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Nascimbeni R, Amato A, Cirocchi R, Serventi A, Laghi A, Bellini M, Tellan G, Zago M, Scarpignato C, Binda GA. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Tech Coloproctol 2020; 25:153-165. [PMID: 33155148 PMCID: PMC7884367 DOI: 10.1007/s10151-020-02346-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
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Affiliation(s)
- R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
| | - A Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy
| | - R Cirocchi
- Department of Surgical and Medical Sciences, University of Perugia, Terni, Italy
| | - A Serventi
- Department of Surgery, Galliano Hospital, Acqui Terme, Italy
| | - A Laghi
- Department of Surgical-Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Tellan
- Department of Internal, Anesthesiological and Cardiovascular Clinical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - C Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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Brandl A, Kratzer T, Kafka-Ritsch R, Braunwarth E, Denecke C, Weiss S, Atanasov G, Sucher R, Biebl M, Aigner F, Pratschke J, Öllinger R. Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach? Can J Surg 2017; 59:254-61. [PMID: 27240131 DOI: 10.1503/cjs.012915] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes. METHODS This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated. RESULTS Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis. CONCLUSION Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.
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Affiliation(s)
- Andreas Brandl
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Theresa Kratzer
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Reinhold Kafka-Ritsch
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Eva Braunwarth
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Christian Denecke
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Sascha Weiss
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Georgi Atanasov
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Robert Sucher
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Matthias Biebl
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Felix Aigner
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Johann Pratschke
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Robert Öllinger
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
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