The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis

Abstract

Introduction Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II–IV complicated acute diverticulitis (CAD). Methods A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). Results Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. Conclusions The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.

Lessons Learned in 11 Years of Experience With Open Abdomen Treatment With Negative-Pressure Therapy for Various Abdominal Emergencies

“…Damage control surgery (DCS), established in the treatment of injured patients by trauma surgeons, has been adopted by general surgeons for various abdominal emergencies (1)(2)(3)(4). DCS meets all requirements for an emergency operation: short operating time, immediate clearance of the septic focus, and improving the patient for definitive reconstruction in a second operation at the ICU, if necessary (11).…”

“…In the setting of perforated diverticulitis with generalized peritonitis, the concept of DCS is already established (1,9,13). We adopted the concept also for patients with anastomotic leakage to allow reanastomosation in the second-look procedure.…”

“…Open abdomen (OA) treatment seems to be effective in treating critically ill patients with abdominal sepsis. However, the indication remains controversial as it is a resource-consuming and a non-anatomic situation with the potential of severe adverse effects (1)(2)(3). Temporary abdominal closure (TAC) with negative-pressure therapy (NPT) allows not only the patient to be resuscitated at the intensive care unit (ICU) but also the decision on the definitive surgical procedure to be postponed to a second look in an elective situation with an experienced colorectal surgeon and the aim of avoiding creation of a temporary stoma (4)(5)(6).…”

Update on the management of sigmoid diverticulitis

“…A reality check, however, confirms that in the United States, more than 90% of surgeons performed a Hartmann resection in the acute setting, and only 7.6% of patients had a primary anastomosis with diverting loop ileostomy performed[ 137 ]. A systematic review revealed a 62% rate of restored intestinal continuity during damage-control surgery[ 138 ]. From a practical standpoint and as a rule of thumb, (1) 2 healthy bowel ends in healthy and stable patients merit a primary anastomosis without diversion; (2) 1 healthy and one suboptimal bowel end may allow for a primary anastomosis with an upstream diversion; and (3) 2 unhealthy bowel ends or an unstable/unfit patient warrant an end colostomy[ 84 ].…”

“…Overall, outcomes data after damage-control surgery for diverticulitis demonstrate a 9.2% risk of mortality and high morbidity of close to 50% including a 7.4% leak rate[ 137 , 138 ]. Wound infection reported at 10%-20% was the most common morbidity with mortality rates being < 5%.…”