Diverticulitis with peritonitis - the Bern concept

Introduction: The colon is the most frequent origine for a diffuse peritoni tis and diverticular perforation is again the most common source of a spont aneous secondary peritonitis. This paper first focuses on the treatment of peritonitis and secondly on the strategies of source control in peritonitis with special emphasis on the tactics (primary anastomosis vs. Hartmann pro cedure with colostomy) for surgical source control. Patient and methods: Pr ospective analysis of 404 patients suffering from peritonitis (11/93-2/98), treated with an uniform treatment concept including early operation, sourc e control and extensive intraoperative lavage (20 to 30 liters) as a standa rd procedure. Other treatment measures were added in special indications "o n demand"only. Peritonitis was graded with the Mannheim Peritonitis Index ( MPI). Tactics of source control in peritonitis due to diverticulitis were p erformed according to"general condition" respectively the MPI of the patien t. Results: The 404 patients averaged a MPI of 19 (0-35) in "local" periton itis and a MPI of 26 (11-43) in "diffuse" peritonitis. The colon as a sourc e of peritonitis resulted in MPI of 16 (0-33) in the case of "local" respec tively 27 (11-43) in "diffuse" peritonitis. From 181 patients suffering fro m diverticulitis 144 needed an operation and in 78 (54 %) peritonitis was p resent, Fourty-six percent (36) of the patients suffered from "local": 54 % (42) from "diffuse" peritonitis. Resection with primary anastomosis was pe rformed in 26 % (20/78) whereas in 74 % (58/78) of the patients a Hartmann procedure with colostomy was performed. The correlating MPI was 16 (0-28) v s. 23 (16-27) respectively. The analysis of complications and mortality bas ed on the MPI showed a decent discrimination potential for primary anastomo sis vs Hartmann procedure: morbidity 35 % vs. 41 %; reoperation 5 % vs. 5 % mortality 0 % vs. 14 %. Conclusion: In case of peritonitis due to divertic ulitis the treatment of peritonitis comes first. Thanks to advances in inte nsive care and improved anti-inflammatory care, a more conservative surgica l concept nowadays is accepted. In the case of diverticulitis the MPI is he lpful to choose between primary anastomosis vs. Hartmann procedure with col ostomy as source control. The MPI includes the "general condition" of the p atient into the tactical decision how to attain source control.