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Purpose: The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann's procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. Methods: Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. Results: Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p <.001), with Hinchey IV diverticulitis (37% vs. 7%, p <.001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p <.001, Charlson Comorbidity Index p <.001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p =.002 and 10.6% vs. 0%, p =.007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p <.001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p =.044). Conclusions: In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors. [ABSTRACT FROM AUTHOR]

Aim: Symptoms of right colon diverticulitis may mimic acute appendicitis. Therefore, most of these patients undergo unnecessary surgical intervention due to suspicion of appendicitis. The aim of this study was to evaluate the clinical and treatment results of our patients with right colon diverticulitis. Material and Methods: Between January 2016 and December 2020, demographic and clinical data of 15 patients diagnosed with right-sided colon diverticulitis among 104 patients with colonic diverticulitis were retrospectively analyzed and radiological evaluation and clinical findings were recorded. Results: Fifteen patients were included from in the study. The mean age of the patients was 37.73, 9 (60%) were female and 6 (40%) were male. The duration of symptoms before hospitalization was 1-4 days, with an average of 2.2 days. Generally, 66.6% of the patients had fever, 46.6% had nausea, 33% had diarrhea, 73% had pain in the lower right abdomen, and 27% had general abdominal pain at the time of admission. Leukocytosis was detected in 86.6% of all patients. High CRP levels were found in all patients (100%). Since two patients had an ultrasound image compatible with acute appendicitis, surgery was performed without computed tomography. In these two patients, Hinchey-1b cecum diverticulitis was found as a surgical finding. Computed tomography with oral and intravenous contrast was used for all other patients. Diagnostic laparoscopy was performed on the computed tomography of a patient after suspicious findings accompanying cecum diverticulitis. In one patient, diverticulitis in the cecum and abscess in the right colon medial was observed (Hinchey-2). This patient underwent percutaneous drainage and IV antibiotherapy accompanied by interventional radiology, and the treatment was successful. In one patient, right hemicolectomy and ileocolic anastomosis were performed due to complicated right colon diverticulitis and acute abdomen (Hinchey 3). Although ultrasound evaluation was performed on all patients, the diagnosis of diverticulitis could not be made clearly for 8 (53.3%) patients. According to localization, 66.6% of patients had diverticulitis in the right colon (except cecum) and 33.3% had diverticulitis in the cecum. Conclusion: In experienced hands, ultrasonography can make it easier to differentiate diverticulitis from acute appendicitis, however, in suspected cases, CT is of great importance to determine the correct diagnosis and suspected complications necessary to choose the right treatment. Acute appendicitis and right colon diverticulitis can be confused, especially cecal diverticulitis, and uncomplicated cecal diverticulitis can usually be managed conservatively. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = −2.03, 95% CI −2.59 to −1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness. [ABSTRACT FROM AUTHOR]

Currently, the most commonly used classification of acute colonic diverticulitis (ACD) is the modified Hinchey classification, which corresponds to a slightly more complex classification by comparison with the original description. This modified classification allows to categorize patients with ACD into four major categories (I, II, III, IV) and two additional subcategories (Ia and Ib), depending on the severity of the disease. Several studies have clearly demonstrated the impact of this classification for determining the best therapeutic approach and predicting perioperative complications for patients who need surgery. This review provides an update on the classification of ACD along with a special emphasis on the corresponding MDCT features of the different categories and subcategories. This modified Hinchey classification should be known by emergency physicians, radiologists, and surgeons in order to improve patient care and management because each category has a specific therapeutic approach. [ABSTRACT FROM AUTHOR]

Background Emergency colonic resection with anastomosis or Hartmann's procedure (with colostomy) is the traditional management of acute diverticulitis complicated by perforation. Recently, promising results have been reported after laparoscopic lavage in these cases. Selection of patients for this technique is of great importance. This study presents our early experience in the management of purulent peritonitis (Hinchey III) due to perforated diverticulitis. Patients and methods A prospective study of 80 patients was conducted during the period between January 2010 and January 2015. All patients with purulent peritonitis (Hinchey III) underwent a trial of laparoscopic peritoneal lavage and drainage. The degree of peritonitis and the procedure-related information were recorded. The primary endpoint of this study was mortality and major morbidity within 30 days of operation. The secondary endpoint included readmission, postoperative complications, length of hospital stay, reoperation, and mortality within 12 months of the emergency surgery. Results A total of 87 patients were treated with laparoscopic peritoneal lavage. Seven patients had fecal peritonitis (Hinchey IV) and were excluded from the study. The other 80 patients with a mean age of 55 years were included in the study; four of them (5%) had Hinchey II disease and 76 (95%) had Hinchey III disease. The mean operative time was 100min. The overall morbidity was 15% and mortality rate was 5%. There were five early reinterventions because of treatment failure. The mean length of hospital stay was 10 days. There was no recurrence of diverticulitis and no intervention was performed after a median follow-up period of 48 months (range= 12-60 months). Conclusion Laparoscopic peritoneal lavage and drainage, for diffuse purulent peritonitis due to perforated diverticulitis, is safe and effective. Using this technique, emergency laparotomy with risk for colostomy can be avoided. [ABSTRACT FROM AUTHOR]

Background/Aims: Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification. Methods: Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups. Results: Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis. Conclusions: This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis. [ABSTRACT FROM AUTHOR]

Background: Non-resectional strategies (NRS) have improved outcomes for a sub-group of patients with perforated diverticulitis. NRS are applicable to patients with non-faeculant peritonitis (Hinchey II and III). Success is dependent on the initial perforation sealing, which Hinchey estimated occurred 'most of the time'. An exact percentage remains ill-defined. Objective: We aimed to define the percentage and clinical significance of a persistent perforation in non-faeculant diverticular peritonitis. Design: A retrospective review was conducted of all patients admitted with a diagnosis of perforated diverticulitis between January 1999 and July 2010. Patients undergoing an emergency operation were analysed according to Hinchey and physiological and operative severity scores and compared with histological findings. Results: One hundred fifteen patients were identified. Fifty-three patients underwent a 'resectional' procedure. At surgery, 15 patients had faeculent peritonitis, 27 patients had purulent peritonitis and 11 patients had a contained abscess. Of the patients with non-faeculant peritonitis, 2/9 (22.2 %) Hinchey II and 10/27 (37.1 %) Hinchey III patients had persistent perforation on review of histology. Persistent perforation was associated with a significant increase in morbidity, length of stay, physiological and operative severity score ( p = 0.015, 0.011, 0.049 and 0.002, respectively). Conclusion: A proportion of patients with non-faeculant peritonitis have a persistent perforation which is associated with a poorer outcome and is likely to result in failure of a non-resectional management strategy. Updated classification systems and tailored peri-operative investigations are required to identify this sub-group of patients and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis. Methods: A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study. Results: A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %. Conclusions: Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications. [ABSTRACT FROM AUTHOR]

Background: Treatment of perforated diverticulitis depends on disease severity classified according to Hinchey's preoperative classification. This study assessed the accuracy of preoperative staging of perforated diverticulitis by computerized tomography (CT) scanning. Methods: All patients who presented with perforated diverticulitis between 1999 and 2009 in two teaching hospitals of Rotterdam, the Netherlands, and in addition had a preoperative CT scan within 24 h before emergency surgery were included. Two radiologists reviewed all CT scans and were asked to classify the severity of the disease according to the Hinchey classification. The CT classification was compared to Hinchey's classification at surgery. Results: Seventy-five patients were included, 48 of whom (64 %) were classified Hinchey 3 or 4 perforated diverticulitis during surgery. The positive predictive value of preoperative CT scanning for different stages of perforated diverticulitis ranged from 45 to 89 %, and accuracy was between 71 and 92 %. The combination of a large amount of free intra-abdominal air and fluid was strongly associated with Hinchey 3 or 4 and therefore represented a reliable indicator for required surgical treatment. Conclusions: The accuracy of predicting Hinchey's classification by preoperative CT scanning is not very high. Nonetheless, free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it is strongly associated with perforated diverticulitis with generalized peritonitis. In 42 % of cases, Hinchey 3 perforated diverticulitis is falsely classified as Hinchey 1 or 2 by CT scanning. [ABSTRACT FROM AUTHOR]

Background: Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe. Methods: All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed. Results: Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula. Conclusion: The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis. [ABSTRACT FROM AUTHOR]

Background: Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann’s procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy. We present our early experience in managing perforated diverticulitis acutely by laparoscopic lavage and drainage. Methods: A retrospective review was conducted of all patients with surgically confirmed perforated diverticulitis. Details concerning the nature of presentation, operative findings, postoperative course and medium-term progress were investigated. Results: Fourteen patients with a mean age of 57.2 years were identified over a 3-year period. All patients presented with peritonitis and systemic sepsis. Ten patients had extraluminal gas on preoperative imaging. Laparoscopic lavage and drainage, without resection or stoma, was the initial management in all cases. Sigmoid diverticulitis was confirmed in all cases, complicated by Hinchey grade 3 purulent peritonitis in 10 patients, grade 2 contamination in 2 patients and grade 4 faeculent peritonitis in 2 patients. Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5–32 days). Three patients did not improve and underwent acute resection. Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks, which was carried out laparoscopically in all but one case. Conclusion: Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis may be a promising alternative to more radical procedures, including the Hartmann’s procedure. Acute resection should still be carried out in patients found to have faecal peritonitis or who fail to improve following lavage. [ABSTRACT FROM AUTHOR]