Sohn MA, et al. - This study entailed an investigation of the damage control strategy (DCS) for the treatment of perforated diverticular disease complicated by generalized peritonitis and to determine the prognostic impact of an ongoing peritonitis (OP) at the time of second surgery. Data demonstrated that ongoing peritonitis after DCS served as a predictor of a worse outcome in individuals with perforated diverticulitis. A negative impact was brought to light of the Enterococcal and fungal infections on the occurrence of OP and overall outcome.

Methods

• The enrollment consisted of consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at 4 surgical centers.
• Herein, damage control strategy was a two-stage emergency procedure: Limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later.
• Hence, the decision was made for definite reconstruction [anastomosis or Hartmann’s procedure (HP)].
• During this study, an ongoing peritonitis at second surgery was defined as the presence of visible fibrinous, purulent, or fecal peritoneal fluid.
• Data accumulation and analysis was conducted with regard to the microbiologic findings from peritoneal smear at first surgery.

Results

• A total of 74 subjects underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34) between 5/2011 and 7/2017.
• Among these, 55% patients presented with ongoing peritonitis (OP) at second surgery.
• A higher rate of organ failure (32 vs 9%, p=0.024), higher Mannheim Peritonitis Index (25.2 vs 18.9; p=0.001), and increased operation time (105 vs 84 min, p=0.008) were reported among patients with OP at first surgery.
• It was noted that an anastomosis was constructed in all patients with no OP (nOP) at second surgery vs 71% in the OP group (p < 0.001).
• A rise was disclosed in the complication rate (44 vs 24%, p=0.092), mortality (12 vs 0%, p=0.061), overall number of surgeries (3.4 vs 2.4, p=0.017), enterostomy rate (76 vs 36%, p=0.001), and length of hospital stay (25 vs 18.8 days, p=0.03) in OP group.
• The occurrence of OP at second surgery was reported notably more often in patients with Enterococcus infection (81 vs 44%, p=0.005) and with fungal infection (100 vs 49%, p=0.007).
• As revealed via the multivariate analysis, Enterococcus infection exhibited a link with increased morbidity (67 vs 21%, p < 0.001), enterostomy rate (81 vs 48%, p=0.017), and anastomotic leakage (29 vs 6%, p=0.042).
• On the other hand, fungal peritonitis correlated with an increased mortality (43 vs 4%, p=0.014).