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International Journal of Colorectal Disease

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01-07-2018 | Original Article

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome

Authors: M. A. Sohn, A. Agha, P. Steiner, A. Hochrein, M. Komm, R. Ruppert, P. Ritschl, F. Aigner, I. Iesalnieks

Published in: International Journal of Colorectal Disease | Issue 7/2018

Abstract

Purpose

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.

Methods

Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann’s procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.

Results

Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014).

Conclusion

Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Oberkofler CE (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256(5):819–826-827CrossRefPubMed

Holmer C, Kreis ME (2014) Diverticular disease - choice of surgical procedure. Chir Z Für Alle Geb Oper Medizen 85(4):308–313CrossRef

Kruis W, Germer C-T, Leifeld L, German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery (2014) Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion 90(3):190–207CrossRefPubMed

Angenete E (2014) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg

Schultz JK (2015) Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA 314:1364–1375CrossRefPubMed

Vennix S (2015) Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet Lond Engl 386(10000):1269–1277CrossRef

Kafka-Ritsch R (2012) Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV. J Gastrointest Surg Off J Soc Surg Aliment Tract 16(10):1915–1922CrossRef

Sohn M, Agha A, Heitland W, Gundling F, Steiner P, Iesalnieks I (2016) Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis. Tech Coloproctol 20(8):577–583CrossRefPubMed

Perathoner A, Klaus A, Mühlmann G, Oberwalder M, Margreiter R, Kafka-Ritsch R (2010) Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis--a proof of concept. Int J Colorectal Dis 25(6):767–774CrossRefPubMed

10.

Langenfeld SJ (2013) Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air. J Trauma Acute Care Surg 74(5):1376CrossRefPubMed

11.

Cirocchi R (2014) Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy. Medicine (Baltimore) 93(25):e184CrossRef

12.

Rogy M, Függer R, Schemper M, Koss G, Schulz F (1990) The value of 2 distinct prognosis scores in patients with peritonitis. The Mannheim peritonitis index versus the Apache II score. Chir Z Für Alle Geb Oper Medizen 61(4):297–300

13.

Függer R, Rogy M, Herbst F, Schemper M, Schulz F (1988) Validation study of the Mannheim peritonitis index. Chir Z Für Alle Geb Oper Medizen 59(9):598–601

14.

Demmel N, Muth G, Maag K, Osterholzer G (1994) Prognostic scores in peritonitis: the Mannheim peritonitis index or APACHE II? Langenbecks Arch Für Chir 379(6):347–352

15.

Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentral

16.

Komen N (2009) After-hours colorectal surgery: a risk factor for anastomotic leakage. Int J Colorectal Dis 24(7):789–795CrossRefPubMedPubMedCentral

17.

Ansari MZ, Collopy BT, Hart WG, Carson NJ, Chandraraj EJ (2000) In-hospital mortality and associated complications after bowel surgery in Victorian public hospitals. Aust N Z J Surg 70(1):6–10CrossRefPubMed

18.

van Ruler O, Lamme B, de Vos R, Obertop H, Reitsma JB, Boermeester MA (2008) Decision making for relaparotomy in secondary peritonitis. Dig Surg 25(5):339–346CrossRefPubMed

19.

Bader FG, Schröder M, Kujath P, Muhl E, Bruch H-P, Eckmann C (2009) Diffuse postoperative peritonitis -- value of diagnostic parameters and impact of early indication for relaparotomy. Eur J Med Res 14(11):491–496CrossRefPubMedPubMedCentral

20.

van Ruler O (2011) Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy. BMC Surg 11(38)

21.

Koperna T, Schulz F (2000) Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg 24(1):32–37CrossRefPubMed

22.

Bodmann K-F, die Expertenkommission der Infektliga (2010) Complicated intra-abdominal infections: pathogens, resistance. Recommendations of the Infectliga on antbiotic therapy. Chir Z Alle Geb Oper Medizen 81(1):38–49CrossRef

23.

Sitges-Serra A, López MJ, Girvent M, Almirall S, Sancho JJ (2002) Postoperative enterococcal infection after treatment of complicated intra-abdominal sepsis. Br J Surg 89(3):361–367CrossRefPubMed

24.

Cercenado E (2010) Multicenter study evaluating the role of enterococci in secondary bacterial peritonitis. J Clin Microbiol 48(2):456–459CrossRefPubMed

25.

Tellor B, Skrupky LP, Symons W, High E, Micek ST, Mazuski JE (2015) Inadequate source control and inappropriate antibiotics are key determinants of mortality in patients with intra-abdominal Sepsis and associated bacteremia. Surg Infect 16(6):785–793CrossRef

26.

Lichtenstern C (2015) Relevance of Candida and other mycoses for morbidity and mortality in severe sepsis and septic shock due to peritonitis. Mycoses 58(7):399–407CrossRefPubMed

27.

Bassetti M (2015) A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality. Intensive Care Med 41(9):1601–1610CrossRefPubMed

28.

Dubler S (2017) The impact of real life treatment strategies for Candida peritonitis-a retrospective analysis. Mycoses 60(7):440–446CrossRefPubMed

29.

Solomkin JS (2010) Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the surgical infection society and the Infectious Diseases Society of America. Surg Infect 11(1):79–109CrossRef

Title: Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome
Authors: M. A. Sohn
A. Agha
P. Steiner
A. Hochrein
M. Komm
R. Ruppert
P. Ritschl
F. Aigner
I. Iesalnieks
Publication date: 01-07-2018
Publisher: Springer Berlin Heidelberg
Published in: International Journal of Colorectal Disease / Issue 7/2018
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-018-3025-7

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Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome

Abstract

Purpose

Methods

Results

Conclusion

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Abstract

Purpose

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