Damage Control Surgery for Perforated Diverticulitis with Generalized Peritonitis: Better a Delayed Anastomosis than a Stoma Right Away.

Introduction. In the last decade, Damage Control Surgery (DCS) has been emerging as a feasible alternative management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS in perforated acute diverticulitis. In this study, we present the outcome from a multi-institutional series of patients presenting with grade III and IV Hinchey’s diverticulitis and managed by DCS. Method. All the partecipating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS and admitted between June 2015 and September 2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment followed by a lavage and the application of an open abdomen technique was performed. After patient resuscitation, a second look was performed after 24/48 hours. Demographics, clinical, intra-operative and post-operative variables were carefully analyzed. Mortality, morbidity, and restoration of bowel continuity were the major outcomes of the study. Results. There were 15 male (44%) and 19 female (56%) with a mean age of 66,9 years (SD ± 12,7). Mean BMI was 28,42 Kg/m² (SD ± 3,33). Based on the severity of the disease, 13 cases (38%) were classified as Wasvary’s modified Hinchey’s stage III, and 21 cases (62%) as Hinchey IV. Mean Mannheim Peritonitis Index (MPI) was 25,12 (SD ± 6,28). In 22 (65%), ASA score was ≥ grade III. In all cases, the open abdomen was created by using a Negative Pressure Wound Therapy (NPWT) technique. At the second operation, twenty-four patients (71%) had a primary anastomosis, while 10 (29%) were treated with an end colostomy (Hartmann’s procedure). In 7/34 (21%) cases, a third look was needed. In 2/24 patients, a temporary loop ileostomy was required: both of them were closed in a second moment. Mortality rate was 12%. Overall morbidity rate was 53% (18/34). According to Claviend and Dindo classification, there were no grade I, 6/18 grade II, 1/18 grade IIIa, 5/18 grade IIIb and 2/18 grade IV. Reinterventions were required in 4/34 (12%): two for intestinal anastomosis dehiscence and two for abdominal wound dehiscence. Mean lenght of hospital stay was 21,9 days. Conclusion. DCS is feasable for patients with generalized peritonitis from perforated diverticulitis and it seems related to a higher rate of bowel reconstruction. Due to the open abdomen, it requires a stay in ICU with a prolonged mechanical ventilation but these same needs are often the burden of the majority of patients undergone surgery for a perforated diverticulitis, whatever the procedure is done.