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 com- plicating 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 dis- ease.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. (REPRINTED) ARCH SURG/ VOL 139, NOV 2004 WWW.ARCHSURG.COM 1221 ©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 pul- monary 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 pa- tient 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