Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis--a proof of concept.
OBJECTIVE
Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.), and second look to restore intestinal continuity was developed.


METHODS
This algorithm allowed for three surgical procedures: primary anastomosis +/- VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III) RESULTS: All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n = 6). Nine patients in group II (n = 15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n = 7), the rate of anastomosis in surviving patients was 70%.


CONCLUSIONS
Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.
Perathoner
Alexander
A
Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
Klaus
Alexander
A
Mühlmann
Gilbert
G
Oberwalder
Michael
M
Margreiter
Raimund
R
Kafka-Ritsch
Reinhold
R
D000005:Abdomen / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003710:Demography; D004239:Diverticulitis, Colonic / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D054843:Negative-Pressure Wound Therapy / Q000379:methods*; D010538:Peritonitis / Q000150:complications* / Q000601:surgery*; D016896:Treatment Outcome