Outcomes of damage control surgery in perforated sigmoid diverticulitis: a comparison before and after implementing a new treatment algorithm.

IntroductionDamage control surgery (DCS) with abdominal negative pressure therapy and delayed anastomosis creation in patients with perforated diverticulitis and generalized peritonitis was established at our Institution in 2006 and has been published. The concept was adopted in other hospitals and published as a case series. This is the first prospectively controlled randomized study comparing DCS and conventional treatment (Group C) in this setting.MethodsAll consecutive patients from 2013 to 2018 with indication for surgery were screened and randomized to Group DCS or Group C. The primary outcome was the rate of reconstructed bowel at discharge and at 6 month. Informed consent was obtained. The trial was approved by the local ethics committee and registered at CinicalTrials.gov: NCT04034407.ResultsA total of 56 patients were screened; 41 patients gave informed consent to participate and ultimately 21 patients (9 female) with intraoperatively confirmed Hinchey III (n = 14, 67%) or IV (n = 7, 33%), and a median (range) age of 66 (42–92), Mannheim Peritonitis Index of 25 (12–37) and Charlson Comorbidity Index of 3 (0–10) were intraoperatively randomized and treated as Group DCS (n = 13) or Group C (n = 8). Per protocol analysis: A primary anastomosis without ileostomy (PA) was performed in 92% (11/12) patients in Group DCS at the second-look operation, one patient died before second look, and one underwent a Hartmann procedure (HP). In Group C 63% (5/8) patients received a PA and 38% (3/8) patients a HP. Two patients in Group C, but none in Group DCS experienced anastomotic leakage (AI). ICU and hospital stay was median (range) 2 (1–10) and 17.5 (12–43) in DCS and 2 (1–62) and 22 (13–65) days in group C. In Group DCS 8% (1/12) patients was discharged with a stoma versus 57% (4/7) in Group C (p = 0.038, n.s., α = 0.025); one patient died before discharge. The odds ratio (95% confidence interval) for discharge with a stoma is 0.068 (0.005–0.861). Intent to treat analysis: A PA was performed in 90% (9/10) of patients randomized to DCS, one patient died before the second look, and one patient received a HP. In group C, 70% (7/10) were treated with PA and 30% (3/10) with HP. 29% (2/7) experienced AI treated with protective ileostomy. In group DCS, 9% (1/11) were discharged with a stoma versus 40% (4/10) in group C (p = 0.14, n.s.). The odds ratio for discharge with a stoma is 0.139 (0.012–1.608).ConclusionThis is the first prospectively randomized controlled study showing that damage control surgery in perforated diverticulitis Hinchey III and IV enhances reconstruction of bowel continuity and can reduce the stoma rate at discharge.

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.

The aim of this meta-analysis was to comparatively evaluate the outcomes of primary anastomosis (PRA) and nonrestorative resection (NRR) as emergency surgery and ostomy reversal in patients with perforated diverticulitis and peritonitis. PubMed, MEDLINE via Ovid, Embase, CINAHL, Cochrane Library and Web of Science databases were systematically searched. Postoperative morbidity following emergency resection was the primary end-point. Quality assessment of the included studies was performed using the Cochrane Quality Assessment Tool including recruitment bias and crossover with intention-to-treat analysis. The Haenszel-Mantel method with odds ratios (OR, 95% CI) and the inverse variance method with mean difference (MD, 95% CI) as effect measures were utilized for dichotomous and continuous outcomes, respectively. Four randomized controlled trials totaling 382 patients (180 PRA vs 204 NRR) were included. Morbidity rates following emergency resection did not differ (OR =0.99, 95% CI0.65, 1.51; P=0.95; number needed to treat/harm (NNT) 96). Organ/space surgical site infection rates were 3.3% in PRA vs 11.3% in NRR (OR =0.29, 95% CI0.12, 0.74; P=0.009; NNT=13). Postoperative morbidity rates following ostomy reversal were significantly lower in PRA (OR =0.31, 95% CI 0.15, 0.64; P=0.001; NNT=7). Pooled ostomy non-reversal rates were 16% in PRA vs 35.5% in NRR (OR =0.37, 95% CI0.22, 0.62; P=0.0001; NNT=6) with high heterogeneity (I2 =63%; τ2 =8.17). Meta-regression analysis revealed significant negative correlation between the PRA-to-NRR crossover rate and the ostomy non-reversal rate (P=0.029). This meta-analysis found that PRA was associated with better short- and long-term outcomes at the cost of significantly longer operating time at emergency surgery.

Perforated diverticulitis is a critical surgical emergency that demands immediate attention and intervention. Damage control surgery (DCS) has emerged as an alternative to traditional approaches for managing physiologically unstable and critically ill patients. This systematic review includes 16 articles published between 2015 and 2025, covering randomized controlled trials, observational cohorts, case reports, and guidelines. The inclusion and exclusion criteria focused on human studies published in English that addressed managing perforated diverticulitis with DCS. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines were used to guide article selection, which was further refined using standardized appraisal tools such as A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), the Newcastle-Ottawa Scale (NOS), Joanna Briggs Institute Checklists (JBI), the Cochrane Risk of Bias (RoB) tool, the Appraisal of Guidelines for Research and Evaluation II (AGREE II), and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). This review highlights DCS as an effective approach for managing perforated diverticulitis. Patient management with DCS showed significant improvement compared to traditional methods such as Hartmann’s procedure. Physiological stabilization reduced complications such as stoma formation and improved anastomosis rates, as supported by the included studies. The findings suggest that DCS reduces morbidity and mortality, lowers the need for a stoma, and enhances bowel continuity in patients with perforated diverticulitis. Several studies also employed negative pressure therapy for temporary abdominal closure. The main prognostic factors identified were ongoing peritonitis and hemodynamic instability, which characterize critically ill patients. These findings underscore the importance of prioritizing patient stability and controlling disease severity at the outset, before proceeding to definitive therapy once the patient is stable. Further high-quality, multicenter studies with larger sample sizes are needed to develop standardized treatment guidelines.

BackgroundThe role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.MethodsPatients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.ResultsIn 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424–4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.ConclusionsThe stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Objective To determine the effect of different surgical modalities on hemodynamics,systemic major organ injury and survival rate following superior mesenteric artery (SMA) injury in an attempt to search a modality that conforms to principles of damage control surgery (DCS).Methods SMA was exposed in 30 domestic hybrid pigs,leaving the blood flow blocked using non-invasive vessel forceps.The animals were divided into control group,primary anastomosis group (anastomosis group) and temporary intravascular shunt (TIVS) group according to random number table.TIVS group was further divided into three subgroups:shunting for 6 hours group (TIVS-6 h group),9 hours group (TIVS-9 h group) and 12 hours group (TIVS-12 h group).At each time point,the angiography was performed for evaluation of shunt patency; hemodynamic parameters were detected,terminal ileum and SMA samples were harvested for pathological analysis.Results All groups suffered extreme physiological conditions including hypothermia,severe acidosis,hypotension,low cardiac output and low oxygen supply.Less requirement of resuscitation fluid,faster restoration of SMA blood flow,earlier clearance of lactate,milder intestinal ischemia-reperfusion injury and higher survival rate were observed in TIVS-6 h and TIVS-9 h groups,compared with anastomosis group.Patency rate in TIVS-6 h,9 h and 12 h groups was 100％,50％ and 0％ respectively.Pathologic outcome of intestine revealed diffuse intestinal necrosis in TIVS-12 h group and reversible intestinal ischemia-reperfusion injury in TIVS-6 h and 9 h groups.Conclusion For SMA injury in severe hemodynamic disarrangement and jeopardized condition,TIVS shortens intestinal ischemia time,maintains systemic hemodynamic stability,relieves intestinal injury,improves early survival rate and keeps long-term intestine patency when compared with primary vascular anastomosis. Key words: Shock; Mesenteric artery, superior; Damage control surgery

Mechanically powered negative pressure dressing reduces surgical site infection after stoma reversal.

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

General Gastroenterological Surgery: Spleen.

Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p= 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p= 0.001), and increased operation time (105 vs. 84min., p= 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p< 0.001). Complication rate (44 vs. 24%, p= 0.092), mortality (12 vs. 0%, p= 0.061), overall number of surgeries (3.4 vs. 2.4, p= 0.017), enterostomy rate (76 vs. 36%, p= 0.001), and length of hospital stay (25 vs. 18.8days, p= 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p= 0.005) and with fungal infection (100 vs. 49%, p= 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p< 0.001), enterostomy rate (81 vs. 48%, p= 0.017), and anastomotic leakage (29 vs. 6%, p= 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p= 0.014). Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Background Patients experiencing rapid weight loss after bariatric surgery are at high risk of developing gallstones. However, the necessity of performing a concomitant cholecystectomy along with Roux-en-Y Gastric Bypass (RYGB) remains debated. Concerns over higher complication rates lead many surgeons to avoid performing concomitant cholecystectomy, particularly in patients without gallbladder pathology. Aims To compare outcomes between patients without cholelithiasis undergoing RYGB with and without concomitant cholecystectomy. Methods We conducted a pilot prospective open randomized study from 2018 to 2023 involving patients without gallstones who underwent RYGB either without concomitant cholecystectomy (control group) or with concomitant cholecystectomy (study group). Follow-up occurred during hospitalization and at 1, 3, 6, 12, and 18 months. The primary composite outcome was intraoperative adverse events (iAEs) and postoperative complications (Clavien-Dindo classification). Secondary endpoints included detailed iAEs and postoperative complications, biliary outcomes, operation duration, length of hospital stay, and quality of life (QoL). Results A total of 95 patients were included in the study. Demographics were similar between groups. There was no statistically significant difference in the composite outcome of intra- and postoperative complications between the control and study group (24.4% vs. 42%, p = 0.083). Detailed iAEs, postoperative complications according to Clavien-Dindo, length of hospital stay, operation duration, and QoL at 1 and 12 months were similar, while the study group showed a higher early comprehensive complication index (mean CCI of 2.10 vs. 6.09, p = 0.047). The incidence of biliary complications during follow-up was 6.8% in the control group and 2.0% in the study group, with 4.5% of patients receiving biliary interventions in the control group. Conclusion While overall intra- and postoperative complications did not significantly differ, patients experiencing concomitant cholecystectomy showed a higher early complication index. The incidence of subsequent biliary interventions was low in this patient cohort without preexisting cholelithiasis.

Perforated colonic diverticulitis usually requires surgical resection, which is associated with significant morbidity. Cohort studies have suggested that laparoscopic lavage may treat perforated diverticulitis with less morbidity than resection procedures. To compare the outcomes from laparoscopic lavage with those for colon resection for perforated diverticulitis. Multicenter, randomized clinical superiority trial recruiting participants from 21 centers in Sweden and Norway from February 2010 to June 2014. The last patient follow-up was in December 2014 and final review and verification of the medical records was assessed in March 2015. Patients with suspected perforated diverticulitis, a clinical indication for emergency surgery, and free air on an abdominal computed tomography scan were eligible. Of 509 patients screened, 415 were eligible and 199 were enrolled. Patients were assigned to undergo laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98) based on a computer-generated, center-stratified block randomization. All patients with fecal peritonitis (15 patients in the laparoscopic peritoneal lavage group vs 13 in the colon resection group) underwent colon resection. Patients with a pathology requiring treatment beyond that necessary for perforated diverticulitis (12 in the laparoscopic lavage group vs 13 in the colon resection group) were also excluded from the protocol operations and treated as required for the pathology encountered. The primary outcome was severe postoperative complications (Clavien-Dindo score >IIIa) within 90 days. Secondary outcomes included other postoperative complications, reoperations, length of operating time, length of postoperative hospital stay, and quality of life. The primary outcome was observed in 31 of 101 patients (30.7%) in the laparoscopic lavage group and 25 of 96 patients (26.0%) in the colon resection group (difference, 4.7% [95% CI, -7.9% to 17.0%]; P = .53). Mortality at 90 days did not significantly differ between the laparoscopic lavage group (14 patients [13.9%]) and the colon resection group (11 patients [11.5%]; difference, 2.4% [95% CI, -7.2% to 11.9%]; P = .67). The reoperation rate was significantly higher in the laparoscopic lavage group (15 of 74 patients [20.3%]) than in the colon resection group (4 of 70 patients [5.7%]; difference, 14.6% [95% CI, 3.5% to 25.6%]; P = .01) for patients who did not have fecal peritonitis. The length of operating time was significantly shorter in the laparoscopic lavage group; whereas, length of postoperative hospital stay and quality of life did not differ significantly between groups. Four sigmoid carcinomas were missed with laparoscopic lavage. Among patients with likely perforated diverticulitis and undergoing emergency surgery, the use of laparoscopic lavage vs primary resection did not reduce severe postoperative complications and led to worse outcomes in secondary end points. These findings do not support laparoscopic lavage for treatment of perforated diverticulitis. clinicaltrials.gov Identifier: NCT01047462.

Background: Stoma reversal, which involves restoring intestinal continuity, is a complex but commonly performed elective procedure in pediatric surgery. However, it carries significant risks, including postoperative complications and even mortality. This study aimed to evaluate early postoperative complications associated with hand-sewn modified double-layer intestinal anastomosis following stoma reversal in children who had previously undergone definitive bowel surgery. Methods: This retrospective study was conducted in the Department of Pediatric Surgery at Chattogram Maa-O-Shishu Hospital Medical College over a period of eleven years, from January 2014 to December 2024. A total of 673 children who underwent stoma closure were included in this study. We analyzed the indications for stoma formation, the duration from creation to closure of the stoma, operative time, and length of hospital stay. Early postoperative complications were assessed using the Clavien-Dindo classification within the first 30 days after surgery. Patients were followed up at two and four weeks after the procedure. Results: The median age of the participants was 2.17 ± 0.8 years (IQR: 1.4 - 4.5 years), with a male-to-female ratio of 2.17:1. The primary indications for the initial surgery, which involved stoma formation, included anorectal malformation (231 cases), Hirschsprung’s disease (183 cases), intussusception (110 cases), jejunoileal atresia (53 cases), meconium ileus (22 cases), pelvic or blunt abdominal trauma (22 cases), postoperative bands and adhesions (18 cases), ileocecal tuberculosis (12 cases), lymphoma (7 cases), Meckel’s diverticulum with bands (11 cases), and typhoid ulcer perforation (4 cases). The median interval between the primary procedure and stoma closure was 62 weeks (IQR: 48–76 weeks). The median operative time was 108 minutes. A total of 219 patients (32.5%) experienced postoperative complications, which included surgical site infection (SSI) (37.8%), anastomotic leak (15.1%), small bowel obstruction or paralytic ileus (9.6%), post-operative diarrhea (8.2%), enterocutaneous fistula (4.2%), gastrointestinal bleeding (3.2%), and postoperative intra-abdominal abscess (2.3%). Medical complications accounted for 19.7% of all complications, with pneumonia (12.3%) being the most common. Reoperations were required due to intestinal obstruction, anastomotic leak, and post-operative intra-abdominal abscess. Additionally, 57 associated procedures were performed, including 13 appendectomies, seven inguinal herniotomies, and 37 circumcisions. Twenty-three patients required a stay in the Pediatric Intensive Care Unit (PICU) following reversal surgery, and seventeen of these patients survived successfully. The median length of hospital stay for these patients was 8.4 days, ranging from 7.3 to 12.1 days. Conclusions: There were several indications for stoma formation in children. Surgical site infections (SSIs) were the most common complication following stoma reversal. While most complications could be managed conservatively, cases of anastomotic leak and intestinal obstruction necessitated reoperation. Journal of Paediatric Surgeons of Bangladesh (2022) Vol. 13 (1 &amp; 2): 36-43

Objective To study the surgical treatment of elderly patients with colorectal cancer.Methods Between 2001 and 2009,surgical treatment datas of 76 cases of edlerly patients with colorectal cancer during perioperative period were retrospectively analyzed.Results Elderly colorectal cancer patients misdiagnosed before admission (44/76),coexisting diseases and more (46/76),tumor resection rate was 90％,postoperative complication rate was 37％,perioperative mortality rate was 8％.Conclusions ①Colorectal cancer increases with age like the other malignant tumors.②Elderly colorectal cancer patients with slow onset,symptoms hidden,comorbidities and more features.③Elderly colorectal cancer is often misdiagnosed.④Elderly colorectal cancer patient' s preoperative preparation is mainly the treatment of coexisting diseases.Perioperative treatment of coexisting diseases is the key to reducing mortality.⑤Treatment options should strictly follow the concept of controlled surgical injury ( Damage control surgery,DCS).Surgical resection is the best treatment for elderly colorectal cancer patient.⑥Treatment of complications is very important. Key words: Colon and rectal cancer; Elderly patients; Surgical treatment