Perforated diverticulitis operated at Sahlgrenska University Hospital 2003-2008

Abstract

All patients with perforated diverticulitis admitted as emergency cases and having undergone colon resection during their initial hospitalisation in the period from 1 January 2003 to 30 June 2008 at one institution were analysed with regard to morbidity and mortality. The group consisted of 106 patients (mean age 65 years, range 32-98 years), 60% of whom had comorbidity. Hartmann's procedure was the initial procedure in 77% and primary resection and anastomosis in 23%. Of these patients 18% underwent reoperation, leading to a mean number of surgical procedures during the initial hospitalisation of 1.3 (range 1-10). The mean length of stay was 17 days, the median stay 12 days (range 1-111 days). A total of 43% of the patients underwent surgery during readmissions. Among the 82 patients operated with Hartmann's procedure, permanent stoma was the end result for 35 patients (43%). Six patients died. This retrospective study confirmed that perforated diverticulitis requiring colon resection was associated with a high risk of reoperation, long hospital stay, readmittance with renewed surgery and permanent stoma. Furthermore, the procedure caused suffering and a considerable drain on resources. The results will be used as the basis for a randomised trial on laparoscopic lavage versus Hartmann's procedure.

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DANISH MEDICAL BULLETIN ϣDan Med Bul ϧϪ/ϣ January ϤϢϣϣ
ABSTRACT
All patients with perforated diverticulitis admitted as
emergency cases and having undergone colon resection
during their initial hospitalisation in the period from
1 January 2003 to 30 June 2008 at one institution were
analysed with regard to morbidity and mortality. The
group consisted of 106 patients (mean age 65 years,
range 32-98 years), 60% of whom had comorbidity. Hart-
mann’s procedure was the initial procedure in 77% and
primary resection and anastomosis in 23%. Of these pa-
tients 18% underwent reoperation, leading to a mean
number of surgical procedures during the initial hospi-
talisation of 1.3 (range 1-10). The mean length of stay
was 17 days, the median stay 12 days (range 1-111
days). A total of 43% of the patients underwent surgery
during readmissions. Among the 82 patients operated
with Hartmann’s procedure, permanent stoma was the
end result for 35 patients (43%). Six patients died. This
retrospective study confirmed that perforated diverticu-
litis requiring colon resection was associated with a high
risk of reoperation, long hospital stay, readmittance with
renewed surgery and permanent stoma. Furthermore,
the procedure caused suffering and a considerable drain
on resources. The results will be used as the basis for a
randomised trial on laparoscopic lavage versus Hart-
mann’s procedure.
In industrial countries, diverticulosis of the colon has a
prevalence of 5% in persons under the age of 40, and
the prevalence rises with age [1]. Most such patients are
asymptomatic, but 15-25% develop diverticulitis [2], and
they are mostly uncomplicated cases. Patients with mild
to moderate lower abdominal pain and subfebrility are
often treated conservatively as outpatients with restric-
tion on oral fluids for the first 2-3 days. Oral antibiotics
have frequently been part of such a regimen; however,
evidence in support of their use is limited [3]. Active
therapy is required for patients with diverticulitis who
develop more complicated disease. The clinical manifes-
tations of such disease may include moderate to severe
abdominal pain, signs of peritonitis, fever and septic
symptoms. Hinchey’s classification of colonic diverticular
disease [4] has been known for decades. Even if it is
rarely used by surgeons, it is useful for disease staging in
connection with the discussion of alternative treatment
modalities.
– Stage Ia: Phlegmona
– Stage Ib: Diverticulitis with pericolic or mesenteric
abscess
– Stage II: Diverticulitis with walled-off pelvic abscess
– Stage III: Diverticulitis with generalised purulent
peritonitis
– Stage IV: Diverticulitis with generalised faecal
peritonitis.
Stages I and II are generally treated with intravenous
antibiotics, but some cases may require surgery. A re-
cent study provided evidence in support of conservative
treatment for Hinchey I and some Hinchey II cases [5].
Stages III and IV (Figure 1) are considered an indication
for emergency surgery. Hartmann’s procedure (HP)
(Figure 2) or primary resection and anastomosis (PRA)
are the most common surgical procedures performed in
acute perforated diverticulitis, and of these HP is the
most frequently used procedure [6]. However, evidence
that HP and PRA are, indeed, the best options remain
low-grade and needs to be substantiated in empirical
studies with higher levels of evidence [7].
The present study aims to describe the results of
emergency surgery for perforated diverticulitis at our in-
stitution. The study will focus on suffering and resource
consumption in terms of number of operations, length
of hospital stay, reoperations during readmissions, per-
manent stoma and mortality. The results will be used as
the point of departure for a randomised trial investigat-
ing recently described alternative treatment [8].
MATERIAL AND METHODS
An application to the Research Ethics Committee was
not filed as retrospective quality control studies require
no such approval under Swedish law.
This retrospective study was undertaken at the
Departments of Surgery at Sahlgrenska University
Hospital from 1 January 2003 to 30 June 2008. The pa-
tient population was identified via the hospital record
system which contains data on all admitted and dis-
ORIGINAL ARTICLE
1) Department of
Surgery, Alingsås
Lasarett, and
2) SSORG/Göteborg,
Department of Surgery,
Sahlgrenska University
Hospital/Östra
Dan Med Bul
2011;58(1):A4173
Perforated diverticulitis operated at
Sahlgrenska University Hospital 2003-2008
Anders Thornell1, Eva Angenete2 & Eva Haglind2

Ϥ DANISH MEDICAL BULLETIN
charged patients registered with the International
Classification of Diseases coding system (ICD-10) and the
specific Swedish surgical procedure codes. The search
criteria were:
– Admission on an emergency basis
– Discharge diagnosis: ICD-10 code K572 or K573
– Abdominal surgery with colon resection during the
hospital stay.
We excluded patients with pathologies like cancer, ap-
pendicitis or gynaecologic conditions.
The study period saw the inclusion of 1,519 patients
admitted from the Emergency Rooms and later dis-
charged with a diagnosis of diverticulitis. A total of 106
of these patients (51 men and 55 women) underwent
colonic resection during their initial hospital stay with
findings of complicated or perforated diverticulitis and
no other pathologies. These patients were included for
further analysis. The follow-up period lasted until 1 June
2009. Hinchey grading had only been used in two cases,
and the population could therefore not be classified ac-
cording to Hinchey.
Data were collected from case records. The follow-
ing information was collected:
– Age
– Comorbidity
– Length of hospital stay
– Initial surgical procedure
– Mortality
– Reoperation during first hospital stay
– Reasons for reoperation
– Readmittance
– Reoperation during readmissions
– Type of operations
– Permanent stoma.
The definition of co-morbidity was cancer, chronic ob-
structive pulmonary disease, cardio-vascular disease or
treatment with immuno-modulating drugs.
The SPSS software was used for statistical analysis.
RESULTS
The patients’ mean age was 65 and it was significantly
lower in men than in women (Table 1). The mean length
of the hospital stay was 17 days, and the median length
was 12 days, (range: 1-111) for the first emergency ad-
mittance. A total of 82% of the patients were operated
once during their first hospital stay, 12% were operated
twice and 6% more than twice. The mean number of op-
erations was 1.3 (range: 1-10). HP was performed in 77%
of the cases and 23% underwent PRA. Comorbidity was
seen in 60%, and 44% of the patients were re-operated
during a later admission, including elective procedures
such as colonic reanastomosis (Table 2). The rate of re-
operation at readmission was 43% (Table 2). Reopera-
tion was more common among men (57%) than women
(31%), p < 0.007. Among patients who underwent Hart-
mann’s procedure (n = 82), 17% (n = 14) were either lost
to follow-up or died, and the stoma was not reversed in
43% (n = 35) of the cases. The decision to leave the
stoma permanently was made by the surgeon in 20
cases and by the patient in 15 cases. Six patients died
during their first admittance, three of whom had faecal
peritonitis, Hinchey IV.
DISCUSSION
Perforated diverticulitis is a potentially lethal condition.
The mortality rate after emergency surgery has been re-
ported to reach 20% [9]. Based mainly on experience
and retrospective case-series, HP or PRA have evolved to
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Perforated diverticulitis of the sigmoid colon
FIGURE 1
Illustration of the anatomy after Hartmann’s procedure with resection of
the perforated, inflamed sigmoid colon and construction of a colostomy
FIGURE 2

DANISH MEDICAL BULLETIN ϥ
become recommended emergency procedures [7]. Over
a 5.5-year period in a large University Hospital with a
catchment area of 700,000 inhabitants, 106 patients
underwent emergency colonic resection for diverticuli-
tis. Having two surgery departments, the hospital was,
and still is, the only hospital with an emergency service
in the city of Göteborg and the surrounding areas. The
annual incidence of perforated diverticulitis treated by
emergency colonic resection was three cases/100,000
inhabitants. Thus, each individual surgeon’s experience
with this procedure is limited. The frequency and sever-
ity of the complications, the postoperative mortality and
the high rate of permanent stomas found in our popula-
tion suggest that patients may suffer unduly and that re-
source consumption is high.
We found a lower mortality than reported in many
previous studies [19] which could reflect selection bias.
Included were all patients admitted as emergency cases
and later diagnosed as having diverticulitis and in whom
a colonic resection was performed during the initial hos-
pital stay. Only if the hospital administrative records are
inaccurate and lack a correct ICD code or surgery code
would cases be missed. However, these records are also
the basis for the hospital’s economic reimbursement.
The lower mortality observed in this population than in
other populations could also be rooted in improvements
in care, e.g. operative care and intensive care as well as
improvements related to diagnostics and treatment of
complications. If the indications for emergency surgery
at our hospital exclude from surgery the oldest and most
severely ill patients, this would also explain the observed
low mortality. We found nothing to suggest the pres-
ence of a systematic bias due to stricter indications for
emergency surgery at any of the surgery departments at
our hospital. Given the retrospective nature of the
present study, it is, however, important to interpret the
results with caution and make no firm conclusions on
the present basis.
The rate of complications was high, and could large-
ly explain the length of hospital stay and the reoperation
rate observed during the initial hospital stay. In a retro-
spective study, Kotzampassakis et al found that patients
younger than 50 years less frequently underwent emer-
gency surgery than older patients, and when they did,
they were more frequently underwent PRA than pa-
tients above this age [11]. In the only large prospective
study on laparoscopic lavage for acute, perforated di-
verticulitis, the mean age was the same as in our retro-
spective material [12].
Earlier studies have reported that older patients are
more likely to require emergency surgery than younger
patients [13], and that a poor outcome is associated
with elderly patients with significant comorbidity [14].
With a mean age of 65 years and significant comorbidity
in 60% of the patients, our findings underline that our
population was, indeed, a risk population. Recently,
Klarenbeek et al discussed the indications for elective
sigmoid resection after diverticulitis and found immuno-
suppression, renal failure and collagen vascular disease
to be risk factors [10]. The mortality after emergency
sigmoid resection in their 10-year material was 13%.
An issue often overseen is the rate of permanent
stomas. In our study, 43% ended up with a permanent
stoma, which is comparable to the findings in a registry-
based study which reported that in 44% of patients with
a colostomy after surgery for diverticulitis the colostomy
was not reversed [15]. Constantinides et al presented a
risk analysis for morbidity and mortality after sigmoid
resection with primary anastomosis or Hartman’s
proced ure and found, among other results, that 27% be-
came permanent stoma carriers after Hartman’s proced-
ure. They advocated a choice between primary resection
and anastomosis with a loop-ileostomy or Hartman’s
procedure, as primary resection with anastomosis with-
out a covering ileostomy entailed a higher risk [7]. The
rate of permanent stoma carriers may also be influenced
by cultural differences.
Recent years have seen several reports on laparo-
scopic lavage and drainage as the surgical choice for
Hinchey III, along with two prospective cohort studies,
which were all recently ‘‘meta-analysed’’ [16, 17].
Toorenvliet et al concluded that at present we only have
low-grade evidence for this ‘‘minimally invasive’’ alter-
native treatment [16]. However, the reported results are
such that if reproduced in a randomised trial, they rep-
resent an improvement of therapy, both in terms of
complications, number of operations and resource con-
sumption. A health technology assessment (HTA) per-
Dan Med Bul ϧϪ/ϣ Januar ϤϢϣϣ
TABLE 1
Male Female Total
n 51 55 106
Age, years
Mean ± standard deviation 58 ± 15.5 71 ± 12.4 –
Minimum 32 36 32
Maximum 88 98 98
Age of all included patients by gender.
Reoperations.
TABLE 2
Male Female Total
no yes total no yes total no yes total
n 22 29 51 38 17 55 60 46 106
% 43 57 100 69 31 100 53 47 100

Ϧ DANISH MEDICAL BULLETIN
formed by the HTA-unit of the Västra Götalands-regi on,
Sweden, concluded that the alternative treatment is in-
teresting and that prospective randomised trials are
needed [18]. A randomised trial called ‘‘DILALA’’ was re-
cently initiated with inclusion of patients from 14 hos-
pitals in Scandinavia. The aim of the trial is to compare
laparoscopic lavage with HP for perforated diverticulitis
Hinchey III.
In summary, this report confirms earlier reports
that perforated diverticulitis requiring emergency sur-
gery comprises a high-risk condition with prolonged con-
sequences for patients. In our hands, mortality was con-
siderable, but possibly somewhat lower than in many
previous reports. Any treatment that may hypothetically
reduce complications and the need for surgery and hos-
pital care should be considered candidates for a ran-
domised trial.
CORRESPONDENCE: Eva Haglind, SSORG/Göteborg, Department of Surgery,
Sahlgrenska University Hospital/Östra, 416 85 Göteborg, Sweden.
E-mail: eva.haglind@vgregion.se
ACCEPTED: 2 November 2010
CONFLICTS OF INTEREST: None
ACKNOWLEDGEMENTS: The authors wish to express their gratitude to An-
ders Rosemar, MD, and Göran Kurlberg, MD, for their interest and support.
The Scandinavian Surgical Outcomes Research Group has supported the work
and also the resulting protocol for a randomised trial of laparoscopic lavage as
a new treatment for perforated diverticulitis (DILALA). The work was sup-
ported by grants from Sahlgrenska University Hospital.
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