Perforated Sigmoid Diverticulitis Research Articles

S2987 Perforated Sigmoid Diverticulitis Presenting With Facial and Neck Swelling

S2987 Perforated Sigmoid Diverticulitis Presenting With Facial and Neck Swelling

Laparoscopic Hartmann's Reversal After Perforated Sigmoid Diverticulitis in a Woman.

Laparoscopic Hartmann's Reversal After Perforated Sigmoid Diverticulitis in a Woman.

Management of Perforated Sigmoid Diverticulitis with Associated Retroperitoneal Abscess and Generalized Peritonitis

Introduction: Diverticulitis represents a relatively common pathology within the gastrointestinal tract. While diverticula can occur throughout the digestive system, their prevalence is notably higher in the left colon, particularly in the sigmoid region. This condition predominantly affects middle-aged and elderly males. The most effective diagnostic methods for this disease are colonoscopy and computed tomography (CT) with contrast. Although severe complications of diverticulitis are infrequent, the optimal classification of these complications has been described by Hinchey.
 The article aims to show the case of a young patient with complicated diverticulitis with perforation and generalized peritonitis, classified as stage III-IV, according to Hinchey.
 Case report: A 43-year-old female patient was urgently admitted to the General Surgery Clinic at Tetovo Clinical Hospital, presenting with severe generalized abdominal pain and signs of peritoneal irritation. Comprehensive diagnostic imaging revealed a large retroperitoneal abscess located above the psoas muscle, accompanied by a significant accumulation of free fluid, suspected to be pus, in the abdominal cavity. Following initial resuscitation, surgical intervention was undertaken. Intraoperative findings included advanced inflammatory changes in the sigmoid colon, characterized by thickened fibrotic walls and a partially constricted lumen. A large abscess was also identified in the retroperitoneal space between the spleen and left kidney. Given these findings, resectioning the distal descending colon and most of the sigmoid colon was considered necessary. The retroperitoneal abscess was incised, its contents aspirated, and a thorough cavity debridement was performed. Subsequently, the Hartmann procedure was executed. Postoperatively, due to the patient's deteriorating condition, she was transferred to the intensive care unit for continued treatment. The patient was discharged from the hospital in stable condition on the tenth day following the surgery.
 Conclusion: While complications from sigmoid diverticula are uncommon, they can occasionally be extremely severe and pose a significant risk to patient survival.

A Case of Necrotizing Fasciitis of the Breast Following Lumpectomy and Oncoplastic Closure

Background. NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. Case Report. The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. Conclusion. This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.

Perforated Sigmoid Diverticulitis Within a Strangulated Inguinal Hernia.

We present a rare case of perforated diverticulitis within an inguinal hernia sac adjacent to a synthetic mesh from a prior incisional hernia. An 80-year-old-female presented to the ED with abdominal pain. Cross-sectional imaging was significant for a small bowel obstruction with a transition point in the right lower quadrant (RLQ). On physical exam, the patient had palpable bilateral inguinal hernias that were reducible; however, after 48hours of nonoperative management she failed to progress. Repeat imaging was concerning for incarcerated bowel within the inguinal hernia sac. She was taken to the operating room for exploratory laparotomy where the right inguinal hernia sac was found to contain sigmoid colon with diverticular perforation. A small bowel resection, right hemicolectomy and Hartmann's procedure were performed. The previously placed synthetic mesh was not contaminated during this operation and was not removed. Her hospital course was otherwise unremarkable but prolonged by the patient's deconditioned state.

PSAT362 Hypothyroidism Associated Colonic Rupture

Abstract A 59 year old female with history of thyroid cancer status post thyroidectomy presented with sudden onset severe and diffuse abdominal pain. CT Abdomen Pelvis with contrast showed extensive pneumoperitoneum suggestive of perforated viscus. The patient was taken to emergent diagnostic laparoscopy showing sigmoid perforation with fecal contamination and multiple large stool balls. Sigmoidectomy and end colostomy was performed for perforated sigmoid diverticulitis with feculent peritonitis. On admission, tests evaluating for thyroid function were consistent with hypothyroidism (TSH 39.700, n 0.400 - 4.500 uIU/mL). Over the previous two years, thyroid function studies were variable with both elevated and low TSH values (range 0.221-117 uIU/ml), although TSH values over the prior 12 months were not elevated. The patient reported adherence to taking levothyroxine 137 mcg daily in the outpatient setting. Furthermore, she endorsed appropriate administration of levothyroxine prior to food and was not taking the medication with any offending vitamins or minerals. Review of systems was negative for alternative causes of colonic rupture including trauma or chronic constipation. A thorough literature review was performed and revealed only 10 cases between 2004-2007 of spontaneous perforation of the colon in the absence of tumors, diverticulosis, or external injury.1 Only two reports were found linking spontaneous perforation of the colon with hypothyroidism, and proposed the causative mechanism as intestinal motility dysfunction causing chronic constipation, megacolon, or even pseudo-obstruction eventually leading to stercoral perforation.[2-3] Hypothyroid status was addressed by increasing levothyroxine dosage to 150 mcg daily. The patient recovered from septic shock and performed a 2 week course of inpatient rehabilitation from which she was discharged home with good functional status. Follow up labs evaluating thyroid status will be performed 4-6 weeks after initial testing and are still pending. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Choice of operative procedure in diverticular disease : Taking the latest treatment strategies into consideration

There are various procedures to be considered in the surgical treatment of complicated diverticulitis, which must be selected depending on the classification of diverticular disease (CDD) type and the condition of the patient. Comparison of surgical procedures with respect to aspects such as morbidity, mortality, reconstructive surgery and postoperative quality of life. Evaluation, analysis and assessment of the current literature on surgical treatment of diverticular disease. Laparoscopic sigmoid resection with primary anastomosis is now considered the standard procedure for complicated sigmoid diverticulitis. It is preferable to open resection because of the better results of the minimally invasive approach with respect to the incidence of wound infections, abdominal abscesses and the occurrence of fascial dehiscence. In an emergency situation with perforation and peritonitis (CDD type2c1/2), primary anastomosis with protective ileostomy should be favored over discontinuity resection (Hartmann's procedure). In particular, it must be taken into account that in alarge proportion of patients there is no restoration of continuity after Hartmann's operation. The damage control strategy can be used in perforated sigmoid diverticulitis with generalized peritonitis (CDD type2c1/2). In individual cases, laparoscopic lavage with insertion of adrainage may be considered as atherapeutic treatment strategy for perforated sigmoid diverticulitis with purulent peritonitis (CDD type2c1). Selection of the surgical procedure for complicated sigmoid diverticulitis remains challenging. Randomized controlled trials of new treatment strategies as well as robotic-assisted surgery should be considered in the choice of surgical procedure in the future.

Perforated sigmoid diverticulitis masquerading as multiple intra and extra abdominal disseminated abscesses

Abscess formation in perforated diverticulitis is most commonly confined to the pelvis, with other intraperitoneal and extraperitoneal locations rarer in the literature. Presented here is the case of a 63-year-old male who was diagnosed with perforated diverticulitis which manifested in multiple intra- and extra-abdominal abscesses. These were identified on abdominopelvic computed tomography to include a presacral abscess, bilateral psoas abscesses, a large left flank abscess located between the internal and external oblique muscles, as well as osteomyelitis of the S1 vertebra. To the best of the authors’ knowledge, this is the first reported case in the literature with this disseminated constellation of abscesses secondary to acute perforated diverticulitis.

S1625 Acute Perforated Diverticulitis as a Potential Complication of SARS-CoV-2 (COVID-19)

INTRODUCTION: Although Coronavirus Disease 2019 (COVID-19) presents predominantly with respiratory symptoms, gastrointestinal symptoms are becoming more recognized. Some studies report that up to 60% of COVID-19 positive patients present with a gastrointestinal complaint. Although our understanding of gastrointestinal symptoms coinciding with disease presentation is improving, gastrointestinal complications after acute COVID-19 infection are not well known. We report a healthy 38-year-old male presenting with acute perforated diverticulitis three days after being discharged from the hospital for respiratory symptoms secondary to COVID-19. CASE DESCRIPTION/METHODS: A healthy 38 year old White Hispanic male with no significant past medical history initially presented to the emergency department (ED) with fever, cough and shortness of breath with no gastrointestinal symptoms. Chest x-ray reported bilateral alveolar opacification (Figure 1) and nasal swab confirmed COVID-19. He was admitted for hypoxic respiratory failure requiring 4 liters of oxygen via nasal cannula. After treatment with hydroxychloroquine and convalescent plasma, he was deemed stable for discharge home. Three days later, he returned to the ED with lower abdominal pain that started one day after discharge. Abdominal CT reported an acute perforated sigmoid diverticulitis without an abscess (Figure 2). Nasal swab remained positive for COVID-19. Surgery was consulted and recommended medical management with IV antibiotics. His condition improved with IV piperacillin/tazobactam and he was discharged home on oral amoxicillin/clavulanic acid. DISCUSSION: Although COVID-19 predominantly presents with respiratory symptoms, there have been numerous reports of extra-respiratory complications including venous thromboembolism, cerebrovascular accidents and myocardial tissue injury. To the best of our knowledge, there have been no reports of acute diverticulitis secondary to COVID-19. Although there is insufficient data to suggest causation, systemic inflammation from COVID-19 may have played a role in the presentation of our patient. We hope that our case sheds light onto a potential gastrointestinal manifestation of COVID-19 that should not go unrecognized. Additionally, stool testing for COVID-19 may be an appropriate testing modality for patients with gastrointestinal symptoms. As more data on COVID-19 becomes available, consideration should be taken to identify potential gastrointestinal complications of the virus.Figure 1.: Bilateral patchy airspace opacities concerning for COVID-19 pneumonia.Figure 2.: Acute sigmoid diverticulitis with perforation.

Necrotizing fasciitis from perforated sigmoid diverticulitis with subsequent pyoderma gangrenosum: a case report.

Postsurgical pyoderma gangrenosum is a very rare form of cutaneous ulceration that is poorly recognized outside of dermatology and in some circumstances has been mistaken for necrotizing fasciitis. Here, we present a rare case of sigmoid diverticulitis with left ureter obstruction that perforated and quickly progressed into necrotizing fasciitis of the left buttock and leg via retroperitoneal spread in an immunocompetent patient. Nearly a year after intense surgical therapy, the patient rapidly developed ulcerating lesions over the left hip which presented a diagnostic dilemma. These were initially thought to represent Marjolin’s ulcers, which would require aggressive local excision. Multiple diagnostic imaging tests and biopsies eventually confirmed pyoderma gangrenosum, which was successfully treated with immunosuppressive therapy. This case highlights the need for a very broad differential diagnosis and wide expertise consultation when managing unusual postsurgical complications, especially when treatment modality critically depends on the correct diagnosis.

Comparison of Hartmann’s procedure vs. resection with primary anastomosis in perforated sigmoid diverticulitis: a retrospective single-center study

The surgical management of perforated sigmoid diverticulitis (PSD) is controversial and challenging. Hartmann’s procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis. However, because less than 50% of patients never achieve restored bowel continuity, alternative surgical procedures have been proposed, including laparoscopic lavage and resection with primary anastomosis (PRA), with or without a covering ileostomy. We performed a retrospective study to compare HP vs. PRA with loop-ileostomy for the treatment of PSD with generalized peritonitis. Data from 194 patients operated on for PSD from January 2008 to December 2018 were analyzed. Patients were classified into two groups: PRA and HP, according to the surgical procedure performed. In all, 113 (58%) patients underwent HP while PRA was performed on 81 (42%) patients. Primary anastomosis was associated with fewer postoperative major complications than HP (p < 0.05). However, patients in the PRA group were significantly younger (median 76 vs. 60 years, p < 0.05), with a reduced proportion of patients with ASA III–V grade (31% vs. 66%, p < 0.05). In 58 patients from the HP group (52%) end colostomies were reversed, whereas the stoma reversal rate after ileostomy was significantly higher (96%, p < 0.05). Primary anastomosis can be performed safely without adding morbidity and mortality in cases of generalized diverticular peritonitis. Hartmann’s procedure should be reserved only for hemodynamically unstable or high-risk patients.

Evaluation of Operative Management for Perforated Sigmoid Diverticulitis

Evaluation of Operative Management for Perforated Sigmoid Diverticulitis

Damage control surgery for perforated diverticulitis: a two center experience with two different abdominal negative pressure therapy devices

Purpose: The adoption of abdominal negative pressure therapy (NPT) during urgent laparotomy has shown to be helpful to control abdominal sepsis, improve morbidity and increase anastomosis rate. The aim of this study was to compare feasibility and outcome of two different abdominal negative pressure devices.Methods: The retrospective two-center study includes 78 consecutive patients with perforated sigmoid diverticulitis, who underwent urgent laparotomy using the ABThera™ (KCI, Wien, Austria) abdominal NPT device (Group A, n = 51) or the Suprasorb® CNP (Lohmann & Rauscher, Wien, Austria) abdominal NPT device (Group B, n = 27).Results: The mean length of abdominal NPT was 3.6 days in Group A and 2.8 days in Group B. Revisional surgery after closure of the abdomen was necessary due to surgical site infections, fascial dehiscence or anastomotic insufficiency in 25% and 29%, respectively. NPT-associated complications like fistula formation or acute bleeding were not observed. Mortality was 15% (Group A) and 7% (Group B).Conclusion: Despite the good feasibility and the well-known positive effect of abdominal NPT, perforated diverticulitis is still associated with high morbidity. However, the analysis did not show significant differences between the two abdominal NPT devices.

Endoscopic Closure of Persistent Anastomotic Leaks Using the US Endoscopy Padlock® Over-the-Scope Clip

Introduction: Persistent anastomotic leaks (PAL) are an uncommon but serious surgical complication associated with significant morbidity and mortality. While traditionally treated by percutaneous drainage and surgical revision, there is an emerging paradigm for endoscopic management using over-the-scope clips (OTSC). We present 4 cases of PAL that were endoscopically treated using the US Endoscopy Padlock® OTSC. Case Presentations: Case 1: A 57-year-old man with sigmoid adenocarcinoma underwent laparoscopic left hemicolectomy complicated by dehiscence at the anastomosis resulting in fluid collection needing percutaneous drainage. A fistulous tract was found at the proximal sigmoid colon anastomosis communicating to the retroperitoneum. Over the course of 3 endoscopies, Padlock OTSCs were used to close the defect. No evidence of PAL noted on follow-up colonoscopy or on subsequent abdominal imaging. Case 2: A 54-year-old man with Lynch syndrome and colon adenocarcinoma underwent total colectomy with ileorectal anastomosis complicated by PAL requiring percutaneous drains. Two openings were noted along the staple line and Padlock® OTSC was applied on each site. No evidence of PAL on follow-up imaging. Case 3: A 55-year-old man with perforated sigmoid diverticulitis underwent diverting colostomy and eventual takedown complicated by a large PAL resulting in multiple pelvic abscesses, for which percutaneous drains were placed. A 2 cm opening was seen distal to the colorectal anastomosis that was closed with adjacent Padlock® OTSCs x2. Subsequent imaging confirmed successful endoscopic closure. Case 4: A 48-year-old woman with sigmoid adenocarcinoma underwent sigmoid colectomy complicated by peritonitis and PAL requiring diverting loop ileostomy. A 2 mm leak was identified along the anastomosis in the proximal rectum and closed using Padlock® OTSC. No evidence of PAL was noted on the follow-up imaging. Discussion: Anastomotic leaks and fistulas are serious post-operative complications that cause significant patient morbidity, prolonged hospitalizations, and multiple invasive interventions. We presented 4 cases of successful endoscopic closure of both small (< 5 mm) and large (>20 mm) anastomotic leaks using the US Endoscopy Padlock® OTSC. Our experience indicates that this novel device is easy to use, minimally invasive, and cost effective, therefore should be considered as an alternative to surgery for closure of anastomotic leaks and fistulae within the GI tract.2105_A Figure 1. (A & B) closure of persistent anastomotic leaks using the US Endoscopy Padlock® over —the-scope clip (A: before the closure; B: after the closure).2105_B Figure 2. (A & B) closure of persistent anastomotic leaks using the US Endoscopy Padlock® over —the-scope clip (A: before the closure; B: after the closure).

The appropriateness of ceftriaxone and metronidazole as empirical therapy in managing complicated intra-abdominal infection-experience from Western Health, Australia.

PurposeThis study aims to assess the microbiological profile, antimicrobial susceptibility and adequacy of intravenous ceftriaxone and metronidazole as empirical therapy for surgical patients presenting with complicated intra-abdominal infection.MethodsThis retrospective audit reviews the microbiological profile and sensitivity of intra-abdominal cultures from adult patients with complicated intra-abdominal infection who presented to the emergency department at Western Health (Melbourne, Australia) between November 2013 and June 2017. Using the hospital’s database, an audit was completed using diagnosis related group (DRG) coded data. Ethics approval has been granted by the Western Health Human Research Ethics Committee. Results are stratified according to surgical conditions (appendicitis, cholecystitis, sigmoid diverticulitis and bowel perforation). The antimicrobial coverage of ceftriaxone and metronidazole is evaluated against these microbial profiles.ResultsA total of 1,412 patients were identified using DRG codes for intra-abdominal infection. All patients with microscopy and sensitivity results were included in the study. Patients without these results were excluded. 162 patients were evaluable. 180 microbiological cultures were performed through surgical intervention or radiologically guided aspiration of the intra-abdominal infection. Single or multiple pathogens were identified in 137 cultures. The most commonly identified pathogens were mixed anaerobes (12.6%), Escherichia coli (E. coli) (12.1%), mixed coliforms (11.6%) and Pseudomonas aeruginosa (7%). Other common pathogens (6% each) included Enterococcus faecalis, Streptococcus anginosus, Vancomycin-resistant Enterococci (VRE) and Extended Spectrum Beta-Lactamases (ESBL) producing E. coli. Organisms isolated in our study are consistent with existing literature. However, a significant proportion of antibiotic resistant organisms was identified in cases of perforated bowel and sigmoid diverticulitis. Broader spectrum antimicrobial therapy should therefore be considered in lieu of ceftriaxone and metronidazole in these cases. Ceftriaxone and metronidazole remain as appropriate empirical therapy for patients who presented with perforated appendicitis and cholecystitis.DiscussionThe empirical regime of ceftriaxone and metronidazole remains appropriate for intra-abdominal infection secondary to appendicitis and cholecystitis. In cases involving perforated small and large bowel, including complicated sigmoid diverticulitis, the judicious use of ceftriaxone and metronidazole is recommended.

Thigh Necrotizing Fasciitis Secondary to Perforated Sigmoid Diverticulitis

Thigh Necrotizing Fasciitis Secondary to Perforated Sigmoid Diverticulitis

Perforated Sigmoid Diverticulitis Resulting in Subcutaneous Abscess

Perforated Sigmoid Diverticulitis Resulting in Subcutaneous Abscess

Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials.

The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann's procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis. A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals. Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14-1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41-4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12-0.96, p = 0.04). PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical optionin patients with generalised peritonitis due to diverticular perforation.