INTRODUCTION: Colonic perforative peritonitis (CPP) is a life-threatening surgical emergency where timely diagnosis is of ultimate impact on outcome.
MATERIALS AND METHODS: For a five-year period (2014 – 2018), 62 patients with CPP were treated in First Clinic of Surgery in St. George University Hospital - Plovdiv. Males were 48 (77.42%) and females 14 (22.58%), with a ratio of 3.4:1.
Patients’ age ranged from 14 to 92 years, with an average age of 71 years ± 2.4.
Colonic perforative peritonitis was more common in patients over 80 years of age (n=21; 33.87%). The main causes of CPP were: perforated colon diverticulitis (n=19), perforated colon cancer (n=18), perforation in incarceration (n=9), sigmoid volvulus (n=6), mesenteric ischemia (n=5) and miscellaneous (n=5). There were 12 patients with local peritonitis (19.36%), with diffuse peritonitis - 21 patients (33.87%), and with total peritonitis - 29 patients (46.77%). The following surgical procedures were performed: Hartmann’s procedure – 21, right hemicolectomy - 13, left hemicolectomy - 9, right hemicolectomy with ileostomy - 8, diverticulectomy - 7, colon excision and suture - 4.
RESULTS: Twenty-four patients (38.71%) were вith subacute perforation type (38.71%), while 38 (61.29%) were with acute type. Atypical clinical presentation with vague symptoms was found in 7 patients (11.29%). Early clinical symptoms in subacute and atypical forms of CPP were nonspecific. According to the elapsed time from the beginning of the perforation to the operation, the patients were divided as follows: up to the 6th hour - 24 (38.71%), from the 6th to the 12th hour - 19 (30.65%), from the 12th to the 24th hour - 12 (19.35%), and over 24 hours - 7 (11.29%). Of the total 62 operated patients with CPP, 49 patients (79.03%) survived. Postoperative mortality was 20.97% (n=13) with an average age of 78.9 years.
CONCLUSION:
Early diagnosis of colonic perforation can be difficult, due to omissions and inaccuracies on admittion and follow-up. The correct and timely diagnosis of CPP is crucial for prompt surgery, lower morbidity and mortality and better outcome.
Sartelli M, Chichom-Mefire A, Labricciosa FM, Hardcastle T, Abu-Zidan FM, Adesunkanmi AK, et al. The management of intraabdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017;12:29. doi: 10.1186/s13017-017-0141-6.
Hsu CW, Wang JH, Kung YH, Chang MC. What is the predictor of surgical mortality in adult colorectal perforation? The clinical characteristics and results of a multivariate logistic regression analysis. Surg Today. 2017;47(6):683–9. doi: 10.1007/s00595-016-1415-4.
Merkel S, Meyer C, Papadopoulos T, Meyer T, Hohenberger W. Urgent surgery in colon carcinoma. Zentralbl Chir. 2007;132(1):16-25. doi: 10.1055/s-2006-958708.
Hecker A, Schneck E, Rohring R, et al. The impact of early surgical intervention in free intestinal perforation: A time-to-intervention pilot study. World J Emerg Surg 2015;10:5.
Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB, et al. Clinical practice guidelines Committee of the American Society of Colon and Rectal Surgeons. Clinical practice guideline for the surgical management of Crohn's disease. Dis Colon Rectum. 2015;58(11):1021-36. doi: 10.1097/DCR.0000000000000450.
Hupfeld L, Burcharth J, Pommergaard HC, Rosenberg J. The best choice of treatment for acute colonic diverticulitis with purulent peritonitis is uncertain. Biomed Res Int. 2014;2014:380607. doi: 10.1155/2014/380607.
Neill JC Jr, Sparkman BK, Carroll JD. Perforated sigmoid diverticulitis resulting in subcutaneous abscess. Am Surg. 2018;84(8):275-6.
Andersen JC, Bundgaard L, Elbrønd H, Laurberg S, Walker LR, Støvring J, et al . Danish national guidelines for treatment of diverticular disease. Dan Med J. 2012;59(5):C4453.
von Rahden BH, Germer CT. Colonic diverticulosis and its complications: pathogenesis, classification and clinical implications. Zentralbl Chir. 2013;138(Suppl 2):81-5. doi: 10.1055/s-0032-1327844.
Illuminati G, Krizzuk D, Calio FG, Urciuoli P, Pizzardi G, Pasqua R. Laparoscopic lavage/drainage as a bridge treatment for perforated diverticulitis with purulent peritonitis associated with an abdominal aortic aneurysm A retrospective case-control study. Ann Ital Chir. 2019;90:258-63.
Reibetanz J, Germer CT. Percutaneous drainage alone as therapy of perforated sigmoid colon diverticulitis: critical comments. Chirurg. 2013;84(9):801. doi: 10.1007/s00104-013-2585-x.
Vermeulen J, Akkersdijk GP, Gosselink MP et all. Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Dig Surg. 2007;24(5):361-6. doi: 10.1159/000107719.
Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, et al. WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg. 2018; 13:36. doi: 10.1186/s13017-018-0192-3.
Yang XF, Pan K. Diagnosis and management of acute complications inpatients with colon cancer: bleeding, obstruction, and perforation. Chin J Cancer Res. 2014;26(3):331–40. doi: 10.3978/j.issn.1000-9604.2014.06.11.
lvarez JA, Baldonedo RF, Bear IG, Truan N, Pire G, Alvarez P. Presentation, treatment, and multivariate analysis of risk factors for obstructive and perforative colorectal carcinoma. Am J Surg. 2005;190(3):376-82. doI: 10.1016/j.amjsurg.2005.01.045.
Ansaloni L, Andersson RE, Bazzoli F, Catena F, Cennamo V, Di Saverio S, et al. Guidelines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society. World J Emerg Surg. 2010;5:29. doi: 10.1186/1749-7922-5-29.
Yeo ES, Ng KH, Eu KW. Perforated colorectal cancer: an important differential diagnosis in all presumed diverticular abscesses. Ann Acad Med Singapore. 2011;40(8):375-8.
Ohtsuka Y, Tsuchiya S, Shida T, Komatsu T. Delayed perforation of the sigmoid colon after endoscopic reduction of sigmoid volvulus. Acute Med Surg. 2014;2(3):207-10. doi: 10.1002/ams2.94.
McGregor DH, Liu X, Ulusarac O, Ponnuru KD, Schnepp SL. Colonic perforation resulting from ingested chicken bone revealing previously undiagnosed colonic adenocarcinoma: report of a case and review of literature. World J Surg Oncol. 2011;9:24. doi: 10.1186/1477-7819-9-24.
Mazuski J, Tessier J, May A, Sawyer R, Nadler E, Rosengart MR, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection, surgical infections. Surg Infect (Larchmt). 2017;18(1):1-76. doi: 10.1089/sur.2016.261.
Email this article (Login required) 
