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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.
Highlights
In the past few decades, the complicated diverticular disease has been an increasing burden on healthcare systems as its incidence has steadily risen in Western countries [1,2,3] including Italy [4]
When generalized peritonitis is diagnosed and an emergency surgical procedure is required, we suggest a stepwise decisional approach
Many surgeons are reluctant to consider a primary anastomosis in the acute setting and the frequency of Hartmann’s procedure (HP) has remained unchanged over the last years [74,75,76,77], these results suggest that primary resection and anastomosis (PRA) is the optimal resective procedure in physiologically normal and immunocompetent patients with either purulent or fecal peritonitis
Summary
In the past few decades, the complicated diverticular disease has been an increasing burden on healthcare systems as its incidence has steadily risen in Western countries [1,2,3] including Italy [4]. In generalized peritonitis and septic shock, the definition of hemodynamic responsiveness versus unresponsiveness may offer guidance for timing (urgent versus emergent), type of primary approach (laparoscopic versus open-resuscitative), and choice of surgical procedure (see “Key-Point 4”). Many surgeons are reluctant to consider a primary anastomosis in the acute setting and the frequency of HP has remained unchanged over the last years [74,75,76,77], these results suggest that PRA is the optimal resective procedure in physiologically normal and immunocompetent patients with either purulent or fecal peritonitis. There is no gold standard to determine the indication for a non-restorative versus a restorative procedure, and as stated in previous key points, patient-related factors and severity of intraoperative findings, as well as surgeon expertise, should be the main criteria for tailoring surgical decision-making in this setting. Two further meta-analyses [113, 114] confirmed that- after open abdominal surgery this PAMORA can accelerate recovery of gastrointestinal function, shorten the length of hospital stay, and reduce POI-related morbidity without compromising opioid analgesia, resulting in a cost-saving approach [115]
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