Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

[Retroperitoneal abscess by suppurative psoas. Case report]

A 51 years old male was admitted to our Emergency Department because a severe pain in the right lumbar area irradiating to homolateral thigh, with fever. Abdomen and pelvis TC scan revealed a big retroperitoneal abscess. An urgent laparotomy was performed. It showed a huge retroperitoneal purulent collection extending caudally to right thigh and all around urinary bladder. The fluid collections were drained and a sample was sent for biological examination. There was the evidence of enterococcus faecalis and specific antibiotic treatment was done. The patient was discharged after 33 days in good general conditions. The aim of this study is to emphasize the difficulty in clinical diagnosis of this pathology due to the lack specific symptoms and signs, and the occasional difficulty to find the original cause of the condition. Moreover we remark the utility of CT scan and of selective collection drainage.