Acute perforative diverticulitis of the colon as a rare cause for the development of abdominal compartment syndrome

Abstract

The aim of this retrospective study was to evaluate the surgical tactics in the treatment of the acute perforative diverticulitis of the colon, resulting in peritonitis and in some cases complicated with abdominal compartment syndrome. In the last 5 years 8 patients underwent emergency operation due to perforative diverticulitis of the colon, 6 men and 2 women. The mean age of the men was 72+-2.6 years, and of women 69+-3.1 years. The two women were with perforation of the cecum, five of the men with perforated diverticulitis of the sigmoid colon and one with perforation of the descend colon. In all of the cases the diagnosis was established intraoperationem, and only in two cases was suspected before that. In the group of patients with pathology in the cecum a right hemicolectomy with primary anastomosis was performed. To the other 6 patients a Hartmann procedure was done, with a second operation several months later. In four of the patients with perforated diverticulitis of the sigmoid colon a total fecal peritonitis was found (stage IV of Hinchey scale, 1978y.), with data for multiorgan failure (MOF), intraabdominal hypertension (IAH)>25 sm H2O and developed abdominal compartment syndrome (ACS). In this group of patients the surgical procedure followed the principles of the so called damage control surgery with obligatory retrograde decompression of the intestines without enterotomy. The operation was followed by the confirmed in our clinic method of temporary abdominal closure (TAC). We use the so called semi-opened method, or modified laparostomy, with many advantaged compared to the classic abdominostomy. We use ampoxen mesh and always leave enough space for the oedematic guts-the so called silo. For to measure the intraabdominal pressure (IAP) we used the indirect transvesical method-the gold standard. The urgent surgical strategy for the treatment of the acute perforative diverticulitis of the colon differs according to the location of the complication, biological status of the patient, the absence or presence of IAH, MOF and ACS. Good orientation value for the practice has the four stage scale of Hinchey, which deals with the different complications of the perforated diverticulitis of the colon. In our study the present fecal peritonitis, valued as stage IV on Hinchey’s scale, with developed ACS defined our tactics to apply damage control surgery, followed by TAC (modified laparostomy). In spite of the severe condition, we did not have lethal outcome, in two patients a post-operative hernia developed. Primary hemicolectomy with one moment anastomosis is the best procedure for patients in good condition and low score in the Hinchey’s scale. The total fecal peritonitis, with IV stage of the Hinchey’s scale and data for developed ACS require procedure Hartmann type, applying the principles of damage control surgery with obligatory technique of TAC for overcoming of the primary and prevention of secondary ACS. Scripta Scientifica Medica 2008;40(1):55-57