Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy.

INTRODUCTION: Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS.

METHODS: All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011-2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study.

RESULTS: There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m2 (SD ± 3.33). Thirteen cases (38%) were Wasvary's modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann's procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender ( p  = 0.010) and MPI ( p  = 0.034) correlated with a high percentage of Hartmann's procedures.

CONCLUSION: DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.