Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome
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.
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.
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).
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.
KeywordsPerforated diverticular disease Damage control surgery Peritonitis
Compliance with ethical standards
Conflict of interests
The authors declare that they have no conflict of interest.
- 3.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):190–207CrossRefPubMedGoogle Scholar
- 4.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 SurgGoogle Scholar
- 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):297–300Google Scholar
- 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):598–601Google Scholar
- 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):347–352Google Scholar
- 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)Google Scholar