The surgical management of purulent peritonitis from perforated diverticulitis

Oberkofler CE, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012 Nov; 256(5):819-26; discussion 826-7.

Full-text for Emory users.

Results: Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group.

Conclusions: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.


Thornell A, et al. Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial. Ann Intern Med. 2016 Feb 2;164(3):137-45.

Full-text for Emory users.

LL vs Hartmann

Continue reading

Sclerosing encapsulating peritonitis

One discussion this week involved small bowel obstruction and sclerosing encapsulating peritonitis (SEP).


Reference: Liberale G, Sugarbaker PH. Sclerosing encapsulating peritonitis as a potential complication of cytoreductive surgery and HIPEC: clinical features and results of treatment in 4 patients. Surgical Oncology. 2018 Dec;27(4):657-662.

Summary: Liberale and Sugarbaker (2018) define SEP as “a rare entity characterized by encapsulation of the small bowel and/or the colon by fibrous tissue forming a shell” (p.657). It is iatrogenic, idiopathic, or secondardy, and its pathophysiology is uncertain. The most common symptoms are abdominal pain, discomfort, and partial or complete obstruction.

In this article, the authors present 4 cases of SEP, all of which required additional surgery to alleviate recurrent episodes of small bowel obstruction.

In discussion, they provide some advice (p.661):

  • An adverse event to avoid is small bowel fistula following surgery.
  • The prevention of fistulization which results in enteric contamination of the peritoneal space is of utmost importance in reoperative surgery.
  • Careful marking of seromuscular tears and their repair prior to closing the abdomen is important.
  • A major problem that may occur in follow-up is the difficulty of distinguishing recurrence of peritoneal metastases from benign causes of bowel obstruction.

There are two types of SEP (p.661):

  • Type I: a fibrous membrane sheathing the bowel loops together without a clearly separated dissection plane. Surgery is challenging and the surgeon needs to open the plane between bowel loops while avoiding causing serosal tears.
  • Type II: a fibrous membrane forming an enterocele or ‘pseudocyst-like’ structure. These are easier to manage as, once the pouch is open, the small bowel can be dissected and separated easily from the surrounding sheath.