting Stoma and Hartmann's Procedure for Colorectal Perforation: A Retrospective Observational Study

Background Hartmann's procedure (HP) is performed for colorectal perforation to avoid the risk of anastomotic leakage. Few reports have compared the safety between primary anastomosis without diverting stoma (PAWODS) and HP for colorectal perforation, and whether PAWODS or HP should be performed has remained controversial. We aimed to investigate the feasibility and safety of performing PAWODS in comparison to HP for colorectal perforation. Methods The data of 97 consecutive patients with colorectal perforation who underwent surgery from April 2010 to December 2020 were collected retrospectively. PAWODS and HP were performed in 51 and 46 patients, respectively. Univariate and multivariate analyses were performed to compare the clinical characteristics and postoperative outcomes of patients treated with PAWODS with those treated with HP. Results In the multivariate analysis, low serum albumin (hazard ratio (HR)=3.49; 95%CI=1.247-9.757; P=0.017) and left-sided colon and rectum perforation (HR=16.8; 95%CI=1.792-157.599; P=0.014) were significantly associated with the decision to perform HP. There was a significant difference in the mortality of the two groups (PAWODS vs. HP: 0% vs. 8.7%; P=0.047). The severe morbidity rate (Clavien-Dindo III-V) was significantly higher in the HP group (PAWODS vs. HP: 10% vs. 30%; P=0.020). In the PAWODS group, anastomotic leakage occurred in five of 51 patients (9.8%), four (8.7%) of whom required re-operation. Conclusions In appropriately selected patients, PAWODS could be safely performed with an acceptable rate of anastomotic leakage. The serum albumin level and site of perforation may be simple and useful factors for guiding decision-making on the surgical procedure.

Management of rectal stump leak following emergency Hartmann’s procedure

We report on the management of three cases of rectal stump leak and sepsis following urgent Hartmann’s procedure for perforated sigmoid diverticulitis or large bowel obstruction. Two patients had significant risk factors for poor tissue healing. All patients developed features of sepsis and computer tomography scans demonstrated rectal stump leak with adjacent collections. All patients required reoperation for drainage and washout of abscess. An intraperitoneal catheter system was introduced together with drains in order to continue on the ward until tract was formed. There was no mortality and minimal morbidity. The key to management of rectal stump leak is the early and aggressive drainage of the associated collection and continued irrigation of the stump.

HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Mortality after emergency surgery in randomized controlled trials. The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity.

AIM

To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment.

METHOD

Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion.

RESULTS

There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion.

CONCLUSION

Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Purpose

The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis.

Methods

Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression.

Results

Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044).

Conclusions

In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

The role of emergency laparoscopic surgery for complicated diverticular disease: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery develops rapidly in both elective and emergency settings. The study aimed to determine the role of different laparoscopic methods for the emergency treatment of complicated diverticulitis.

METHODS

MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to November 2019 to identify all published articles related to the topic. Statistical analysis was performed using Stata 15.

RESULTS

Fourteen publications were included in the analysis. Laparoscopic surgery was applied in 425 patients, and 493 patients underwent open colon resection (OCR). Postoperative mortality, morbidity, severe complications, and reoperation rates were not significantly different between the laparoscopic and open surgery groups. Subgroup analysis was performed based on the different laparoscopic methods (laparoscopic colon resection [LCR] and laparoscopic lavage and drainage [LLD]). Subgroup analysis indicated that LCR was superior to OCR in terms of morbidity, while OCR was superior to LLD in terms of severe complications.

CONCLUSIONS

The safety of laparoscopic surgery for the emergency treatment of complicated diverticulitis is related to different surgical methods. LCR is suggested to be a better choice according to the postoperative outcomes. More definite conclusions can be drawn in future randomized controlled trials.

Preliminary Experience with Laparoscopic Peritoneal Lavage for Complicated Diverticulitis: A New Algorithm for Treatment?

Patients with findings suggestive of a perforated diverticulitis may be subject to colostomy with the attendant morbidity and quality-of-life concerns. Recent literature demonstrates decreased use of laparotomy and colostomy when diagnostic laparoscopy reveals absence of fecal peritonitis. Ten patients presenting with diverticulitis between May 2009 and February 2012 underwent diagnostic laparoscopy. The indication for surgery in nine patients was failure of medical management with or without percutaneous drainage and one had significant pneumoperitoneum at presentation. A comprehensive algorithm was subsequently developed governing medical and surgical management of diverticulitis including the use of diagnostic laparoscopy and laparoscopic peritoneal lavage for patients with Hinchey Stage 3 diverticulitis or abscess formation not amenable to percutaneous drainage. Eight patients underwent diagnostic laparoscopy and laparoscopic peritoneal lavage, whereas two patients underwent diagnostic laparoscopy with conversion to open procedures (low-anterior resection with diverting ileostomy and Hartmann's procedure). Mortality was 0 per cent. Four patients were subsequently readmitted for relapse or recurrence. Two required laparotomy at the time of readmission, ultimately receiving a diagnosis of adenocarcinoma. Two were managed medically and later underwent elective laparoscopic sigmoid colon resection. Diagnostic laparoscopy and laparoscopy peritoneal lavage appear feasible and safe and may be an alternative to more invasive surgery, avoiding laparotomy and colostomy and staging patients for elective laparoscopic resection. Based on our institutional experience, we propose a novel algorithm for the treatment of hospitalized patients with diverticulitis, which incorporates diagnostic laparoscopy and laparoscopic peritoneal lavage while emphasizing patient selection based on clinical examination and imaging.

Emergency Surgery in Acute Diverticulitis: A Systematic Review

BACKGROUND

Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis.

OBJECTIVE

The aim of this systematic review was to define the accurate surgical management of acute diverticulitis.

DATA SOURCES

Medline, Embase, and the Cochrane Library were sources used.

STUDY SELECTION

One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee.

INTERVENTIONS

The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach.

MAIN OUTCOME MEASURES

Morbidity, mortality, long-term stoma rates, and quality of life were measured.

RESULTS

Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach.

LIMITATIONS

Trials specifically assessing Hinchey IV diverticulitis have not yet been completed.

CONCLUSIONS

High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

The management of diverticulitis: a review of the guidelines

Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis. CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred. Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management. Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis. For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively. For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3-5 cm should be drained percutaneously. Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery. Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non-operative management. Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria.

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

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/m2 (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.

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis

AIM

It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates.

METHOD

The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)].

CONCLUSION

This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.

Mortality and Morbidity After Hartmann's Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study

BACKGROUND

The benefit of primary anastomosis (PA) without a diverting stoma over Hartmann's procedure (HP) for colorectal perforation remains controversial. We compared postoperative mortality and morbidity between HP and PA without a diverting stoma for colorectal perforation of various etiologies.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we extracted data on patients who underwent emergency open laparotomy for colorectal perforation of various etiologies from July 1, 2010 to March 31, 2014. We compared 30-day mortality, postoperative complication rates, and postoperative critical care interventions between HP and PA groups using propensity score matching, inverse probability of treatment weighting, and instrumental variable analyses to adjust for measured and unmeasured confounding factors.

RESULTS

We identified 8500 eligible patients (5455 HP and 3045 PA). In the propensity score-matched model, a significant difference between the HP and PA groups was detected in 30-day mortality (7.7% vs. 9.6%; risk difference, 1.9%; 95% confidence interval [CI], 0.5-3.4). The inverse probability of treatment weighting showed similar results (8.8% vs. 10.7%; risk difference, 1.9%; 95% CI, 1.0-2.8). In the instrumental variable analysis, the point estimate suggested similar direction to that of the propensity score analyses (risk difference, 4.4%; 95% CI, -3.3 to 12.1). The PA group had significantly higher rates of secondary surgery for complications (4.6% vs. 8.4%; risk difference, 3.8%; 95% CI, 2.5-4.1) and slightly longer duration of postoperative critical care interventions.

CONCLUSIONS

This study revealed a significant difference in 30-day mortality between HP and PA without a diverting stoma.

Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials

INTRODUCTION

The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann's procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis.

METHODS

A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals.

RESULTS

Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14-1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41-4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12-0.96, p = 0.04).

CONCLUSIONS

PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical option in patients with generalised peritonitis due to diverticular perforation.

Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy

This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.

A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine

The management of patients with colonic diverticular perforation is still evolving. Initial lavage with or without simple suture and drainage was suggested in the late 19th century, replaced progressively by the three-stage Mayo Clinic or the two-stage Mickulicz procedures. Fears of inadequate source control prompted the implementation of the resection of the affected segment of colon with formation of a colostomy (Hartman procedure) in the 1970's. Ensuing development of the treatment strategies was driven by the recognition of the high morbidity and mortality and low reversal rates associated with the Hartman procedure. This led to the wider use of resection and primary anastomosis during the 1990's. The technique of lavage and drainage regained popularity during the 1990's. This procedure can also be performed laparoscopically with the advantage of faster recovery and shorter hospital stay. This strategy allows resectional surgery to be postponed or avoided altogether in many patients; and higher rates of primary resection and anastomosis can be achieved avoiding the need for a stoma. The three recent randomized controlled trials comparing laparoscopic peritoneal lavage alone to resectional surgery reported inconsistent outcomes. The aim of this review is to review the historical evolution and future reflections of surgical treatment modalities for diffuse purulent and feculent peritonitis. In this review we classified the various surgical strategies according to Krukowski et al. and Vermeulen et al. and reviewed the literature related to surgical treatment separately for each period.

[Treatment of the acute diverticulitis: A systematic review]

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.

Influence of Surgical Technique, Performance Status, and Peritonitis Exposure on Surgical Site Infection in Acute Complicated Diverticulitis: A Matched Case-Control Study

BACKGROUND

Acute generalized peritonitis secondary to complicated diverticulitis is a life-threatening condition; the standard treatment is surgery. Despite advances in peri-operative care, this condition is accompanied by a high peri-operative complication rate (22%-25%). No definitive evidence is available to recommend a preferred surgical technique in patients with Hinchey stage III/IV disease.

METHODS

A matched case-control study enrolling patients from four surgical units at Italian university hospital was planned to assess the most appropriate surgical treatment on the basis of patient performance status and peritonitis exposure, with the aim of minimizing the surgical site infection (SSI). A series of 1,175 patients undergoing surgery for Hinchey III/IV peritonitis in 2003-2013 were analyzed. Cases (n=145) were selected from among those patients who developed an SSI.

THE CASE

control ratio was 1:3. Cases and control groups were matched by age, gender, body mass index, and Hinchey grade. We considered three surgical techniques: T1=Hartman's procedure; T2=sigmoid resection, anastomosis, and ileostomy; and T3=sigmoid resection and anastomosis. Six scoring systems were analyzed to assess performance status; subsequently, patients were divided into low, mild, and high risk (LR, MR, HR) according to the system producing the highest area under the curve. We classified peritonitis exposition as P1=<12 h; P2=12-24 h; P3=>24 h. Univariable and multivariable analyses were performed.

RESULTS

The Apgar scoring system defined the risk groups according to performance status. Lowest SSI risk was expected when applying T3 in P1 (OR=0.22), P2 (OR=0.5) for LR and in P1 (OR=0.63) for MR; T2 in P2 (OR=0.5) in LR and in P1 (OR=0.61) in MR; T1 in P3 (OR=0.56) in LR; in P2 (OR=0.63) and P3 (OR=0.54) in MR patients, and in each P subgroup (OR=0.93;0.97;1.01) in HR.

CONCLUSIONS

Pre-operative assessment based on Apgar scoring system integrated with peritonitis exposure in complicated diverticulitis may offer a ready-to-use tool for reducing SSI-related complications and applying appropriate treatment, reducing the need for disabling ostomy.

A proposal for a CT driven classification of left colon acute diverticulitis

Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis. The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Emergency surgery for perforated diverticulitis in the immunosuppressed patient

AIM

Immunosuppression is believed to worsen outcomes for patients who require surgery for perforated diverticulitis. The aim of this study was to compare surgical outcomes between immunocompromised and immunocompetent patients undergoing surgery for complicated diverticulitis.

METHOD

All patients who underwent emergency surgery for complicated diverticulitis between 2004 and 2012 in a single unit were studied. Patients were classified as immunosuppressed (group I) or immunocompetent (group II). Operation type and postoperative morbidity and mortality were compared between groups. The impact of operating surgeons' specialization and the Peritonitis Severity Score (PSS) were also evaluated to determine their impact on the restoration of gastrointestinal (GI) continuity.

RESULTS

One-hundred and sixteen patients (mean age: 63.7 years), 41.4% women, were included. Fifty-three (45.7%) patients were immunosuppressed (group I): 42 underwent Hartmann's procedure (HP) (79.2%), nine (17.0%) underwent resection and primary anastomosis (RPA) with ileostomy (IL) and two (3.8%) underwent RPA without IL. In group II, 15 HP (23.8%), nine RPA with IL (14.3%) and 39 RPA without IL (61.9%) were performed. Postoperative morbidity and mortality were 79.2% and 26.4%, respectively, in group I and 63.5% and 6.3%, respectively, in group II. The overall mean PSS was 9.5, with a mean PSS of 11.1 in group I and of 8.1 in group II. The decision to perform a primary anastomosis differed significantly between colorectal surgeons and general surgeons in the patients with a PSS of 9-10-11.

CONCLUSION

In immunocompromised patients, RPA with IL can be a safe surgical option, whereas HP should be reserved for patients with a PSS of > 11. Colorectal surgical specialization is associated with higher rates of restoration of GI continuity in patients with perforated diverticulitis, especially in patients with an intermediate PSS score. Evaluation of each patient's PSS facilitates decision making in surgery for perforated diverticulitis.

Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease

BACKGROUND

The management of diverticulitis in young Asian patients remains challenging. This study aimed to highlight the issues of managing diverticulitis in young Asians.

METHODS

A retrospective review of all patients who were admitted for acute colonic diverticulitis from October 2003 to December 2008 was performed. Patients who were ≤50 year old were considered 'young' and formed the study group.

RESULTS

The study group consisted of 142 patients. The majority (n = 126, 88.7%) had right-sided diverticulitis and most (n = 117, 82.4%) were mild in severity. Most of the patients who underwent emergency surgery were for suspected appendicitis (39/56, 69.6%). When we compared between those aged ≤50 and >50 years, the older group had worse diverticulitis (odds ratio (OR), 4.90, 95% confidence interval (CI), 2.00-11.99), been operated for indications other than suspected appendicitis (OR, 13.08, 95% CI, 5.42-31.56) and undergone a colectomy (OR, 9.96, 95% CI, 4.12-24.10). The younger group had a much higher incidence of right-sided disease (OR: 7.80, 95% CI: 4.32-14.07). Over a median follow-up of 40 (6-90) months, 7 (4.9%) patients were readmitted for a total of eight times for recurrent attacks of diverticulitis and all were successfully treated conservatively. Five other patients underwent elective surgery for persistent symptoms.

CONCLUSION

Diverticulitis in young Asians is often right-sided and mild in severity. A significant proportion is only diagnosed when operated for presumed appendicitis. Recurrent attacks are uncommon and can often be treated non-surgically.

Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis--a comparison of stoma reversal rates

PURPOSE

The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies.

METHODS

A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire.

RESULTS

A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4-118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p = 0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p = 0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p = 0.167). According to the Clavien-Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p = 0.014).

CONCLUSION

The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.

Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis

BACKGROUND

This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.

OBJECTIVE

This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.

METHODS

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.

RESULTS

Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).

CONCLUSIONS

Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV

OBJECTIVE

With the use of abdominal vacuum therapy, we have developed a damage control concept for patients with perforated diverticulitis and generalized peritonitis. The primary aim of this concept was to enhance recovery and allow bowel reconstruction in a second-look operation.

METHODS

A total of 51 patients (28 female, 55%) with a median (range) age of 69 (28-87) years, with perforated diverticulitis Hinchey III (n = 40, 78%) or Hinchey IV (n = 11, 22%) and a median (range) Mannheim peritonitis index of 26 (12-39), admitted between October 2006 and September 2011, were prospectively enrolled in the study. At initial operation, limited resection of the diseased segment, lavage, and application of abdominal vacuum-assisted closure dressing was performed. After patient resuscitation, a second look was performed in an elective setting.

RESULTS

Hospital mortality rate was 9.8%; 35 (76%) of patients were discharged with reconstructed colon, and 93% of patients live without a stoma at follow-up. Risk factors for mortality were American Society of Anesthesiologist score (p = 0.01), organ failure at initial presentation (p = 0.03), cardiac comorbidity (p = 0.05), and a Hartmann procedure at second look (p = 0.00).

CONCLUSION

With this abdominal vacuum-based damage control concept, an acceptable hospital mortality rate and a high rate of bowel reconstruction at second look were achieved in patients with perforated diverticulitis and generalized peritonitis.

Laparoscopic lavage for perforated diverticulitis: a population analysis

BACKGROUND

Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies.

OBJECTIVE

This study investigated national trends in management of perforated diverticulitis.

DESIGN

This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008.

SETTINGS

The study was conducted in Ireland.

PATIENTS

Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included.

MAIN OUTCOME MEASURES

The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications.

RESULTS

Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p < 0.001), complications (14.1% vs 25.0%, p < 0.001), and length of stay (10 days vs 20 days, p < 0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p < 0.001), as were those with connective tissue disease (OR 7.3, p < 0.05) or chronic kidney disease (OR 8.0, p < 0.001).

LIMITATIONS

This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group.

CONCLUSIONS

The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.

Complicated diverticular disease: the changing paradigm for treatment

The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies.

Intestinal stomas: indications, management, and complications

The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.

Morbidity and mortality of the Hartmann procedure for diverticular disease over 18 years in a single institution

AIM

Hartmann's procedure for perforated diverticulitis is associated with substantial morbidity and mortality. This study analyses factors associated with morbidity/mortality and possible changes over time.

METHOD

Patients treated by urgent Hartmann's procedure for perforated diverticulitis between 1992 and 2010 were studied, and information was collected on age, sex, perioperative details, 30-day morbidity and mortality recorded in an institutional review board approved database supplemented by chart review. Patients were divided into four groups based on the year of surgery. Univariate and multivariate logistic regression analysis was performed to identify risk factors associated with morbidity and mortality.

RESULTS

In all, 199 patients (51% female, mean age 65 years, mean body mass index 28 kg/m(2)) were identified. The American Society of Anesthesiologists (ASA) score was 4 in 30% of patients and Hinchey Stage IV in 16%. The mean length of stay was 12.5 ± 10 days. Mortality was 15% and did not change significantly over time. Overall morbidity was 52% and significantly increased over time on univariate analysis (P = 0.007) but not on multivariate analysis (P = 0.11). Independent predictors of morbidity on multivariate analysis were Hinchey IV (P < 0.001) and hypoproteinaemia (P = 0.001). Independent predictors for mortality were ASA > 3 (P = 0.01), abnormal creatinine (P = 0.007), steroid use (P = 0.007), Hinchey IV (P = 0.032), low albumin (P < 0.001) and low body mass index (P = 0.001).

CONCLUSION

Mortality after Hartmann's procedure for perforated diverticulitis has not decreased during the last 18 years. Morbidity has actually increased over time although this is related to increased disease severity and comorbidity. Future efforts should focus on the identification of patient subgroups benefiting from earlier elective surgery and alternative surgical approaches when perforated diverticulitis does occur.

Laparoscopic Hartmann's procedure for fecal peritonitis resulting from perforation of the left-sided colon in elderly and severely ill patients

BACKGROUND

Traditional treatment for fecal peritonitis resulting from perforation of the left-sided colon has been performed using Hartmann's procedure to reduce the high mortality caused by anastomotic leakage. However, the morbidity rates associated with abdominal incision (due in great part to wound infection, and dehiscence of abdominal fascia) are high. Therefore, we propose using laparoscopic Hartmann's procedure with abdominal incisions only for the port site to reduce the high morbidity associated with the laparoscopic procedure as compared to open surgery.

METHODS

Between April 2008 and July 2011, we treated 16 consecutive patients (median age, 83 years) with fecal peritonitis resulting from perforations in the left-sided colon due to various causes. The American Society of Anesthesiologists score of each patient was either IV or V. Patients underwent a four-port laparoscopic Hartmann's procedure. Specimens were extracted through the stoma site. Irrigation of the abdominal cavity with more than 10 L of saline was performed in every case, as was insertion of three 10-mm silicon drains via the port site into the left- and right subphrenic spaces or the pouch of Douglas.

RESULTS

The median total surgical time was 166 min (range, 123-250 min). There were no intraoperative complications, and there was no need to convert to open surgery. Fourteen patients survived. There was no wound infection or dehiscence of abdominal fascia. Successful laparoscopic reversals of the laparoscopic Hartmann's procedure were performed in all 14 survivors.

CONCLUSIONS

This laparoscopic Hartmann's procedure is a promising surgical strategy for treating fecal peritonitis arising from perforation of the left-sided colon.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study

AIM

The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity.

METHOD

A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined.

RESULTS

Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD.

CONCLUSION

Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Management of diverticulitis: results of a survey among gastroenterologists and surgeons

AIM

The study aimed to investigate current management strategies for left-sided diverticulitis and compare them with current international guidelines. Differences between surgeons and gastroenterologists and between gastrointestinal and nongastrointestinal surgeons were assessed.

METHOD

A web-based survey of treatment options for uncomplicated and complicated diverticulitis was carried out among surgeons and gastroenterologists in the Netherlands. Only surgeons were asked about surgical strategy.

RESULTS

A total of 292 surgeons and 87 gastroenterologists responded, representing 92% of all surgical and 46% of all gastroenterology departments. Ninety per cent of respondents treated mild diverticulitis without antibiotics. About one-fifth (18% gastroenterologists; 19% surgeons) regarded a CT scan as mandatory in the initial assessment. Most surgeons and gastroenterologists used some form of bowel rest, would consider outpatient treatment and would perform a colonoscopy on follow up. For Hinchey Stage 3, 78% of surgeons would consider resection and primary anastomosis and laparoscopic lavage was viewed as a valid alternative by 30% of gastrointestinal and 2% of nongastrointestinal surgeons. For Hinchey stage 4, 46% of gastrointestinal and 72% of nongastrointestinal surgeons would always perform Hartmann's procedure.

CONCLUSION

The treatment of diverticulitis in the Netherlands shows major differences when compared with guidelines for all stages of disease.

New and emerging treatments for the prevention of recurrent diverticulitis

Sigmoid diverticulitis is a common benign condition which carries significant morbidity and socioeconomic burden. This article describes the management of sigmoid diverticulitis with a focus on indications for surgical intervention. The mainstay of management of uncomplicated diverticulitis is broad-spectrum antibiotic therapy. The old surgical dictum that two episodes of sigmoid diverticulitis warranted surgical intervention has been challenged by recently published data. Surgery for diverticulitis thus needs to be tailored to suit individual presentation; patients presenting with recurrent diverticulitis, severe symptoms or debilitating disease impacting patient’s quality of life mandate surgical intervention. Complicated diverticular disease typically prompts intervention to resect a diseased, strictured sigmoid colon, fistulizing disease, or a life-threatening colonic perforation. Laterally, minimally invasive surgery has been utilized in the management of this disease and recent data suggests that localized colonic perforation may be managed by laparoscopic peritoneal lavage, without resection. This review focuses discussion on available evidence for contemporary surgical and nonoperative management of diverticulitis.

Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis?

PURPOSE

Hartmann's procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience.

METHODS

From January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP.

RESULTS

A total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation.

CONCLUSIONS

RPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis

INTRODUCTION

It was previously reported that in patients with acute perforated diverticulitis with Hinchey categories I to III sigmoidectomy with primary anastomosis (PA) is superior to Hartmann's procedure (HP) as later closure of colostomy involves substantial morbidity. We evaluated our experience with PA for patients with perforated diverticulitis over a 10-year period and aimed to investigate whether Hinchey category or co-morbidity are more relevant for postoperative outcome.

METHODS

Records of all patients treated at our institution for sigmoid diverticulitis between 1996 and 2006 were retrieved from an in-hospital database (N = 787, median age 66 years, range 30 to 94, female:male ratio 1.3:1); 73 patients who underwent immediate emergency surgery for perforated diverticulitis were included in this study. American Society of Anesthesiology (ASA) classification to gauge co-morbidity and Hinchey category for intraoperative extent of inflammation were evaluated as regards their relevance for postoperative mortality and major complications.

RESULTS

47 patients (64%) underwent sigmoid colectomy and PA, which was combined with loop ileostomy in 11 patients (15%). Sigmoid colectomy and HP was performed in 26 patients (36%). Major postoperative complications occurred in 26 patients (36%). In the PA group, 10 of 47 patients (21%) had anastomotic leakage. Three leakages occurred despite a loop ileostomy. Anastomotic leakage was independent of Hinchey category (Hinchey I: three patients, Hinchey II: four patients, Hinchey III: three patients, n.s.), but associated with co-morbidity (one patient ASA II, six patients ASA III, three patients ASA IV, P < 0.05). Total mortality was 12%. Seven patients died after HP and two patients after PA. No mortality was observed in PA patients with loop ileostomy.

CONCLUSIONS

Emergency surgery for perforated sigmoid diverticulitis is associated with high morbidity and mortality rates. Anastomotic leakage was associated with patient co-morbidity rather than with intraoperative Hinchey category, suggesting that the decision to perform PA should better be based on patient's general condition rather than on intraoperative extent of inflammation.

Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?

BACKGROUND

Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe.

METHODS

All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed.

RESULTS

Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula.

CONCLUSION

The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.

Principles of source control in the early management of sepsis

Source control refers to the spectrum of physical measures that are undertaken to control a focus of infection, and to facilitate restoration of optimal anatomy and physiology. These measures are classified as drainage-the evacuation of infected liquid through the creation of a controlled sinus or fistula, debridement-the physical removal of necrotic infected tissue, device removal, and the definitive measures that comprise the process of reconstruction and rehabilitation. Effective and timely source control is critical to the successful management of life-threatening infection. This article reviews the principles of diagnosis and source-control management, and their application to common infections that result in severe sepsis and septic shock.