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Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis
M Sohn1, A Agha2, W Heitland3
1Department of General, Abdominal, Vascular and Thoracic Surgery, Städtisches Klinikum München Bogenhausen, Englschalkinger Strasse 77, 81925, Munich, Germany. maximilian.sohn@klinikum-muenchen.de.
Background:
The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy.
Methods:
All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24-48 h later At this point a choice was made between anastomosis and Hartmann's procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann's procedure) at the initial operation.
Results:
Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (p = 0.66).
Conclusions:
Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.
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