Impact of Primary Resection on the Outcome of Patients with Perforated Diverticulitis

ORIGINAL ARTICLE Impact of Primary Resection on the Outcome of Patients With Perforated Diverticulitis

Vidhan Chandra, MD; Heidi Nelson, MD; Dirk Russell Larson, MS; Jeffrey Robert Harrington, MA

Background: Primary resection has replaced the con- thirty-one patients (94.9%) underwent primary resection, ventional drainage procedure in the management of pa- 6 patients (4.3%) underwent resection and primary anas- tients with generalized peritonitis complicating diver- tomosis, and 1 patient required total colectomy and end ileo- ticular disease of the colon. This study investigates the stomy. Thirteen of the 138 patients in the present group died impact of primary resection on operative mortality, iden- (1983-1998), representing a perioperative mortality rate of tifies predictors of mortality, and compares the results 9%. There was no significant difference in mortality when with those of our earlier experience. compared with our earlier study (1972-1982), which had Hypothesis: Primary resection of the perforated dis- a mortality rate of 12%, considering that more than 25% eased segment of the colon is associated with lower mor- of the patients in that group were managed by colostomy tality rates than the drainage procedure in patients with and drainage alone. Factors identified univariately as pre- Hinchey stages 3 and 4 diverticulitis. dictors of mortality were age of more than 70 years (P=.047), 2 or more comorbid conditions (PϽ.01), obstipation at ini- Design: Retrospective analysis. tial examination (P=.02), use of steroids (P=.01), and pe- Ͻ Setting: Tertiary care referral center. rioperative sepsis (P .001). Patients: We included 138 consecutive patients who un- Conclusions: Primary resection has become the stan- derwent emergent operation for generalized peritonitis com- dard practice for patients with generalized peritonitis complicating diverticular disease of the colon (Hinchey stages plicating diverticulitis. Mortality rates have not signifi- 3 and 4) during a period of 16 years (January 1983 to May cantly declined despite more aggressive surgical 1999). management of the septic source. Because advanced age, comorbid conditions, and perioperative sepsis predict Main Outcome Measures: The 30-day mortality rate mortality, it is suggested that further reduction in mor- was analyzed and predictors of mortality identified. tality will require improvement in medical management Results: Patients were classified as having spreading pu- of perioperative sepsis and comorbid conditions. rulent peritonitis (n=44, 31.9%), diffuse peritonitis (n=64, 46.4%), or fecal peritonitis (n=30, 21.7%). One hundred Arch Surg. 2004;139:1221-1224

IVERTICULOSIS OF THE CO- agement of these patients with general- lon is very common in the ized peritonitis included a 3-stage drainage Western population, af- procedure as advocated by Smithwick3 in fecting one third of the 1942. This was associated with an unac- population older than 45 ceptably high morbidity and mortal- years of age and up to two thirds of the ity16,17 attributed to the diseased segment D 1,2 population older than 85 years of age. of colon, which was left in situ. In an ef- Fortunately, only 10% to 25% of these fort to improve the outcome, a 2-stage ap- individuals develop symptomatic dis- proach involving resection of the disease.3-10 Although most patients with symp- eased colon at the initial surgery was tomatic diverticulitis resolve with conser- recommended,18-20 which has become the vative management, 20% of them develop current practice at most centers. Our own complications including obstruction, ab- institution’s experience with the manage- scesses, fistulas, and perforation, often re- ment of this disease, as reported in 1985, quiring surgical intervention.11 Free per- also supported and recommended the foration causing generalized peritonitis 2-stage approach.21 Author Affiliations: (Hinchey stages 3 and 412) is the most se- Our continued experience prompted us Departments of General Surgery 13 (Dr Chandra), Colon and Rectal vere of these complications. These pa- to undertake this retrospective review to Surgery (Dr Nelson), and tients require emergent operation with study the changing trend in the surgical Biostatistics (Messrs Larson and mortality rates reported in the literature approach in the management of this dis- Harrington), Mayo Clinic, ranging from 0% to 100%.14,15 The con- ease and determine its impact on patient Rochester, Minn. ventional surgical approach in the man- outcomes.

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 fidence intervals. All statistical tests were 2-sided, and P values Table 1. Comparison of Age, Sex, Degree of Contamination, Ͻ.05 were considered significant. The analyses were performed and Mortality in Groups A and B* using SAS version 8.02 (SAS Institute Inc, Cary, NC).

Group A Group B (1983-1999) (1971-1982) RESULTS No. of patients 138 121 No. of men/women 60/78 64/57 DEMOGRAPHICS Age mean, y 68 61 Age range, y 30-94 27-82 We reviewed the records of 138 consecutive patients with Initial manifestation perforated sigmoid diverticulitis and generalized perito- Pain 83 80 nitis admitted to the Mayo Clinic between January 1983 Diarrhea 23 28 and May 1999. There were 78 women (56.5%), and the Vomiting 38 31 median age was 70 years (range, 30-94 years). The dif- Obstipation 31 54 Fever 46 84 ference in median age of the men (68 years) and women Hypotension 8 15 (72 years) was not statistically significant (P=.10). Onset of symptoms to surgery, days 2.7 5.1 Previous diverticulitis 28 32 CLINICAL PROFILE Corticosteroid use (current) 43 20 Peritonitis Eighty-three percent of the patients had abdominal pain. Spreading purulent 32 44 Other symptoms at the initial examination included fever Diffuse purulent 46 42 (oral Ͼ100.9°F, 46%), obstipation (31%), vomiting (38%), Fecal peritonitis 22 14 diarrhea (23%), bleeding per rectum (8%), and hypoten- Surgical procedure Ͻ Drainage 0 26 sion (systolic blood pressure 90 mm Hg, 8%). The me- Resection 95 69 dian duration from the initial onset of symptoms to refer- Primary anastomosis 4 3 ral to the Mayo Clinic for operative intervention was 2 days. Mortality, overall 9.4 12 COMORBIDITIES *Data are presented as percentages unless otherwise indicated. Eighty-one percent of the patients had 1 or more of the following comorbid conditions: coronary artery disease/ METHODS hypertension, respiratory disease (chronic obstructive pulmonary disease, emphysema), diabetes mellitus, visceral malignancy, and immunosuppressive therapy. The me- We collected data on 138 consecutive patients with generalized peritonitis following diverticulitis who underwent an emer- dian number of comorbid conditions was 1 (range, 0-4). gency operation at our institution from January 1983 to Decem- ber 1998. Patients were identified from the hospital’s diagnostic LABORATORY FINDINGS index and operating records. The grading system for the degree of perforation by Hinchey et al12 was used for classification of per- Sixty-seven percent of the patients had preoperative leu- foration. Patients belonging to Hinchey stages 3 and 4 were in- cocytosis (white blood count Ͼ12000), with a median ab- cluded. Patients were classified as having spreading purulent peri- solute leukocyte count of 14400 cells/µL (range, 1200- tonitis (n=44, 31.9%), diffuse peritonitis (n=64, 46.4%), and fecal 34000). Forty-one percent of the patients were anemic, with peritonitis (n=30, 21.7%). Patients with perforations causing a median absolute hemoglobin value of 12 g/dL (range, 7-18 phlegmons, fistulae, or contained intramesenteric or perico- g/dL). Free intraperitoneal air was evident in 80 patients lonic abscesses were excluded. Patient demographics; clinical fea- (58%), while 114 patients (83%) had evidence of ileus or tures; physical, radiological, and laboratory findings; type of sur- partial intestinal obstruction. gical procedure; length of hospital stay; postoperative complications; and mortality statistics were abstracted from patient records. Follow-up was continued until intestinal continu- PERITONITIS ity was reestablished or judged to be medically contraindicated. Collected data were analyzed focusing on the association of Ruptured pericolonic abscess with spreading purulent peri- preoperative and postoperative risk factors with perioperative tonitis was found in 44 patients (32%), diffuse purulent mortality. Risk factors included demographics, the clinical pro- peritonitis involving the entire peritoneal cavity was found file, operative approach, and postoperative complications. Means in 64 patients (46%), and diffuse fecal peritonitis (gross and standard deviations were used as data summaries for con- feces throughout the peritoneal cavity) was present in 30 tinuous measures and counts, and percentages were used for dis- patients (22%). Among clinical and laboratory findings, cretevariables.Initially,␹2 analysiswasusedtoevaluatetheunivari- bleeding per rectum was the only item that resulted in a ate association of each risk factor with perioperative mortality. statistically significant difference (P=.04) between patients While the small number of events suggests against using mul- with spreading purulent peritonitis (15.9%) and those with tivariable analysis, the associations among the significant risk diffuse or fecal peritonitis (4.3%). factors presented a complex scenario for interpretation of the univariate results. Consequently, a logistic regression model us- One hundred thirty-one patients (94.9%) underwent pri- ing stepwise selection was used, including each of the univari- mary resection, 6 patients (4.3%) underwent resection and ately significant factors as potential covariates. The final model primary anastomosis, and 1 patient required total colec- contained 2 covariates; the effects of these variables on peri- tomy and end ileostomy. All patients received broad- operative mortality were reported as odds ratios with 95% con- spectrum intravenous antibiotics for the duration of their

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Cause Perioperative Withdrawal Age, y/Sex Comorbid Conditions Steroid Peritonitis Complications of Death Day of Death DNI/DNR of Support 86/M CAD, leukemia No Diffuse Hypotension, reexploration Septicemia 18 No Yes bleeding, failed extubation 74/M COPD, CAD Yes Fecal MI, failed extubation Myocardial 9 Yes Yes failure 54/M CHF, CRI, CMOP, COPD No Fecal ARDS, wound infection, Septicemia 30 Yes Yes fecal fistula, reoperation 93/M CAD, PVD, CRI No Diffuse Hypotension, respiratory failure, Septicemia 13 No Yes lung collapse 74/F ITP, COPD, CAD, DM, CRI Yes Diffuse ARDS, CHF, pneumonia Septicemia 10 Yes Yes 77/F Temporal arteritis, COPD, CRI, DM, Yes Fecal Intracranial bleed, CVA 8 No No larynx and renal carcinoma coagulopathy due to CRI 79/F CAD, COPD, CRI, DM, vasculitis Yes Diffuse Atrial fibrillation, Septicemia 3 No Yes gram-negative septicemia 72/F Polyarteritis nodosa, Yes Diffuse Hypotension, shock, Septicemia 20 No Yes CAD, COPD, CRI respiratory failure 59/F Lymphoma, SCC tongue, DM, Yes Fecal Hypotension, DIC, ARDS Septicemia 14 Yes Yes liver failure 75/F Vasculitis, CAD, DM, Yes Diffuse ARDS, wound dehiscence, CHF, PE, Septicemia 21 No Yes restrictive lung disease necrotizing fasciitis 70/M Prostate carcinoma, brain METS Yes Diffuse Neutropenia, respiratory failure, PE, Septicemia 13 Yes Yes lower gastrointestinal bleed 64/F Leiomyosarcoma, COPD, CAD, Yes Spreading Wound infection, abdominal abscess, Septicemia 28 Yes Yes brain METS fecal fistula computed axial tomography–guided drain 83/M COPD, stroke Yes Fecal VT, stroke Myocardial 20 No Yes failure

Abbreviations: ARDS, acute respiratory distress syndrome; CAD, coronary artery disease; CHF, congestive heart failure; CMOP, cardiomyopathy; COPD, chronic obstructive pulmonary disease; CRI, chronic renal insufficiency; CVA, cerebrovascular accident; DIC, diffuse intravascular coagulopathy; DM, diabetes mellitus; DNI, do not intubate; DNR, do not resuscitate; ITP, idiopathic thrombocytopenic purpura; METS, metastasis; MI, myocardial infarction; PE, pulmonary embolism; PVD, peripheral vascular disease; SCC, squamous cell carcinoma; TIA, transient ischemic attack; VT, ventricular tachycardia. *The 30-day mortality rate was 9.4%. The Hartmann procedure was used in every case.

hospital stay. The clinical profile of patients in this study (Group A) was similar to our earlier review of 121 similar Table 3. Predictors of Perioperative Mortality patients (Group B) at our institution published in 1985 by Nagorney et al21 (Table 1). However, none of the pa- Mortality Rate* tients in the present study underwent a drainage proce- Predictive Factor Present Absent P Value dure, as compared with 26% of the patients in the earlier Age Ͼ70 y 14 4 .047 group. The overall mortality, however, was not markedly Obstipation 19 5 .02 different between the 2 studies. Comorbid conditions Ͼ2173 Ͻ.01 Steroid use 17 4 .01 MORTALITY Postoperative sepsis 39 3 Ͻ.001

There were 13 perioperative deaths (mortality rate, 9.4%). *Mortality rates are presented as percentages. Perioperative mortality was defined as death in hospital or postdischarge and within 30 days of surgery. There were 5 men and 8 women, with a median age of 75 years. All patients who died had significant comorbid conditions (at least A multivariable model was used to simultaneously evalu- ate the 5 univariately significant risk factors. Two statis- 1 condition) (Table 2). Eight (61.5%) of the 13 patients had diffuse peritonitis, 4 patients (30.8%) had fecal peri- tically significant covariates were identified: the exist- tonitis, and 1 patient (7.7%) had spreading purulent peri- ence of 2 or more comorbidities (odds ratio, 8.3; 95% tonitis. Withdrawal of life-supportive measures was the im- confidence interval, 1.6-44.7; P=.01) and the presence of postoperative septicemia (odds ratio, 18.9; 95% confi- mediate cause of death in 12 patients (92.3%). Underlying Ͻ pathologic features contributing to mortality were septice- dence interval, 4.7-76.3; P .001). After accounting for mia and its associated complications in 10 patients (77%), these 2 factors, none of the other candidate variables con- perioperative myocardial infarction/cardiac failure in 2 pa- tributed significantly to the model. tients (15%), and cerebrovascular accident in 1 patient (8%). On univariate analysis, the 5 factors predictive of peri- COMMENT operative mortality were age older than 70 years, 2 or more comorbid conditions, obstipation at initial examination, use This study confirms that primary resection has replaced the of steroid, and postoperative septicemia (Table 3). conventional 3-stage drainage procedure in the manage-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 ment of patients with generalized peritonitis complicat- not improved despite adoption of primary resection. In ing diverticular disease of the colon (Hinchey stages 3 and fact, the medical condition of the patients may be more 4). Perioperative sepsis is the major cause of death, and the critical than the precise surgical procedure in determin- mortality associated with this condition continues to be high. ing the overall outcome. Until further randomized pro- In the past, critically ill patients with significant comor- spective data are available, primary resection, which so bid conditions were considered to be at high surgical risk far provides the best control of the disease process, will for colonic resection and were managed by drainage alone. remain the standard of care for this highly challenging The results of our study, however, prove that primary re- group of patients. section is as safe and can be performed in sick patients with- This study confirms that patients with Hinchey stages out added mortality. Primary resection is more appealing 3 and 4 disease still have a high rate of perioperative mor- than drainage; it not only eradicates the source of infection tality. The change in the surgical approach from the con- but also provides histological confirmation of diagnosis and ventional 3-stage diversion with drainage to a 2-stage pro- involves 1 less operation compared with the conventional cedure of resection and drainage is a safe practice and 3-stageprocedure.Inourownearlierstudy,wehadobserved has not resulted in an increase in mortality. Future ef- a significant difference (PϽ.05) in mortality in patients man- forts to reduce perioperative mortality need to be fo- aged by colostomy and drainage (mortality rate, 26%) com- cused on the management of comorbid conditions and paredwithprimaryresection(mortalityrate,7%).Morethan the systemic manifestations of sepsis. one fourth of the patients in that study had undergone the drainage procedure. Based on the results of several similar studies, it was assumed that the drainage procedure was the Accepted for Publication: May 20, 2004. underlying problem, which contributed to postoperative Correspondence: Heidi Nelson, MD, Department of sepsis and death. The drainage procedure gradually lost Colon and Rectal Surgery, Mayo Clinic, 200 First St SW, ground,andprimaryresectionbecamethepreferredapproach Rochester, MN 55905 ([email protected]). in managing these patients. With the adoption of primary resection as the standard REFERENCES of care, it was anticipated that results would improve. Un- fortunately, our present study fails to show a significant dif- 1. Welch CE, Aleen AW, Donaldson GA. An appraisal of resection of the colon for diverticulitis of the sigmoid. Ann Surg. 1953;138:332-343. ference in mortality rates despite totally abandoning the 2. Roberts P, Abel M, Rosen L, et al; the Standards Task Force American Society of drainage procedure. 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