Primary resection in patients with perforated diverticulitis

November's issue of Archives of Surgery publishes a report into the impact of primary resection on operative mortality, which finds that mortality rates have not significantly declined despite more aggressive surgical management of the septic source.

Primary resection has replaced the conventional drainage procedure in the management of patients with generalized peritonitis complicating diverticular disease of the colon.

Dr Chandra and colleagues from Minnesota, America, designed a study in order to investigate the impact of primary resection on operative mortality.

The team also aimed to identify predictors of mortality, and to compare the results with those of the research group's earlier experience.

The researchers hypothesized that primary resection of the perforated diseased segment of the colon is associated with lower mortality rates than the drainage procedure in patients with Hinchey stages 3 and 4 diverticulitis.

The investigators carried out a retrospective analysis of 138 consecutive patients from a tertiary care center.

The participants had undergone emergent operation for generalized peritonitis complicating diverticular disease of the colon (Hinchey stages 3 and 4) between January 1983 and May 1999.

The research group analyzed the 30-day mortality rate and then identified the predictors of mortality.

The team classified patients as having spreading purulent peritonitis (n = 44), diffuse peritonitis (n = 64), or fecal peritonitis (n = 30).

Predictors of mortality: age of more than 70 years, 2 or more comorbid conditions, obstipation at initial examination and use of steroids

Archives of Surgery

131 patients underwent primary resection, 6 patients underwent resection and primary anastomosis, and 1 patient required total colectomy and end ileostomy.

The researchers noted that 13 of the 138 patients in the present group died (1983-1998), representing a perioperative mortality rate of 9%.

The group found that there was no significant difference in mortality when comparing data with their earlier study (1972-1982), which had a mortality rate of 12%, considering that more than 25% of the patients in that group were managed by colostomy and drainage alone.

The researchers identified predictors of mortality as: age of more than 70 years, 2 or more comorbid conditions, obstipation at initial examination, use of steroids, and perioperative sepsis.

Dr Chandra commented, "Primary resection has become the standard practice for patients with generalized peritonitis complicating diverticulitis."

"Mortality rates have not significantly declined despite more aggressive surgical management of the septic source."

Dr Chandra concluded that "Because advanced age, comorbid conditions, and perioperative sepsis predict mortality, further reduction in mortality will require improvement in medical management of perioperative sepsis and comorbid conditions".