The Damage Control Strategy for the Treatment of Perforated Diverticulitis of the Sigmoid Colon With Diffuse Peritonitis
The Damage Control Strategy for the Treatment of Perforated Diverticulitis of the Sigmoid Colon With Diffuse Peritonitis
The best approach for the treatment of perforated diverticulitis of the sigmoid colon is
 still under debate. Concurrent techniques are 1) resection with primary colorectal
 anastomosis with or without additional loop ileostomy; 2) end colostomy (Hartmann´s
 procedure); 3) Damage control strategy; 4) laparoscopic lavage and placement of a drainage.
 It is hypothesized, that the use of the damage control strategy leads to a significant
 reduction of the stoma rate.

 The damage control strategy constitutes a two stage procedure.

 Emergency surgery:

 limited resection of the diseased colonic segment with oral and aboral blind closure,
 abdominal lavage, temporary vacuum assisted abdominal closure

 Second look surgery (48-72 hours later):

 Reexploration with

 1. definite reconstruction (Colorectal anastomosis -/+ diverting ileostomy vs. end
 colostomy)

 2. lavage, vacuum assisted abdominal closure, third look 72 hours after emergency surgery

 Within the study, data of DCS-procedures will be collected retrospectively in a multicentric
 and transnational approach. Those will be compared to a cohort of patients treated with a
 "no-DCS"-technique (resection with primary anastomosis or Hartmann´s procedure).
Research question/objective of the study

 It is assumed that the application of the Damage Control Strategy (DCS) in patients with
 perforated diverticulitis of the sigmoid colon with generalized peritonitis leads to a
 reduction of the stoma rate with the same degree of safety as other procedures (Hartmann´
 procedure, sigmoid resection with primary anastomosis, laparoscopic lavage).

 Definitions

 The damage control strategy constitutes a two stage procedure.

 Emergency surgery:

 limited resection of the diseased colonic segment with oral and aboral blind closure,
 abdominal lavage, temporary vacuum assisted abdominal closure

 Second look surgery (48-72 hours later):

 Reexploration with

 1. definite reconstruction (Colorectal anastomosis -/+ diverting ileostomy vs. end
 colostomy)

 2. lavage, vacuum assisted abdominal closure, third look 72 hours after emergency surgery

 Basis and scientific knowledge

 The majority of patients with acute diverticulitis of the left colon are currently treated
 conservatively. However, diverticular perforation with diffuse peritonitis remains a
 challenging and life-threatening situation requiring emergency surgical intervention.
 Regardless of the frequency and severity of the disease, there is yet no generally accepted
 treatment algorithm. Sigmoid resection with blind closure of the rectal stump and formation
 of an end colostomy (Hartmann´s procedure) as well as sigmoid resection with primary
 anastomosis with or without additional loop ileostomy are alternative procedures. As an
 additional approach, laparoscopic lavage and drainage has not yet been widely established.
 Accordingly, the technique is not recommended in the current German S2K guidelines for the
 treatment of diverticular disease. Within Damage Control Strategy (DCS), a limited resection
 of the affected sigmoid segment with oral and aboral blind closure is performed during the
 initial intervention. After abdominal lavage, a temporary vacuum-assisted closure of the
 abdominal cavity is then performed. 24 to 72 hours later, the decision on the definite
 reconstruction procedure is made within the scope of the planned second-look laparotomy.
 Generally, a colorectal anastomosis with or without loop ileostomy is intended. If this is
 not possible, end colostomy is available as additional option. Principal criteria for the
 decision on the type of definite reconstruction are the local and general findings of the
 patient. According to the results of a first cohort from the Innsbruck University Hospital, a
 colorectal anastomosis can be achieved in almost 80% of patients within second operation. In
 about half of the patients, a loop ileostomy is additionally created. Using DCS, morbidity
 and mortality are comparable to the above mentioned competing procedures. An own study from
 2016 shows similar results. After the initial hospital stay, 47% of the patients were stoma
 carriers after the application of DCS, compared to 83% of the patients from the control group
 to which all "other" surgical procedures (Hartmann operation, Primary anastomosis with or
 without loop ileostoma) were assigned. At the end of follow-up, 88% of patients were
 stoma-free after use of DCS. The mortality rate was 11 percent. A systematic review of the
 available specific literature on DCS is yet underway. The manuscript is currently undergoing
 peer review at the World Journal of Gastroenterology. In the course of this process the above
 mentioned results could be confirmed. A total of eight publications from five study groups
 were identified (status 11/2019). In 73% of the cases a colorectal anastomosis could be
 performed during the second-look laparotomy. 15% of the patients additionally received a loop
 ileostomy. End colostomy (secondary Hartmann´s procedure) was necessary in only 27% of the
 patients. The cumulative anastomotic leak rate was 13%, surgical morbidity 31% and 30-day
 mortality was 9%. A stoma rate of 45% at discharge should be emphasized. Thus, the number of
 patients in whom intestinal continuity could be restored during the initial hospital stay was
 considerably higher when using the damage control strategy than in most studies on the
 treatment of perforated diverticulitis with diffuse peritonitis. In addition, a stoma rate of
 <50% at discharge was achieved. These aspects should be highlighted as key benefits. Further
 positive aspects of the method are the fast and technically simple focus repair during the
 initial intervention.
Inclusion Criteria:

 all patients who were operated for perforated diverticulitis with generalized peritonitis

 Exclusion Criteria:

 incomplete data sets