Management of Complicated Diverticulitis
Annotation for Point G
In the early 1980s, trauma surgeons recognized the high mortality associated with operating in the setting of ‘‘bloody vicious cycle’’ of acidosis, hypothermia, and coagulopathy.22 This prompted the development of the concept of a truncated laparotomy using packing to stop bleeding with a temporary abdominal closure (e.g., towel clip closure of the skin) and triage to the intensive care unit (ICU), with the intent of optimizing physiology and then returning to the OR after 24 to 48 hours for definitive treatment of injuries and abdominal closure.23 This concept was initially promoted for major liver injuries but was soon extended to all emergency laparotomies.24-26
During the next decade, this concept evolved into ‘‘damage control’’ (DCL), which was a major paradigm shift for trauma surgeons.27 This practice has become standard of care worldwide and has saved the lives of many patients who previously exsanguinated on the OR table. However, the role of DCL in emergency abdominal surgery is controversial.28,29 It is often confused with the concept of a ‘‘planned relaparotomy.’’ This strategy has been debated for more than 30 years. Reoperations are performed every 48 hours for ‘‘washouts’’ until the abdomen is free of ongoing peritonitis and then the abdomen is closed. This supposedly prevents and/or provides early treatment of secondary infections, thus decreasing late multiple organ failures and deaths. The downside of the planned relaparotomy approach is increased resource utilization and the increased potential risk for gastrointestinal fistulas and delayed hernias. The alternative is referred to as ‘‘laparotomy on demand,’’ where relaparotomy is performed for clinical deterioration or lack of improvement. The potential downside to this approach is harmful delays in diagnosing secondary abdominal infections and the presence of more dense adhesions if there is a need to reoperate. Over the years, there have been eight case series that have offered conflicting results regarding the impact of this strategy on outcome. A meta-analysis of the data concluded that ‘‘laparotomy on demand’’ was the preferred approach in patients with APACHE II less than 10.30 However, a recent prospective randomized trial by van Ruler et al.31 in patients with APACHE II higher than 10 indicates that the practice of ‘‘planned relaparotomy’’ offered no clinical advantage over ‘‘laparotomy on demand’’ and was associated with substantial increases in expenditure of hospital resources.
The purpose of DCL is to perform a truncated operation to correct immediate life-threatening problems and then triage the patient to the ICU to correct abnormal physiology before returning to the OR for a second definitive operation. In trauma, the life-threatening issue is exsanguinations, and the abnormal physiology is the ‘‘bloody vicious cycle’’ of acidosis, hypothermia, and coagulopathy. Although the ‘‘bloody vicious cycle’’ can occur with intra-abdominal sepsis, exsanguination is uncommon. Rather, patients with grade III or IV complicated diverticulitis can present the ‘‘persistent septic shock cycle’’ (Fig. 2). Initially, they are too sick to undergo immediate operation. In these cases, there has been a paradigm shift (Fig. 3). The traditional approach was to move relatively quickly to the OR for source control by performing the HP. However, septic shock patients, by definition, require vasopressors, and when subjected to general anesthesia, they require higher doses of vasopressors. If the patient undergoes definitive resection HP, the prolonged exposure to high-dose vasopressors causes acute kidney injury (AKI) which sets the stage for multiorgan failure and prolonged ICU stays.32 The DCL strategy requires preoperative optimization, as described in Preoperative Optimization, which may take 2 to 3 hours. The patient is then moved to the OR, and the surgeon assesses the patient for evidence of physiologic derangement, including acidosis, evidence of disseminated intravascular coagulation, and/or the need for vasopressors. If the patient is judged to be physiologically deranged, the surgeon informs the OR team that a DCL is going to be performed. A limited colon resection of the inflamed colon is performed using staplers, with no colostomy, and a temporary abdominal closure is performed. The patient is returned to the ICU for ongoing resuscitation. Once physiologic abnormalities are corrected, the patient is returned to the OR for peritoneal lavage and colostomy formation.