Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment
- 25 January 2012
- journal article
- research article
- Published by Springer Science and Business Media LLC in Surgical Endoscopy
- Vol. 26 (7), 2061-2071
- https://doi.org/10.1007/s00464-012-2157-z
Abstract
In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of “perforated” AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas “distant” location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100–450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4–23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.Keywords
This publication has 37 references indexed in Scilit:
- Missed opportunities for primary repair in complicated acute diverticulitisSurgery, 2010
- Prospective Evaluation of the Value of Magnetic Resonance Imaging in Suspected Acute Sigmoid DiverticulitisDiseases of the Colon & Rectum, 2008
- DiverticulitisNew England Journal of Medicine, 2007
- Acute colonic diverticulitis in a community-based hospital: CT evaluation in 138 patientsEmergency Radiology, 2006
- Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scanSurgical Endoscopy, 2006
- Complicated DiverticulitisAnnals of Surgery, 2005
- Classification of Surgical ComplicationsAnnals of Surgery, 2004
- Computed tomography in the initial management of acute left-sided diverticulitisDiseases of the Colon & Rectum, 1992
- Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in SepsisChest, 1992
- AN APPRAISAL OF RESECTION OF THE COLON FOR DIVERTICULITIS OF THE SIGMOID*Annals of Surgery, 1953