• endoscopic surgery
• guideline
• large intestine

• Humans
• Clinical Competence
• Endoscopy, Gastrointestinal/standards
• Endoscopy, Gastrointestinal/education

• diagnostic peritoneal aspiration
• diagnostic peritoneal lavage
• moderate hypotension
• severe hypotension

• Humans
• Adolescent
• Abdominal Injuries/surgery
• Peritoneal Lavage
• Peritoneum
• Wounds, Nonpenetrating/diagnosis
• Wounds, Nonpenetrating/diagnostic imaging
• Hypotension/etiology

Background

Peritonitis was previously considered a contraindication for minimally invasive surgery due to the risk of malignant hypercapnia partial pressure of carbon-dioxide (PCO2) and toxic shock syndrome. The objective of this retrospective study was to evaluate the role of laparoscopic surgery (LS) in selected patients with perforative peritonitis and to study its feasibility, safety, and outcomes.

Patients and methods

This was a retrospective study of 25 patients spanning over five years from 2015 to 2020. This study comprised all patients who were diagnosed with perforative peritonitis on preoperative physical/clinical examination, radiological evaluations, and who were stable enough to withstand pneumoperitoneum. Patients were evaluated for causes, operative time, duration of hospital stay, intra-, and postoperative complications, time taken to resume normal activity, and conversion to open surgery. Data was extracted from the hospital electronic medical records, for the above-mentioned parameters.

Results

Twenty-five patients with perforative peritonitis underwent diagnostic and therapeutic LS in our institute. The mean age was 46 years (35-79 years). Ten patients (40%) were diagnosed with gastro-duodenal perforation. Out of these ten patients, ninepatients (90%) were managed totally laparoscopically, while one patient (10%) required conversion to open surgery. There were 15 patients (60%) with small bowel perforation. Thirteen of the 15 patients were managed laparoscopically, with the remaining two requiring conversion to open surgery. The average time taken for the procedure was 90 minutes. The mean time to initiate the postoperative peroral liquid diet was 3.4 days. The mean postoperative stay was 6.9 days. The time taken to resume normal activity was 10-12 days.

Conclusions

Laparoscopic management is feasible and safe for patients with perforative peritonitis. Careful patient selection and the surgeon’s experience with the procedure are critical determinants of success.

• laparoscopy
• malignant hypercapnia
• peritonitis
• pneumoperitoneum
• toxic shock syndrome

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

• Acute diverticulitis
• Diffuse peritonitis
• Diverticular disease
• Septic shock

• Anastomosis, Surgical
• Colostomy
• Diverticulitis/surgery
• Diverticulitis, Colonic/surgery
• Humans
• Intestinal Perforation/etiology
• Intestinal Perforation/surgery
• Italy
• Laparoscopy
• Peritonitis/complications
• Peritonitis/surgery

• Università degli Studi di Brescia

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

• Age Factors
• Colonoscopy
• Diagnostic Imaging
• Digestive System Surgical Procedures
• Disease Management
• Diverticulitis, Colonic/diagnosis
• Diverticulitis, Colonic/therapy
• Humans
• Risk Factors

• K23 DK118192 NIDDK NIH HHS

• Laparoscopic lavage
• long-term follow-up
• perforated diverticulitis

• Acute diverticulitis
• Complicated diverticulitis
• Hinchey 3 diverticulitis
• Laparoscopic lavage
• Purulent peritonitis

• Acute Disease
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Drainage/methods
• Humans
• Laparoscopy/methods
• Peritonitis/complications
• Peritonitis/surgery
• Sigmoid Diseases/surgery
• Therapeutic Irrigation/methods

• Colon
• Consenso
• Consensus
• Disease
• Diverticula
• Diverticulitis
• Divertículos
• Enfermedad
• Mexico
• México

• Colonic Diseases/therapy
• Consensus
• Delphi Technique
• Diverticular Diseases/therapy
• Diverticulitis/therapy
• Guidelines as Topic
• Humans
• Mexico

• Acute Disease
• Colostomy/statistics & numerical data
• Conversion to Open Surgery/statistics & numerical data
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Female
• Humans
• Laparoscopy/methods
• Male
• Middle Aged
• Peritoneal Lavage/methods
• Peritonitis/etiology
• Peritonitis/surgery
• Reoperation/statistics & numerical data
• Retrospective Studies
• Sepsis/prevention & control

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/adverse effects
• Colon, Sigmoid/surgery
• Colonic Diseases
• Colostomy/adverse effects
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/etiology
• Female
• Humans
• Ileostomy
• Intestinal Perforation/etiology
• Length of Stay
• Male
• Middle Aged
• Peritonitis/etiology
• Retrospective Studies
• Shock, Septic/complications
• Shock, Septic/etiology
• Surgical Stomas/statistics & numerical data
• Treatment Outcome

• Hartmann procedure
• Laparoscopic peritoneal lavage
• Left colectomy
• Perforated sigmoid diverticulitis
• Purulent peritonitis

• Diverticulitis
• Emergency
• Lavage
• Peritonitis
• Surgery

• Diverticular disease
• Documento de consenso
• Enfermedad diverticular
• Hartmann procedure
• Intervención de Hartmann
• Lavado peritoneal
• Outpatient management
• Peritoneal lavage
• Position statement
• Tratamiento ambulatorio

Laparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study.

This study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention‐to‐treat) for up to 1 year after randomization.

Eighty‐eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € − 3512, 95 per cent bias‐corrected and accelerated c.i. −16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € − 2509 to −4438).

Laparoscopic lavage for perforated diverticulitis is more cost‐effective than sigmoid resection.

Further evidence of lavage superiority

• Diverticulitis/etiology
• Diverticulitis/pathology
• Diverticulitis/surgery
• Diverticulum, Colon/complications
• Female
• Hospital Mortality/trends
• Humans
• Laparoscopy/methods
• Laparoscopy/mortality
• Male
• Peritoneal Lavage/methods
• Peritoneal Lavage/mortality
• Peritonitis/etiology
• Peritonitis/pathology
• Peritonitis/surgery
• Prognosis
• Randomized Controlled Trials as Topic
• Risk Assessment
• Severity of Illness Index
• Survival Rate
• Treatment Outcome

• Emergency Treatment
• Evidence-Based Medicine/methods
• Humans
• Specialties, Surgical

• Acute care surgery
• Acute diverticulitis
• Colorectal surgery
• Emergency surgery
• Hartmann resection
• Laparoscopic lavage
• Perforated diverticulitis

• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Evidence-Based Medicine/methods
• General Surgery/history
• History, 20th Century
• Humans
• Peritonitis/etiology
• Peritonitis/surgery
• Therapeutic Irrigation/history
• Therapeutic Irrigation/methods

• Diverticulitis
• Elderly patients
• Laparoscopic peritoneal lavage
• Urgency

Over the years various therapeutic techniques for diverticulitis have been developed. Laparoscopic peritoneal lavage (LPL) appears to be a safe and useful treatment, and it could be an effective alternative to colonic resection in emergency surgery.

This prospective observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage in perforated sigmoid diverticulitis.

We surgically treated 70 patients urgently for complicated sigmoid diverticulitis. Thirty-two (45.7%) patients underwent resection of the sigmoid colon and creation of a colostomy (Hartmann technique); 21 (30%) patients underwent peritoneal laparoscopic lavage; 4 (5.7%) patients underwent colostomy by the Mikulicz technique; and the remaining 13 (18.6%) patients underwent resection of the sigmoid colon and creation of a colorectal anastomosis with a protective ileostomy.

The 66 patients examined were divided into 3 groups: 32 patients were treated with urgent surgery according to the Hartmann procedure; 13 patients were treated with resection and colorectal anastomosis; 21 patients were treated urgently with laparoscopic peritoneal lavage. We had no intraoperative complications. The overall mortality was 4.3% (3 patients). In the LPL group the morbidity rate was 33.3%.

Currently it cannot be said that LPL is better in terms of mortality and morbidity than colonic resection. These data may, however, be proven wrong by greater attention in the selection of patients to undergo laparoscopic peritoneal lavage.

• Hartmann's procedure
• colon resection
• diverticular disease
• laparoscopic peritoneal lavage
• urgency

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

• Diverticulitis
• Laparoscopy
• Emergent
• Lavage
• Drainage
• Peritonitis
• Purulent
• Stercoral
• Complicated
• Perforation

• Colon
• Diverticular disease
• Diverticulitis
• Diverticulosis

• Abscess/etiology
• Abscess/surgery
• Anti-Bacterial Agents/therapeutic use
• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Colectomy/methods
• Colon/pathology
• Colon/surgery
• Colonography, Computed Tomographic
• Colonoscopy
• Colorectal Surgery/standards
• Diet/methods
• Dietary Fiber
• Diverticulum, Colon/complications
• Diverticulum, Colon/diagnosis
• Diverticulum, Colon/therapy
• Elective Surgical Procedures/methods
• Gastrointestinal Agents/therapeutic use
• Humans
• Italy
• Laparoscopy/methods
• Mesalamine/therapeutic use
• Multidetector Computed Tomography/methods
• Peritonitis/etiology
• Peritonitis/surgery
• Probiotics/therapeutic use
• Rifamycins/therapeutic use
• Rifaximin

• Colon, Sigmoid/surgery
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Diverticulitis, Colonic/therapy
• Female
• Humans
• Intestinal Perforation/etiology
• Intestinal Perforation/surgery
• Laparoscopy
• Male
• Middle Aged
• Peritoneal Lavage
• Peritonitis/etiology
• Peritonitis/surgery
• Treatment Outcome

• Colon, Sigmoid/surgery
• Diverticulitis, Colonic/surgery
• Female
• Humans
• Intestinal Perforation/surgery
• Male
• Peritoneal Lavage
• Peritonitis/surgery

• Age Factors
• Colectomy/methods
• Colonic Neoplasms/complications
• Colonic Neoplasms/pathology
• Colonic Neoplasms/surgery
• Humans
• Laparoscopy
• Neoplasm Staging
• Treatment Outcome