|
|
| Line 1: |
Line 1: |
| __NOTOC__ | | __NOTOC__ |
| | |
| {{CMG}}; {{AE}} {{MAD}} | | {{CMG}}; {{AE}} {{MAD}} |
|
| |
|
| ==Overview== | | ==Overview== |
| Indications for abdominal exploration
| |
|
| |
| Many patients will require urgent surgical intervention to limit ongoing abdominal contamination and manage the perforated site. Immediate surgical consultation is appropriate whenever perforation is confirmed or even strongly suspected to determine if immediate surgical intervention is needed and the interval of time to surgery.
| |
| Patients with evidence of perforation and the following clinical signs benefit from immediate surgery:
| |
| Abdominal sepsis or worsening or continuing abdominal pain and/or signs of diffuse or extensive peritonitis.
| |
| Complete or closed-loop bowel obstruction
| |
| Bowel ischemia: Main initial management is recommended except vasoconstricting agents and digitalis should be avoided, since they can exacerbate mesenteric ischemia. If vasopressors are needed, dobutamine, low-dose dopamine, or milrinone are preferred since they have less of an effect on mesenteric perfusion as compared with other vasopressors. Pain control and systemic anticoagulation are recommended to prevent thrombus formation and propagation, unless patients are actively bleeding.
| |
| Specific organs management
| |
| Esophagus
| |
| Open surgery remains the mainstay of treatment. Surgical options for esophageal perforation include primary repair, repair over a drain. [51,117]
| |
| Endoscopically-placed-stents can be used to manage some patients with esophageal perforation. Complications associated with stents include bleeding, fistula and injury to adjacent structures. [119].
| |
| Primary repair of the perforation site is the optimal procedure, even if the diagnosis is delayed greater than 24 hours. 12-14].
| |
| A primary repair is performed when the closure can heal.
| |
| When there has been a delay in diagnosis greater than 24 hours, and substantial extraluminal contamination from the leakage of fluid and debris has occurred, the integrity of the repair can be enhanced with the use of a vascularized pedicle flap. The most common flap used is the intercostal muscle flap.
| |
| The surgical approach to control a perforation in the cervical esophagus begins with an incision in the left neck along the lower third of the sternocleidomastoid (SCM) muscle (figure 8), unless the perforation is documented or visualized from the right neck [15].
| |
| The surgical dissection proceeds with identification of the anatomic structures such as the carotid sheath, trachea, spine, and recurrent laryngeal nerve, which should be preserved. Soft retractors, including the fingers of the surgeon and first assistant, are used to retract the esophagus and trachea in order to avoid recurrent laryngeal nerve injury.
| |
| A laparotomy is the preferred approach to repair a perforation of an intra-abdominal esophagus.
| |
| Stomach and duodenum
| |
|
| |
| The most common surgery for perforated peptic ulcer disease is oversewing the ulcer or the use of a Graham patch, which is used because suturing an inflamed ulcer can be difficult or impossible. [123-131].
| |
| It is important to obtain a biopsy of the ulcer margins in all patients with a gastric perforation to rule out gastric carcinoma.
| |
| Treatment for perforated duodenal diverticulum is usually diverticulectomy with closure of the duodenum.
| |
| Omental fat can be used to buttress the repair with drainage tubes to permit egress of residual infected fluid.
| |
| A subtotal gastrectomy with a Billroth II procedure or Roux-en-Y is sometimes used when extensive inflammation is present in the region.
| |
| A major decision when treating patients with ulcer perforation is whether and when to operate.
| |
| After resuscitation, emergent operation and closure with a piece of omentum is the standard of care for patients with an acute perforation and a rigid abdomen with free intraperitoneal air. If the patient is stable or improving, especially if spontaneous sealing of the perforation has been demonstrated, nonoperative management with close monitoring is a reasonable option. With any free perforation, regardless of the presence or size of the leak, if the patient's status is deteriorating, urgent surgery is indicated. Prolonged efforts to establish a diagnosis or pursue nonoperative care despite worsening status can be counterproductive, since a needed operation will be delayed. In addition, surgery is indicated in circumstances where the cause of an acute abdomen has not been established or the patient's status cannot be closely monitored. (See "Surgical management of peptic ulcer disease", section on 'Perforated peptic ulcer'.)
| |
| The management of patients with small to moderate leaks who are clinically stable is less clear. Currently, the standard of care for such patients is surgery, but some studies suggest that these patients can be managed nonoperatively:
| |
| The efficacy of initial conservative therapy with a nasogastric tube, antibiotics, and H2 blockers was compared with immediate laparoscopic surgical repair in a randomized trial of 83 patients with a perforated peptic ulcer [84]. Surgery was required in 11 of 40 patients (28 percent) in the conservative therapy group because of failure to improve clinically after 12 hours. The other 29 patients in the conservative therapy arm were successfully managed without surgery. The two groups did not differ significantly in terms of morbidity or mortality. However, the hospital stay was 35 percent longer in the group treated conservatively. Also, patients over 70 years old were less likely to respond to conservative treatment. The authors concluded that an initial period of nonoperative treatment with careful observation was safe in patients under age 70 years.
| |
| If patients did not show clinical improvement after 24 hours, surgery was performed.
| |
| Factors associated with surgery included the size of the pneumoperitoneum, abdominal distension, heart rate >94 beats per minute, pain on digital rectal examination, and age >59 years. Overall mortality in the study was 1 percent.
| |
| If spontaneous sealing occurs, patients do well without surgery. [77]
| |
| The probability of sealing with nonoperative care and intravenous PPIs or H2 receptor antagonists has not been studied; however, over 50 percent of patients with perforated duodenal ulcers have sealed spontaneously when first examined.
| |
| Nonoperative management may also be considered for patients with delayed presentations.
| |
| Other options in this setting include nonoperative care with percutaneous peritoneal drainage, especially for patients who are not good surgical candidates [87].
| |
| Patients with perforated ulcers should have an upper endoscopy to look for evidence of malignancy, to biopsy for H. pylori, and to assess for ulcer healing.
| |
| If the procedure does not need to be done urgently, we prefer to wait six to eight weeks to allow for ulcer healing.
| |
| The change in symptom pattern may be gradual or sudden; it usually involves a loss of cyclicity of the pain with meals, and loss of food and antacid relief. The pain typically becomes more intense, of longer duration, and is frequently referred to the lower thoracic or upper lumbar region.
| |
| Antral and duodenal ulcers can penetrate into the pancreas. Pyloric or prepyloric ulcers can penetrate the duodenum, eventually leading to a gastroduodenal fistula evident as a "double" pylorus.
| |
| Gastrocolic fistulae are seen with greater curvature gastric ulcers, particularly marginal ulcers. [72,94]
| |
| Small intestine
| |
|
| |
| Treatment of small intestinal perforation is performed by closing the perforation in one or two layers.
| |
| A small bowel resection is performed in case:
| |
| Long-standing perforation
| |
| Indurated tissues
| |
| Appendix
| |
|
| |
| The management of perforated appendicitis depends on the condition of the patient:[69]
| |
| Unstable patients or patients with free perforation
| |
|
| |
| A free perforation of the appendix can cause intraperitoneal dissemination of pus and fecal material and generalized peritonitis. These patients are typically quite ill and may be septic or hemodynamically unstable, thus requiring preoperative resuscitation. The diagnosis is not always appreciated before exploration.
| |
| For patients who are septic or unstable, and for those who have a free perforation of the appendix or generalized peritonitis, emergency appendectomy is required, as well as drainage and irrigation of the peritoneal cavity. Emergency appendectomy in this setting can be accomplished open or laparoscopically; the choice is determined by surgeon preference with consideration of patient condition and local resources.
| |
| Stable patients
| |
|
| |
| Stable patients with perforated appendicitis who have symptoms localized to the right lower quadrant can be treated with immediate appendectomy or initial nonoperative management. [70].
| |
| Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous, image-guided drainage of the abscess.
| |
| Patients who fail initial antibiotic therapy clinically or radiographically require rescue appendectomy, whereas those who respond to initial antibiotic therapy can be discharged with oral antibiotics to complete a 7- to 10-day course (in total) and return for follow-up in six to eight weeks.
| |
| Colon and rectum
| |
|
| |
| Most cases of diverticulitis with contained perforation or small abscess can be treated nonoperatively with antibiotics with or without percutaneous drainage.
| |
| Resection is usually required for more severe diverticular complications [139].
| |
| A myriad of other etiologies can lead to colonic or rectal perforation. NSAID use has been associated with serious diverticular perforation, with diclofenac and ibuprofen being the most commonly implicated drugs [43]. Glucocorticoids are also associated with diverticular perforation. Stercoral perforation, caused by ischemic necrosis of the intestinal wall by stool, is also possible, particularly in older individuals [142,143]. Perforation after barium enema or colonoscopy has been reported in patients with collagenous colitis [140]. Foreign bodies, either ingested or inserted, can cause colorectal perforation [144]. Colon perforation can also be related to collagen-vascular diseases such as Ehlers-Danlos syndrome type IV [145,146], Behcet's syndrome [147], and eosinophilic granulomatosis with polyangiitis (Churg-Strauss) [148]. Perforation has been reported with anorectal manometry in the setting of a rectal anastomosis [149]. Perforation is also associated with invasive amebiasis of the colon [150]. In pediatric populations, bacterial colitis, particularly with nontyphoid Salmonella, can lead to perforation [151].
| |
| Colon perforations can be treated by simple suture if the perforation is small, often using a laparoscopic approach [152]. If the perforation is larger and devascularizing the colonic wall, colon resection will be necessary [153]. Patients with a perforated colon due to neoplasm also require resection [154]. Laparoscopic treatment of complicated disease is feasible but has a higher rate of conversion to open operation compared with uncomplicated disease [155]. A primary anastomosis is preferred, whenever feasible [139,156]. Primary anastomosis may be combined with proximal "protective" ostomy in those with complicated diverticulitis or malignancy. Colonic perforation due to Ehlers-Danlos syndrome is best treated with resection or exteriorization, or subtotal colectomy.
| |
| Since most patients with diverticulitis are treated medically, surgery is only indicated when diverticular disease is either not amenable or refractory to medical therapy (algorithm 1) [5,7-9].
| |
|
| |
| Indication for emergency surgery — Acute diverticulitis with frank (free) perforation is a life-threatening condition that mandates emergency surgery [5,9-11]. (See 'Resection' below.)
| |
|
| |
| Indications for urgent surgery — Urgent surgery (in which an operation is generally required during the same hospitalization) should be performed in patients with one of the indications discussed below.
| |
|
| |
| Failure of medical treatment — Patients who deteriorate or fail to improve after three to five days of inpatient intravenous antibiotics may require urgent surgery, as further medical therapy is unlikely to resolve their diverticulitis. (See "Acute colonic diverticulitis: Medical management", section on 'Failure of inpatient medical treatment'.)
| |
|
| |
| Obstruction — Patients who present with colonic obstruction attributable to acute diverticulitis should undergo surgical resection of the involved colonic segment. Because acute diverticulitis and colon cancer can both cause colonic obstruction and are difficult to distinguish by abdominopelvic computed tomography (image 1), surgery in this setting is required to rule out cancer and also to relieve symptoms of obstruction. (See "Acute colonic diverticulitis: Medical management", section on 'Obstruction' and "Overview of mechanical colorectal obstruction", section on 'Surgical management'.)
| |
|
| |
| Colonic obstruction due to diverticular disease is rarely complete, which allows bowel preparation to be attempted. Alternatively, on-table lavage can be used to clean out the fecal load, which may also permit a primary anastomosis.
| |
|
| |
| Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis. In a systematic review, treating benign colorectal obstructions (most due to diverticulitis) with self-expanding stents resulted in more cases of perforation (12 versus 4 percent), stent migration (20 versus 10 percent), and recurrent obstruction (14 versus 7 percent) than stenting malignant colorectal obstructions [12]. When stenting was used as a bridging therapy to surgery, only 43 percent of patients with diverticulitis successfully avoided a stoma. (See "Enteral stents for the management of malignant colorectal obstruction".)
| |
|
| |
| Abscess failing nonoperative intervention — In contemporary practice, diverticular abscesses are typically treated with percutaneous image-guided drainage or with intravenous antibiotics if the abscess is too small or inaccessible to percutaneous drainage. Surgery may be indicated for patients who deteriorate or fail to improve within two to three days of percutaneous intervention or antibiotic therapy, as a persistent intraabdominal abscess is unlikely to respond to further nonoperative management. (See "Acute colonic diverticulitis: Medical management", section on 'Abscess'.)
| |
|
| |
| Indications for elective surgery — Patients may require elective colon surgery because of persistent symptoms from conditions such as diverticular fistula or chronic smoldering diverticulitis. In addition, asymptomatic patients with a history of acute diverticulitis may be offered elective surgery based upon their risk of developing serious complications or dying from a recurrent diverticulitis attack.
| |
|
| |
| Fistula — As a result of diverticulitis, a fistula can develop between the colon and another pelvic organ, such as the bladder, vagina, uterus, small bowel, or the abdominal wall. Diverticular fistulas rarely close spontaneously, and therefore require surgical correction. The management of diverticular fistula is discussed separately. (See "Acute diverticulitis complicated by fistula formation".)
| |
|
| |
| Chronic smoldering diverticulitis — Patients with acute diverticulitis who initially respond to medical treatment but subsequently develop recurrent symptoms, such as left lower quadrant abdominal pain, alteration in bowel movements, and/orrectal bleeding, are described as having chronic smoldering diverticulitis. If the symptoms persist for longer than six weeks, patients should be referred for surgical evaluation. However, since patients with irritable bowel syndrome or other functional gastrointestinal disorders may present similarly, patients with chronic symptoms after an acute diverticulitis attack must be evaluated carefully before being offered surgery. (See "Acute colonic diverticulitis: Medical management", section on 'Symptomatic patients after initial attack'.)
| |
|
| |
| Asymptomatic but high-risk patients — We offer elective surgery to patients who had a prior episode of complicated diverticulitis and those who are immunosuppressed because such patients could develop serious complications or die from recurrent attacks of diverticulitis.
| |
|
| |
| Patients with prior complicated attack — Elective surgery is indicated for patients with one prior episode of complicateddiverticulitis, such as a microperforation that was treated with antibiotics, or an abscess that was treated with percutaneous drainage and/or antibiotics. Studies show that such patients are at a greater risk of developing complications or dying from a recurrent attack, and therefore would benefit from early elective surgery [13,14]. (See "Acute colonic diverticulitis: Medical management", section on 'Complicated first attack'.)
| |
|
| |
| Patients who are immunocompromised — Most surgeons would offer elective surgery to immunocompromised patients after a single attack of diverticulitis because they often require emergency surgery due to an atypical and delayed presentation. Elective surgery is associated with lower morbidity and mortality rates compared with emergency surgery in these and other patients. (See "Acute colonic diverticulitis: Medical management", section on 'Immunosuppression'.)
| |
|
| |
| CHOOSING A SURGICAL TECHNIQUE — For patients who require surgery for diverticulitis, the choice of technique depends upon the patient's hemodynamic stability, extent of peritoneal contamination, and surgeon experience [15].
| |
|
| |
| Resection — The primary goal of surgery is to remove the diseased colonic segment, the feasibility of which is predicated upon a patient's hemodynamic stability.
| |
|
| |
| Hemodynamically unstable patients — Patients who require emergency surgery for perforated diverticulitis may be too ill to tolerate a definitive colon resection and reconstruction. For such patients, a damage control laparotomy with limited resection of the diseased colonic segment with or without reconstruction should be performed expeditiously [16]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and 'Drainage procedures' below.)
| |
|
| |
| Hemodynamically stable patients — Patients undergoing emergency surgery who are hemodynamically stable and all other patients undergoing urgent or elective surgery should be able to tolerate a definitive resection of the involved colonic segment [17-21] (figure 1). (See 'Colonic resection with end colostomy (ie, Hartmann's procedure)' below.)
| |
|
| |
| Reconstruction — The secondary goal of surgery is to restore intestinal continuity if possible. The choice of reconstructive techniques largely depends upon the extent of peritoneal contamination as assessed by the Hinchey classification system [22]:
| |
|
| |
| ●Stage I – Pericolic or mesenteric abscess
| |
|
| |
| ●Stage II – Walled-off pelvic abscess
| |
|
| |
| ●Stage III – Generalized purulent peritonitis
| |
|
| |
| ●Stage IV – Generalized fecal peritonitis
| |
|
| |
| Diffuse contamination (Hinchey III or IV) — Hinchey III or IV diverticulitis is characterized by generalized purulent or fecal peritonitis, for which a primary anastomosis is contraindicated. The preferred surgical treatment is a Hartmann's procedure with end colostomy. (See 'Colonic resection with end colostomy (ie, Hartmann's procedure)' below.)
| |
|
| |
| Localized contamination (Hinchey I or II) — Hinchey I or II diverticulitis is characterized by one or more localized abscesses in the pericolonic, mesenteric, or pelvic locations. Patients with Hinchey I or II diverticulitis can usually tolerate a preoperative bowel preparation. Thus, if the abscess can be resected with the colonic segment, a primary anastomosis can be performed in these patients. (See 'One-stage procedures' below.)
| |
|
| |
| If there are concerns about either contamination or inflammation involving the surrounding tissue (eg, with a large pelvic abscess), a primary anastomosis can be performed while protected by a diverting ostomy (eg, loop ileostomy or colostomy). Compared with an end colostomy, a protective loop ostomy is easier to reverse at a later time. (See 'Colonic resection with primary anastomosis and protective ostomy' below.)
| |
|
| |
| Minimal contamination (elective surgery) — Elective surgery is typically performed six or more weeks after an episode of acute diverticulitis when all infection and inflammation have resolved. Thus, a primary anastomosis without protective ostomy (ie, a one-stage procedure) is standard. (See 'One-stage procedures' below.)
| |
|
| |
| SURGICAL TECHNIQUES
| |
|
| |
| A one-stage colon resection for diverticulitis can be performed open or laparoscopically. The laparoscopic approach is preferred when feasible. Growing evidence suggests that laparoscopic surgery in this setting can be performed safely with superior short-term outcomes and comparable long-term outcomes [25-35]. As examples:
| |
|
| |
| ●In a meta-analysis of 19 studies comparing 1014 patients undergoing elective laparoscopic surgery with 1369 patients undergoing open surgery, open surgery was associated with significantly higher rates of wound infection (relative risk [RR] 1.85, 95% CI 1.25-2.78), blood transfusion (RR 4.0, 95% CI 1.67-10.0), postoperative ileus (RR 2.70, 95% CI 1.52-5.0), and incisional hernia (RR 3.70, 95% CI 1.56-8.33) [36]. The rates of serious complications (eg, anastomotic leak or stricture, inadvertent enterotomy, small bowel obstruction, intraabdominal bleeding, or abscess formation) were comparable between the groups.
| |
|
| |
| ●A randomized trial performed after the meta-analysis found that laparoscopic surgery resulted in a significantly shorter duration of postoperative ileus (76 versus 106 hours) and length of hospital stay (5 versus 7 days), as well as a trend towards less postoperative pain (4 versus 5 on a visual analog pain scale), when compared with open surgery [37].
| |
|
| |
| ●Another randomized trial found that patients who underwent laparoscopic versus open surgery had similar complication rates and reported similar quality of life during the early postoperative period and at 12 months [38].
| |
|
| |
| Laparoscopic surgery for diverticular disease can be performed with the standard multiport technique or with a technique called single-incision laparoscopic colectomy (SILC). Studies showed that SILC is feasible and safe when performed by experienced surgeons [39,40]. In a prospective study of 330 patients with diverticular disease, patients who underwent SILC had lower peak pain scores compared with patients who underwent a standard laparoscopic procedure (4.9 versus 5.6) [39]. The techniques of single-incision laparoscopic surgery are discussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision ports and placement'.)
| |
|
| |
| A two-stage procedure is primarily used for patients with Hinchey III or IV diverticulitis, and for those with Hinchey I or II diverticulitis who have excessive contamination or inflammation of the surrounding tissues or other risk factors for anastomotic leakage. (See 'Diffuse contamination (Hinchey III or IV)' above and 'Localized contamination (Hinchey I or II)'above.)
| |
|
| |
| Colonic resection with end colostomy
| |
|
| |
| Hartmann's procedure is the most commonly performed two-stage procedure and the preferred approach for patients with Hinchey III or IV diverticulitis. (See 'Diffuse contamination (Hinchey III or IV)' above.)
| |
|
| |
| A Hartmann's procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, followed by reversal of the colostomy three months later [18] (figure 1).
| |
|
| |
| Because creating a mucous fistula by bringing the distal end of the transected bowel through the abdominal wall is often not possible after resecting the entire sigmoid colon, many surgeons mark the rectal stump with a long nonabsorbable suture and tack it to the anterior abdominal wall or sacral promontory to help identify the rectal stump at the second-stage operation.
| |
|
| |
| Subsequent closure of the colostomy is a technically difficult operation associated with high morbidity and mortality rates [41,42]. As a result, colostomy closure is only performed in approximately 50 to 60 percent of all patients after a Hartmann's procedure [43,44].
| |
|
| |
| Colonic resection with primary anastomosis and protective ostomy
| |
|
| |
|
| Another two-stage approach resects the colonic segment and creates a primary anastomosis protected by a proximal diverting stoma (colostomy or ileostomy) at the first operation (figure 2), and closes the stoma at the second operation.
| | === Indications for abdominal exploration === |
| | Many patients will require urgent surgical intervention. |
|
| |
|
| This approach is most commonly used in Hinchey I or II diverticulitis when there are relative contraindications to primary anastomosis (eg, excessive contamination/inflammation of surrounding tissue) but the bowel is not edematous. It is the preferred approach in this setting because a protective stoma is easier to close than an end colostomy with a rectal stump [45,46]. (See 'Localized contamination (Hinchey I or II)' above.)
| | Patients with the following clinical signs: |
| | * Abdominal sepsis or worsening or continuing abdominal pain and/or signs of diffuse or extensive peritonitis. |
| | * Complete or closed-loop bowel obstruction |
| | * Bowel ischemia: Main initial management is recommended except vasoconstricting agents and digitalis should be avoided, since they can exacerbate mesenteric ischemia. |
| | * If vasopressors are needed, dobutamine, low-dose dopamine, or milrinone are preferred since they have less of an effect on mesenteric perfusion as compared with other vasopressors. |
| | * Pain control and systemic anticoagulation are recommended to prevent thrombus formation and propagation, unless patients are actively bleeding. Specific organs management |
|
| |
|
| Although a primary anastomosis is generally not performed for perforated (Hinchey III or IV) diverticulitis, a primary anastomosis protected by a diverting ileostomy has been attempted in such patients. In a randomized trial of 62 patients with left-sided colonic perforation due to Hinchey III or IV diverticulitis, patients treated with a primary anastomosis with diverting ileostomy, compared with patients treated with a Hartmann's procedure, had similar mortality (9 versus 13 percent) and morbidity rates (75 versus 67 percent) after the first operation [47]. However, a greater percentage of patients treated with a primary anastomosis with diverting ileostomy underwent stoma reversal (90 versus 57 percent); and reversal of the diverting ileostomy in those patients required less operative time (73 versus 183 minutes), length of hospital stay (6 versus 9 days), and resulted in fewer serious complications (0 versus 20 percent), compared with colostomy reversals in patients treated with a Hartmann's procedure. Further studies are required before this approach can be recommended for general use in all patients with Hinchey III or IV diverticulitis.
| | === Esophagus === |
| | * Open surgery is the mainstay of treatment. |
| | * Surgical options include primary repair, repair over a drain. [51,117] |
| | * Primary repair of the perforation site is the optimal procedure, even if the diagnosis is delayed greater than 24 hours. A primary repair is performed when the closure can heal. |
| | * Endoscopically-placed-stents can be used to manage some patients with esophageal perforation. |
| | * Complications associated with stents include bleeding, fistula and injury to adjacent structures. [119] 12-14]. |
| | * When there has been a delay in diagnosis greater than 24 hours, a vascularized pedicle flap can be used to overcome the lack of integrity in the mucosa. The most common flap used is the intercostal muscle flap. |
| | * A laparotomy is the preferred approach to repair a perforation of an intra-abdominal esophagus. |
|
| |
|
| Drainage procedures
| | === Stomach and duodenum === |
| | * A major decision when treating patients with ulcer perforation is whether and when to operate. {123-131] |
| | * With any free perforation if the patient's status is deteriorating, urgent surgery is indicated. Emergent operation and closure with a piece of omentum is the standard of care for patients with an acute perforation and a rigid abdomen with free intraperitoneal air. |
| | * If the patient is stable or improving, especially if spontaneous sealing of the perforation has been demonstrated, nonoperative management with close monitoring is a reasonable option. |
| | * Surgery is indicated in circumstances where the cause of an acute abdomen has not been established or the patient's status cannot be closely monitored. |
| | * Currently, the standard of care for such patients is surgery. [84]. |
| | * an initial period of nonoperative treatment with careful observation was safe in patients under age 70 years. If patients did not show clinical improvement after 24 hours, surgery was performed. |
| | * Factors associated with surgery included the size of the pneumoperitoneum, abdominal distension, heart rate >94 beats per minute, pain on digital rectal examination, and age >59 years. Overall mortality in the study was 1 percent. If spontaneous sealing occurs, patients do well without surgery. [77] |
| | * over 50 percent of patients with perforated duodenal ulcers have sealed spontaneously when first examined. |
| | * Nonoperative management may also be considered for patients with delayed presentations. [87] |
| | * Patients with perforated ulcers should have an upper endoscopy to look for evidence of malignancy. It is important to obtain a biopsy of the ulcer margins in all patients with a gastric perforation to rule out gastric carcinoma. If the procedure does not need to be done urgently, we prefer to wait six to eight weeks to allow for ulcer healing. |
| | * Antral and duodenal ulcers can penetrate into the pancreas. |
| | * Pyloric or prepyloric ulcers can penetrate the duodenum. Gastrocolic fistulae are seen with greater curvature gastric ulcers. [72,94] |
|
| |
|
| Drainage procedures include laparoscopic lavage and a classic three-stage procedure. Drainage procedures are rarely performed because they do not definitively address the underlying diverticular disease. However, they may be useful in treating septic patients who are too ill to tolerate a resectional procedure. (See 'Hemodynamically unstable patients'above.)
| | === Small intestine === |
| | * Treatment of small intestinal perforation is performed by closing the perforation in one or two layers. |
| | * A small bowel resection is performed in case: |
| | * Long-standing perforation |
| | * Indurated tissues |
|
| |
|
| Laparoscopic lavage
| | === Appendix === |
| | * The management of perforated appendicitis depends on the condition of the patient:[69] |
|
| |
|
| Laparoscopic lavage and drainage were introduced as an approach to avoid laparotomy and fecal diversion in patients with complicated diverticulitis [48-51]. Based upon the best available data, we do not use laparoscopic lavage in stable patients with Hinchey III or IV diverticulitis. Instead, we perform sigmoidectomy with or without a colostomy depending upon each patient's clinical condition. (See 'Diffuse contamination (Hinchey III or IV)' above.)
| | ==== Unstable patients ==== |
| | * A free perforation of the appendix can cause intraperitoneal dissemination of pus and fecal material and generalized peritonitis. |
| | * These patients are typically quite ill and may be septic or hemodynamically unstable, thus requiring preoperative resuscitation. The diagnosis is not always appreciated before exploration. |
| | * For patients who are septic or unstable, and for those who have a free perforation of the appendix or generalized peritonitis, emergency appendectomy is required, as well as drainage and irrigation of the peritoneal cavity. |
| | * Emergency appendectomy in this setting can be accomplished open or laparoscopically; the choice is determined by surgeon preference with consideration of patient condition and local resources. |
|
| |
|
| Although a 2010 systematic review of retrospective studies found a low mortality rate of 2 percent and avoidance of a permanent stoma in the majority of patients who underwent laparoscopic lavage [52], subsequent randomized trials reported conflicting results:
| | ==== Stable patients ==== |
| | * Stable patients with perforated appendicitis who have symptoms localized to the right lower quadrant can be treated with immediate appendectomy or initial nonoperative management. [70]. |
| | * Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous, image-guided drainage of the abscess. Patients who fail initial antibiotic therapy clinically or radiographically require rescue appendectomy, whereas those who respond to initial antibiotic therapy can be discharged with oral antibiotics to complete a 7- to 10-day course (in total) and return for follow-up in six to eight weeks. |
|
| |
|
| ●In one trial (SCANDIV), 199 patients suspected of having perforated diverticulitis based upon detection of free air by abdominal computed tomography scan were randomly assigned to undergo emergency surgery with laparoscopic lavage or sigmoidectomy [53]. Compared with sigmoidectomy, laparoscopic lavage achieved similar mortality (13.9 versus 11.5 percent) and severe morbidity rates (30.7 versus 26 percent) at 90 days. However, patients who were treated with laparoscopic lavage were more likely to require reoperation (20.3 versus 5.7 percent) for complications such as secondary peritonitis (6 versus 0 patients) or missed sigmoid cancer (4 versus 0 patients).
| | === Colon and rectum === |
| | * Most cases of diverticulitis with contained perforation or small abscess can be treated nonoperatively with antibiotics with or without percutaneous drainage. |
| | * Colon perforations can be treated by simple suture if the perforation is small, often using a laparoscopic approach [152]. |
| | * If the perforation is larger and devascularizing the colonic wall, colon resection will be necessary [153]. |
| | * Patients with a perforated colon due to neoplasm also require resection [154]. |
| | * Laparoscopic treatment of complicated disease is feasible but has a higher rate of conversion to open operation compared with uncomplicated disease [155]. |
| | * A primary anastomosis is preferred, whenever feasible [139,156]. Primary anastomosis may be combined with proximal "protective" ostomy in those with complicated diverticulitis or malignancy. Colonic perforation due to Ehlers-Danlos syndrome is best treated with resection or exteriorization, or subtotal colectomy. |
| | * Since most patients with diverticulitis are treated medically, surgery is only indicated when diverticular disease is either not amenable or refractory to medical therapy (algorithm 1) [5,7-9]. |
|
| |
|
| ●Another randomized trial (LOLA) including 90 patients with purulent perforated diverticulitis showed that laparoscopic lavage produced a higher combined major morbidity and mortality rate within 30 days compared with sigmoidectomy (39 versus 19 percent) [54]. At 12 months, the rates were comparable between the two groups (65 percent for lavage versus 63 percent for sigmoidectomy).
| | * Acute diverticulitis with free perforation is a life-threatening condition that mandates emergency surgery. [5,9-11] |
| | * Patients who deteriorate or fail to improve after three to five days of inpatient intravenous antibiotics may require urgent surgery, as further medical therapy is unlikely to resolve their diverticulitis. |
|
| |
|
| ●Another trial (DILALA) randomly assigned 83 patients to laparoscopic lavage or Hartmann's procedure after a laparoscopic diagnosis of purulent perforated diverticulitis [55,56]. The mortality rates were similar at both 90 days (8 versus 11 percent) and one year (14 versus 15 percent); the major morbidity rates were similar at 30 (13 versus 18 percent) and 90 days (21 versus 25 percent). The reoperation rates were similar at 30 days (13 versus 17 percent). At one year, however, fewer patients required reoperation after laparoscopic lavage (28 versus 63 percent). In addition, laparoscopic lavage resulted in shorter operative time (1 versus 2.5 hours) and hospital stay (6 versus 9 days for index admission; 8 versus 14 days at one year).
| | ==== Colonic obstruction ==== |
| | * Patients who present with colonic obstruction should undergo surgical resection of the involved colonic segment. |
| | * It is difficult to differentiate between obstruction due to cancer and diverticulitis. Surgery is required to rule out cancer and also to relieve symptoms of obstruction. |
| | * Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis due to high rates of failure, perforation, or migration. |
| | * Diverticular abscess is treated with percutaneous image-guided drainage or with intravenous antibiotics. In case of failed conservative therapy, urgent surgery is indicated. |
|
| |
|
| In all three trials, the major morbidity and mortality rates were similar between the two groups. The trials, however, reported different reoperation rates, which affected their conclusions (table 1). DILALA was the only trial that favored laparoscopic lavage, largely due to lower reoperation rates.
| | ====== Fistula ====== |
| | * Diverticular fistulas rarely close spontaneously, and therefore require surgical correction. |
|
| |
|
| However, reoperation rates can be affected by how they are calculated (table 1). All patients in DILALA assigned to sigmoidectomy underwent colostomy, and colostomy reversals were counted as reoperations. Thus, the reoperation rate in this trial of 63 percent at one year after sigmoidectomy was almost entirely accounted for by colostomy reversals. In contrast, only approximately one-half of patients assigned to sigmoidectomy in LOLA underwent initial colostomy, and colostomy reversals were not counted as reoperations, resulting in a reoperation rate of just 19 percent. SCANDIV only reported 90-day reoperation rates, which would not have been affected by colostomy reversals, as reversals typically occur three to six months after the initial surgery.
| | ==== Chronic smoldering diverticulitis ==== |
| | * Patients with acute diverticulitis who initially respond to medical treatment but subsequently develop recurrent symptoms, such as left lower quadrant abdominal pain, alteration in bowel movements, and/orrectal bleeding, are described as having chronic smoldering diverticulitis. |
| | * If the symptoms persist for longer than six weeks, patients should be referred for surgical evaluation. |
|
| |
|
| Short-term (30- or 90-day) reoperation rates, which by definition excluded colostomy reversals, are more comparable among the three trials (table 1). After laparoscopic lavage, the short-term reoperation rates were lower in DILALA (13 percent at 30 days) than in SCANDIV (20 percent at 90 days) and LOLA (48 percent at 30 days). The lower reoperation rate after laparoscopic lavage in DILALA may be attributed to better pre-enrollment identification and exclusion of patients with fecal perforation and sigmoid carcinoma, which were the major reasons for reoperations in all three trials. In SCANDIV, patients did not undergo a diagnostic laparoscopy before randomization. In LOLA, although patients did undergo a diagnostic laparoscopy, the authors argued that patients with perforated diverticulitis often developed a phlegmon that obscured visualization of the deep pelvis.
| | ==== Asymptomatic but high-risk patients ==== |
| | * Elective surgery is indicated for patients who had a previous episode of complicated diverticulitis. [13,14]. |
| | * For immunocompromised patients, elective surgery should be offered after a single attack of diverticulitis. |
|
| |
|
| In common practice, it is unclear how conclusively fecal perforation and/or sigmoid carcinoma can be excluded during the initial evaluation. Thus, sigmoidectomy remains our standard treatment for perforated diverticulitis. We only use laparoscopic lavage in select patients after excluding fecal perforation (Hinchey class IV) by diagnostic laparoscopy, and after excluding either colon cancer or ongoing colonic air leak (from perforation) by intraoperative sigmoidoscopy.
| | === Techniques === |
| | * For patients who require surgery for diverticulitis, the choice of technique depends upon the patient's hemodynamic stability, extent of peritoneal contamination, and surgeon experience [15]. |
|
| |
|
| Patients who are candidates for laparoscopic lavage should be advised that a reoperation (usually sigmoidectomy) may be necessary if laparoscopic lavage fails to control the sepsis or a sigmoid carcinoma is later found. The reoperation rate is likely to increase further with longer follow-up; LOLA reported that 20 percent of patients treated with laparoscopic lavage developed recurrent diverticulitis within just the first year [54].
| | * The primary goal of surgery is to remove the diseased colonic segment. |
|
| |
|
| Drainage and diversion
| | * For too ill patients to tolerate a definitive colon resection and reconstruction, a laparotomy with limited resection of the diseased colonic segment should be performed. [16 |
| | * A one-stage colon resection for diverticulitis can be performed open or laparoscopically. The laparoscopic approach is preferred when feasible. Growing evidence suggests that laparoscopic surgery in this setting can be performed safely with superior short-term outcomes and comparable long-term outcomes [25-35]. |
| | * A two-stage procedure is primarily used for patients with Hinchey III or IV diverticulitis, and for those with Hinchey I or II diverticulitis who have excessive contamination or inflammation of the surrounding tissues or other risk factors for anastomotic leakage. |
|
| |
|
| A classic procedure for colonic perforation includes three stages: the first stage involves drainage but not resection of the diseased segment and construction of a proximal diverting stoma; the second stage involves resection of the diseased segment with a primary anastomosis under the protection of the proximal stoma; the third stage closes the proximal stoma.
| | * Hartmann's procedure is the most commonly performed two-stage procedure and the preferred approach for patients with Hinchey III or IV diverticulitis. |
| | * A Hartmann's procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, followed by reversal of the colostomy three months later [18]. |
| | * Colonic resection with primary anastomosis and protective ostomy |
|
| |
|
| This classic procedure has been largely replaced by other procedures (eg, the Hartmann's procedure) because of a higher postoperative mortality rate with the three-stage procedure (26 versus 7 percent) [57,58]. In contemporary practice, the three-stage procedure is only performed when inflammation precludes safe pelvic dissection of the colon from critical sidewall structures (eg, iliac vessels and ureters), or when the patient is unstable. Drainage and fecal diversion in these situations can serve as a temporizing measure to allow treatment of infection and inflammation before further surgery or transfer to a more experienced center. (See "Overview of mechanical colorectal obstruction", section on 'Three-stage'.)
| | ==== Reconstruction ==== |
| | The choice of reconstructive techniques largely depends upon the extent of peritoneal contamination as assessed by the Hinchey classification system [22]: |
| | * Stage I – Pericolic or mesenteric abscess |
| | * Stage II – Walled-off pelvic abscess |
| | * Stage III – Generalized purulent peritonitis |
| | * Stage IV – Generalized fecal peritonitis |
|
| |
|
| ==References== | | ==References== |