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

  • M. A. Sohn
  • A. Agha
  • P. Steiner
  • A. Hochrein
  • M. Komm
  • R. Ruppert
  • P. Ritschl
  • F. Aigner
  • I. Iesalnieks
Original Article

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.

Keywords

Perforated diverticular disease Damage control surgery Peritonitis 

Notes

Compliance with ethical standards

Conflict of interests

The authors declare that they have no conflict of interest.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • M. A. Sohn
    • 1
  • A. Agha
    • 1
  • P. Steiner
    • 2
  • A. Hochrein
    • 3
  • M. Komm
    • 4
  • R. Ruppert
    • 4
  • P. Ritschl
    • 5
  • F. Aigner
    • 5
  • I. Iesalnieks
    • 1
  1. 1.Department of General-, Abdominal-, Endocrine and Minimally Invasive SurgeryStädtisches Klinikum München BogenhausenMunichGermany
  2. 2.Department of General-, Abdominal- and Vascular SurgeryStädtisches Klinikum München HarlachingMunichGermany
  3. 3.Department of SurgeryOCM MünchenMunichGermany
  4. 4.Department of General- and Abdominal Surgery, Endocrine Surgery and ColoproctologyStädtisches Klinikum München NeuperlachMunichGermany
  5. 5.Department of Surgery, Campus Charité Mitte | Campus Virchow-KlinikumCharité–Universitätsmedizin BerlinBerlinGermany

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