title: Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?
abstract: BACKGROUND
  Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe.
  
  
  METHODS
  All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed.
  
  
  RESULTS
  Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula.
  
  
  CONCLUSIONS
  The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.
authors.affiliation: Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies, Trinidad, West Indies.
authors.forename: V
authors.initials: V
authors.lastname: Naraynsingh
authors.forename: R
authors.initials: R
authors.lastname: Maharaj
authors.forename: D
authors.initials: D
authors.lastname: Hassranah
authors.forename: S
authors.initials: S
authors.lastname: Hariharan
authors.forename: D
authors.initials: D
authors.lastname: Dan
authors.forename: A P
authors.initials: AP
authors.lastname: Zbar
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D003657:Decision Making; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004239:Diverticulitis, Colonic / Q000150:complications / Q000601:surgery*; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications / Q000601:surgery*; D008875:Middle Aged; D010538:Peritonitis / Q000209:etiology / Q000601:surgery*; D012720:Severity of Illness Index; D012810:Sigmoid Diseases / Q000601:surgery*; D016896:Treatment Outcome; D058106:Wound Closure Techniques