Impact of primary resection on the outcome of patients with perforated diverticulitis

Background: Primary resection has replaced the conventional drainage procedure in the management of patients with generalized peritonitis complicating diverticular disease of the colon. This study investigates the impact of primary resection on operative mortality, identifies predictors of mortality, and compares the results with those of our earlier experience. Hypothesis: 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. Design: Retrospective analysis. Setting: Tertiary care referral center. Patients: We included 138 consecutive patients who underwent emergent operation for generalized peritonitis complicating diverticular disease of the colon (Hinchey stages 3 and 4) during a period of 16 years (January 1983 to May 1999). Main Outcome Measures: The 30-day mortality rate was analyzed and predictors of mortality identified. Results: Patients were classified as having spreading purulent peritonitis (n=44, 31.9%), diffuse peritonitis (n=64, 46.4%), or fecal peritonitis (n=30, 21.7%). One hundred thirty-one patients (94.9%) underwent primary resection, 6 patients (4.3%) underwent resection and primary anastomosis, and 1 patient required total colectomy and end ileostomy. Thirteen of the 138 patients in the present group died (1983-1998), representing a perioperative mortality rate of 9%. There was no significant difference in mortality when compared with our 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. Factors identified univariately as predictors of mortality were age of more than 70 years (P=.047), 2 or more comorbid conditions (P<.01), obstipation at initial examination (P=.02), use of steroids (P=.01), and perioperative sepsis (P<.001). Conclusions: 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. Because advanced age, comorbid conditions, and perioperative sepsis predict mortality, it is suggested that further reduction in mortality will require improvement in medical management of perioperative sepsis and comorbid conditions.