title: Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis.
abstract: BACKGROUND
  It was previously reported that in patients with acute perforated diverticulitis with Hinchey categories I to III sigmoidectomy with primary anastomosis (PA) is superior to Hartmann's procedure (HP) as later closure of colostomy involves substantial morbidity. We evaluated our experience with PA for patients with perforated diverticulitis over a 10-year period and aimed to investigate whether Hinchey category or co-morbidity are more relevant for postoperative outcome.
  
  
  METHODS
  Records of all patients treated at our institution for sigmoid diverticulitis between 1996 and 2006 were retrieved from an in-hospital database (N = 787, median age 66 years, range 30 to 94, female:male ratio 1.3:1); 73 patients who underwent immediate emergency surgery for perforated diverticulitis were included in this study. American Society of Anesthesiology (ASA) classification to gauge co-morbidity and Hinchey category for intraoperative extent of inflammation were evaluated as regards their relevance for postoperative mortality and major complications.
  
  
  RESULTS
  47 patients (64%) underwent sigmoid colectomy and PA, which was combined with loop ileostomy in 11 patients (15%). Sigmoid colectomy and HP was performed in 26 patients (36%). Major postoperative complications occurred in 26 patients (36%). In the PA group, 10 of 47 patients (21%) had anastomotic leakage. Three leakages occurred despite a loop ileostomy. Anastomotic leakage was independent of Hinchey category (Hinchey I: three patients, Hinchey II: four patients, Hinchey III: three patients, n.s.), but associated with co-morbidity (one patient ASA II, six patients ASA III, three patients ASA IV, P < 0.05). Total mortality was 12%. Seven patients died after HP and two patients after PA. No mortality was observed in PA patients with loop ileostomy.
  
  
  CONCLUSIONS
  Emergency surgery for perforated sigmoid diverticulitis is associated with high morbidity and mortality rates. Anastomotic leakage was associated with patient co-morbidity rather than with intraoperative Hinchey category, suggesting that the decision to perform PA should better be based on patient's general condition rather than on intraoperative extent of inflammation.
authors.affiliation: Department of Surgery, Ludwig-Maximilians-University, Munich, Germany.
authors.forename: Mario H
authors.initials: MH
authors.lastname: Mueller
authors.forename: Martina
authors.initials: M
authors.lastname: Karpitschka
authors.forename: Bernhard
authors.initials: B
authors.lastname: Renz
authors.forename: Axel
authors.initials: A
authors.lastname: Kleespies
authors.forename: Michael S
authors.initials: MS
authors.lastname: Kasparek
authors.forename: Karl-Walter
authors.initials: KW
authors.lastname: Jauch
authors.forename: Martin E
authors.initials: ME
authors.lastname: Kreis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D012809:Colon, Sigmoid / Q000601:surgery*; D015897:Comorbidity; D004239:Diverticulitis, Colonic / Q000150:complications* / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D007249:Inflammation / Q000150:complications / Q000473:pathology; D007416:Intestinal Perforation / Q000150:complications* / Q000453:epidemiology / Q000601:surgery*; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011300:Preoperative Care; D012307:Risk Factors; D016896:Treatment Outcome