Table Of ContentSartellietal.WorldJournalofEmergencySurgery2013,8:3
http://www.wjes.org/content/8/1/3 WORLD JOURNAL OF
EMERGENCY SURGERY
REVIEW Open Access
2013 WSES guidelines for management of
intra-abdominal infections
Massimo Sartelli1*, Pierluigi Viale2, Fausto Catena3, Luca Ansaloni4, Ernest Moore5, Mark Malangoni6,
Frederick A Moore7, George Velmahos8, Raul Coimbra9, Rao Ivatury10, Andrew Peitzman11, Kaoru Koike12,
Ari Leppaniemi13, Walter Biffl5, Clay Cothren Burlew5, Zsolt J Balogh14, Ken Boffard15, Cino Bendinelli14,
Sanjay Gupta16, Yoram Kluger17, Ferdinando Agresta18, Salomone Di Saverio19, Imtiaz Wani20, Alex Escalona21,
Carlos Ordonez22, Gustavo P Fraga23, Gerson Alves Pereira Junior24, Miklosh Bala25, Yunfeng Cui26,
Sanjay Marwah27, Boris Sakakushev28, Victor Kong29, Noel Naidoo30, Adamu Ahmed31, Ashraf Abbas32,
Gianluca Guercioni33, Nereo Vettoretto34, Rafael Díaz-Nieto35, Ihor Gerych36, Cristian Tranà37, Mario Paulo Faro38,
Kuo-Ching Yuan39, Kenneth Yuh Yen Kok40, Alain Chichom Mefire41, Jae Gil Lee42, Suk-Kyung Hong43,
Wagih Ghnnam44, Boonying Siribumrungwong45, Norio Sato11, Kiyoshi Murata46, Takayuki Irahara47,
Federico Coccolini4, Helmut A Segovia Lohse48, Alfredo Verni49 and Tomohisa Shoko50
Abstract
Despite advances indiagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated
intra-abdominal infections remain exceedingly high.
The 2013 updateof the World Society ofEmergencySurgery (WSES) guidelines for themanagement of
intra-abdominal infections contains evidence-based recommendations for managementof patients with
intra-abdominal infections.
Introduction progress and worsen, and the underlying physiological
The clinical recommendations discussed in these guide- stabilityofthepatient.
lines are based on research conducted by members of The procedure used to treat the infection depends on
the WSES Expert Panel. These updated guidelines re- the anatomical site of infection, the degree of peritoneal
place those previously published in 2010 [1]. The guide- inflammation, the generalized septic response, the pa-
lines outline clinical recommendations based on the tient’s underlying condition, and the available resources
Grading of Recommendations Assessment, Development, of the treatment center. IAIs are subcategorized in 2
and Evaluation (GRADE) hierarchy criteria summarized groups:uncomplicated andcomplicated IAIs [5].
inTable1[2,3]. In the event of an uncomplicated case of IAI, the in-
fection involves a single organ and does not spread to
the peritoneum. Patients with such infections can be
Principlesofsurgicalmanagement
treated with either surgical intervention or antibiotics.
Intra-abdominal infections (IAIs) encompass a variety of
When the infection is effectively resolved by means of
pathological conditions, ranging from uncomplicated ap-
surgery, a 24-hour regimen of perioperative antibiotics is
pendicitistofecalperitonitis[4].
typically sufficient. Patients with uncomplicated intra-
As a general principle, every verified source of infec-
abdominal infections, such as acute diverticulitis, acute
tion should be controlled as soon as possible. The level
cholecystitis, and acute appendicitis, may be treated non-
of urgency of treatment is determined by the affected
operativelybymeansofantimicrobialtherapy.
organ(s), the relative speed at which clinical symptoms
In the event of complicated IAI, the infectious process
proceeds beyond a single organ, causing either loca-
*Correspondence:[email protected]
1DepartmentofSurgery,MacerataHospital,Macerata,Italy lized or diffuse peritonitis. The treatment of patients with
Fulllistofauthorinformationisavailableattheendofthearticle
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Table1GradingofrecommendationsfromGuyattandcolleagues[1,2]
Gradeofrecommendation Clarityofrisk/benefit Qualityofsupportingevidence Implications
1A
Strongrecommendation, Benefitsclearlyoutweighrisk RCTswithoutimportantlimitationsor Strongrecommendation,appliestomost
high-qualityevidence andburdens,orviceversa overwhelmingevidencefromobservational patientsinmostcircumstanceswithout
studies reservation
1B
Strongrecommendation, Benefitsclearlyoutweighrisk RCTswithimportantlimitations(inconsistent Strongrecommendation,appliestomost
moderate-qualityevidence andburdens,orviceversa results,methodologicalflaws,indirector patientsinmostcircumstanceswithout
imprecise)orexceptionallystrongevidence reservation
fromobservationalstudies
1C
Strongrecommendation, Benefitsclearlyoutweighrisk Observationalstudiesorcaseseries Strongrecommendationbasedonlimited
low-qualityorverylow- andburdens,orviceversa evidence;recommendationsmaychange
qualityevidence whenhigherqualityormoreextensive
evidencebecomesavailable
2A
Weakrecommendation, Benefitscloselybalancedwith RCTswithoutimportantlimitationsor Weakrecommendation,bestactionmay
high-qualityevidence risksandburdens overwhelmingevidencefromobservational differdependingoncircumstances,
studies expertiseofclinician,thepatientin
question,orothersocialissues
2B
Weakrecommendation, Benefitscloselybalancedwith RCTswithimportantlimitations(inconsistent Weakrecommendation,bestactionmay
moderate-qualityevidence risksandburdens results,methodologicalflaws,indirector differdependingoncircumstances,
imprecise)orexceptionallystrongevidence expertiseofclinician,thepatientin
fromobservationalstudies question,orothersocialissues
2C
Weakrecommendation, Uncertaintyintheestimates Observationalstudiesorcaseseries Veryweakrecommendation;other
Low-qualityorverylow- ofbenefits,risks,andburdens; alternativesmaybeequallyreasonable
qualityevidence benefits,risks,andburdens
maybecloselybalanced
complicatedintra-abdominalinfectionsinvolvesboth sur- severe sepsis representsthe diagnostic threshold separat-
gicalandantibiotictherapy[5]. ingstableandcriticalclinicalconditions.
The safety and efficacy of ultrasound- and CT-guided Thus, early detection of severe sepsis and prompt, ag-
percutaneous drainage of abdominal abscesses has been gressive treatment of the underlying organ dysfunction
documented in patients with appendiceal and diverticular isan essential componentofimprovingpatient outcome.
abscesses. Percutaneous image-guided drainage may also If untreated, sepsis dysfunction can lead to global tissue
beusedtoaddresscasesofadvancedacutecholecystitis. hypoxia, direct tissue damage, and ultimately to multiple
organfailure [8-10].
Sepsismanagement Sepsis in the surgical patient continues to be a com-
Patientswithseveresepsisorsepticshockofabdominal mon and potentially lethal problem. Early identification
originrequireearlyhemodynamicsupport,sourcecon- of patients and timely implementation of evidence-based
trol,andantimicrobialtherapy(Recommendation1A). therapies continue to represent significant clinical chal-
Abdominal sepsis occurs as result of intra-abdominal lengesforcareproviders.Theimplementationofasepsis
or retroperitoneal infection. Early detection of the site of screening program in conjunction with protocol for the
infection and timely therapeutic intervention are cru- delivery of evidence-based care and rapid source control
cial steps for improving the treatment outcome of sepsis can improve patientoutcomes[11].
patients. Early, correctly administered resuscitation can im-
Sepsis is a complex, multifactorial, evolutive syndrome prove the outcome of patients with severe sepsis and
thatcanprogress toconditionsof varying severity.Ifim- septic shock(Recommendation1A).
properly treated, it may cause the functional impairment Rivers et al. demonstrated that a strategy of early goal-
of one or more vital organs or systems, which could lead directed therapy (EGDT) decreases the in-hospital mor-
to multiple organ failure [6]. Previous studies have de- tality of patients admitted to the emergency department
monstrated that there is an increased risk of death as insepticshock[9].
patientstransitionfrom sepsistoseveresepsis andseptic In surgical patients early intervention and implemen-
shock [7]. In the context of intra-abdominal infections, tation of evidence-based guidelines for the management
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of severe sepsis and septic shock improve outcomes in prevention of acute renal failure was not justified on the
patientswith sepsis[12]. basisofavailable evidence.
Patients with severe sepsis and septic shock may pre- Norepinephrine is a potent alpha-adrenergic agonist
sent with inadequate perfusion. Poor tissue perfusion can with minimal beta-adrenergic agonist effects. Norepine-
leadtoglobaltissuehypoxiaand,inturn,toelevatedlevels phrine can successfully increase blood pressure in pa-
of serum lactate. Fluid resuscitation should be initiated as tients who are septic and remain hypotensive following
earlyaspossibleinpatientswithseveresepsis. fluid resuscitation. Norepinephrine is effective to treat
The Surviving Sepsis Campaign guidelines [10] re- hypotension in septic shock patients. In many studies
commend that fluid challenge in patients with suspected norepinephrine administration at doses 0.01 to 0.3 μg/
hypovolemia begin with >1000 mL of crystalloids or kg/min hasbeenshownmaybeeffective[16,17].
300–500 mL of colloids administered over a period of Martin and coll. [18] published a randomized trial
30 minutes. Quicker administration and greater volumes comparing norepinephrine vs dopamine. 32 volume-re-
of fluid may be required for patients with sepsis-induced suscitated septic patients were given either dopamine or
tissue hypoperfusion. Given that the volume of distri- norepinephrine to achieve and maintain normal hemo-
bution is smaller for colloids than it is for crystal- dynamicandoxygentransportparametersforatleast6h.
loids, colloid-mediated resuscitation requires less fluid Dopamine administration was successful in only 31% of
to achieve the same results. A colloid equivalent is an patients, whereas norepinephrine administration was suc-
acceptable alternative to crystalloid, though it should cessful in93%.Ofthe11patientswhodidnotrespondto
be noted that crystalloids are typically less expensive. dopamine, 10responded whennorepinephrinewasadded
When fluid challenge fails to restore adequate arterial to therapy. Serum lactate levels were decreased as well,
pressure and organ perfusion, clinicians should resort to suggesting that norepinephrine therapy improved tissue
vasopressor agents. Vasopressor drugs maintain adequate oxygenation.
blood pressure and preserve perfusion pressure, thereby Recently a prospective trial by Patel and coll. com-
optimizingbloodflowinvariousorgans. pared dopamine to norepinephrine as the initial vaso-
Both norepinephrine and dopamine are the first-line pressor in fluid resuscitated 252 adult patients with
vasopressoragentstocorrecthypotensioninsepticshock. septic shock [19]. If the maximum dose of the initial
Both norepinephrine and dopamine can increase blood vasopressor was unable to maintain the hemodynamic
pressure in shock states, although norepinephrine seems goal,thenfixeddose vasopressinwasaddedtoeachregi-
tobemorepowerful.Dopaminemaybeusefulinpatients men. If additional vasopressor support was needed to
with compromised cardiac function and cardiac reserve achieve the hemodynamic goal, then phenylephrine was
[13], but norepinephrine is more effective than dopami- added. In this study dopamine and norepinephrine were
ne in reversing hypotension in patients with septic shock. equally effective as initial agents as judged by 28-day
Dopamine has also potentially detrimental effects on the mortality rates. However, there were significantly more
release of pituitary hormones and especially prolactin, cardiacarrhythmiaswithdopamine treatment.
although the clinical relevance of these effects is still The Surviving Sepsis Campaign guidelines [10] state
unclear and can have unintended effects such as tachyar- that there is no sufficient evidence to suggest which
rhythmias. Dopamine has different effects based on the agent is better as initial vasopressor in the management
doses[14]. ofpatientswithseptic shock.
A dose of less than 5 μg/kg/min results in vasodilation Phenylephrine is a selective alpha-1 adrenergic receptor
of renal, mesenteric, and coronary districts. At a dose of agonist primarily used in anesthesia to increase blood
5–10 μg/kg/min, beta-1-adrenergic effects increase car- pressure.Althoughstudiesarelimited[20],itsrapidonset,
diac contractility and heart rate. At doses about 10 μg/ short duration, and primary vascular effects make it an
kg/min,alpha-adrenergic effectslead to arterial vasocon- important agent in the management of sepsis-associated
striction and increase blood pressure. Its major side hypotension; however, it should be noted that there are
effectsaretachycardia andarrhythmogenesis. concerns regarding its potential to reduce cardiac output
Theuseofrenal-dosedopamineinsepsisisacontrover- incertainpatients.
sial issue. In the past, low-dose dopamine was routinely Epinephrine is a potent α-adrenergic and β-adrenergic
used because of the possible renal protective effects. Do- agent that increases mean arterial pressure by increasing
pamine at a dose of 2–3 μg/kg/min was known to stimu- both cardiac index and peripheral vascular tone. The pri-
latediuresisbyincreasingrenalbloodflow. mary concern regarding the use of epinephrine in septic
A meta-analysis of literature from 1966 to 2000 for patients is its potential to decrease regional blood flow,
studiesaddressingtheuseofdopamineintheprevention particularlyinthesplanchniccirculation[21].
and/or treatment of renal dysfunction [15] concluded Vasopressin infusion of 0.01 to 0.04 U/min in patients
that the use of low-dose dopamine for the treatment or with septic shock increases plasma vasopressin levels to
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those observed in patients with hypotension attributable Initially,thepainmaybedullandpoorlylocalized(vis-
to other etiologies, such as cardiogenic shock. Increased ceral peritoneum) before progressing to steady, severe,
vasopressin levels are associated with a reduced demand andmore localizedpain(parietal peritoneum).
for other vasopressors. Urinary outputmay increase, and Signs of hypotension and hypoperfusion such as lactic
pulmonary vascular resistance may decrease. Infusions acidosis, oliguria, and acute alteration of mental status
>0.04 U/min may lead to adverse, vasoconstriction-me- areindicativeofapatient’stransitiontoseveresepsis.
diatedevents[22].Lowdosesof vasopressin(0.03U/min) Diffuse abdominal rigidity suggests peritonitis and
may be effective in raising blood pressure in patients re- should be addressed promptly by means of aggressive
fractory to other vasopressors and may convey other resuscitation and surgical intervention.
therapeuticbenefits. Plain films of the abdomen are often the first ima-
Dobutamine is frequently used to treat septic shock ging analyses obtained for patients presenting with intra-
patients as an inotropic agent that increases cardiac out- abdominalinfections.
put, stroke index, and oxygen delivery (Do ). However, Upright films are useful for identifying free air beneath
2
the tendency of dobutamine to increase Do to supra- the diaphragm (most often on the right side) as an indi-
2
normal values in critically ill patients has raised serious cation ofperforatedviscera.
questions regarding its saftey in the treatment of septic The diagnostic approach to confirming the source of
shock. The Surviving Sepsis Campaign Guidelines [10] abdominal infection in septic patients depends largely on
recommend that a dobutamine infusion be administered thehemodynamicstabilityofthepatient[24].
in the event of myocardial dysfunction as indicated by For unstable patients who do not undergo an im-
elevatedcardiacfillingpressures andlowcardiac output mediatelaparotomyandwhosecriticalconditionpre-
Theclinicalbenefitsofcorticosteroidsinthetreatment vents them from leaving the ICU for further imaging
ofseveresepsis andsepticshockremaincontroversial. analysis, ultrasound is the best available imaging mo-
A systematic review of corticosteroids in the treatment dality (Recommendation1B).
of severe sepsis and septic shock in adult patients was For stable, adult patients who do not undergo an
recently published in which the authors discussed 17 immediate laparotomy, computerized tomography
randomized trials (2138 patients) and 3 quasi-rando- (CT) is the imaging modality of choice for diag-
mized trials (n=246) of acceptable methodological qual- nosing intra-abdominal infections. In children and
ity and pooled the results in a subsequent meta-analysis young adults,exposure to CT radiation isof particu-
[23]. The authors concluded that corticosteroid therapy lar concern and must be taken into consideration
has been used in varied doses for treating sepsis and (Recommendation1B).
related syndromes for more than 50 years, but its ability When patients are stable, computerized tomography
to reduce mortality rates has never been conclusively (CT) is the optimal imaging modality for assessing most
proven. Since 1998, studies have consistently used pro- intra-abdominalconditions [24,25].
longed low-dose corticosteroid therapy, and follow-up When possible, computed tomography (CT) of the ab-
analyses of this subgroup have found that such regimens domen and pelvis is the most effective means of diag-
tendtoreduce short-term mortality. nosing intra-abdominalinfections.
According to the findings of the meta-analysis, corti- The value of both CT imaging and ultrasound in the
costeroids should be considered at daily doses of 200– diagnostic work-up of intra-abdominal infections has
300 mg of hydrocortisone (or equivalent), administered been comprehensively studied in the context of acute
as either an intravenous bolus or continuous infusion. appendicitis.
Although the evidence supporting this claim was not In 2006, a meta-analysis by Doria et al. demonstrated
particularly robust, the authors nevertheless suggested that CT imaging featured significantly higher sensitivity
that treatment be administered at full dosage for at least and resolution than ultrasound in studies of both chil-
100 hours in adult patients presenting with vasopressor- drenandadultswithacute appendicitis [26].
dependent septicshock. However, when examining children and young adults,
clinicians must always take into account the risk of radi-
Diagnosis ationexposure associatedwith CT.
Early diagnosis and prompt treatment of intra- Although CTscans are very useful in a clinical setting,
abdominal infections can minimize complications children are more radiosensitive than adults and their
(Recommendation 1C). exposuretoionizingradiation shouldbeminimized[27].
Detection of complicated intra-abdominal infections is Recently, a single-blind, noninferiority trial, evaluated
primarilyaclinicaldiagnosis.However,criticallyillpatients the rate of negative (unnecessary) appendectomies fol-
may be difficult to evaluate due to distracting injuries, re- lowing low-dose and standard-dose abdominal CTs in
spiratoryfailure,obtundation,orothercomorbidities. young adults with suspected appendicitis. Low-dose CTs
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were noninferior to standard-dose CTs with respect to results of laparoscopic and conventional open surgery
negative appendectomy rates in young adults with sus- [32]. 56 studies comparing laparoscopic appendectomies
pected appendicitis [18]. However low-dose CTs could (with or without diagnostic laparoscopy) to open ap-
not detect perforated viscera as effectively as their stan- pendectomies for adult patients were included in the
dard-dosecounterparts. meta-analysis. Wound infections were less likely fol-
When CTand abdominal ultrasound are not available lowinga laparoscopic appendectomy(LA)thanthey were
diagnostic options, diagnostic peritoneal lavage may be following an open appendectomy (OA), but the laparo-
usefulfor thediagnosis ofcomplicatedIAIs [24]. scopic procedure showed an increased prevalence of
intra-abdominal abscesses. The duration of surgery was
Acuteappendicitis onaverage10minuteslongerforLAsthatitwasforopen
The appendectomy remains the treatment of choice procedures. Compared to OAs, LAs typically resulted in
for acute appendicitis. Antibiotic therapy is a safe less post-operative pain; on day 1 after surgery, patients
means of primary treatment for patients with un- who underwent a laparoscopic procedure reported
complicated acute appendicitis, but this conservative reducedpainby8mmona100mmvisualanaloguescale
approach is less effective in the long-term due to sig- compared to patients who had undergone the open pro-
nificantrecurrence rates.(Recommendation 1A). cedure. Further, the overall hospital stay was reduced for
Although the standard treatment for acute appen- patients who underwent LAs compared to those who
dicitis has historically been the appendectomy, the me- underwent OAs. While the operational costs of LAs were
dical community has recently seen a notable increase significantly higher, the costs associated with recovery
in the use of antibiotic therapy as a primary means of were substantially reduced. 7 studies of children were in-
treatment. cluded in the review, but the results did not differ sig-
Several meta-analyses have been published overviewing nificantly from those of similar adult-focused studies.
a series of randomized trials comparingantibiotictherapy Diagnostic laparoscopy reduced the risk of unnecessary
to appendectomies for acute uncomplicated appendicitis appendectomies, though this trend was most common in
(caseswithoutabscessesorphlegmon)[28-31]. fertilewomenascomparedtounselectedadults[33].
Althoughnon-operative,antibioitic-mediatedtreatments However, in many cases the strong predictive power of
of uncomplicated appendicitis are associated with signifi- CTand ultrasound analysis renders the diagnostic lapar-
cantlyfewercomplications,moremanageablepaincontrol, oscopyclinicallysuperfluous.
and shorter patient sick leave, this conservative approach In 2011, Masoomi et al. used the Nationwide Inpatient
features high rates of recurrence and is therefore inferior Sample Database to evaluate the clinical data of adult
tothetraditionalappendectomy. patients in the United States who had undergone either
Considering that only a small number of RCTs of poor LAs or OAs for suspected acute appendicitis from 2006
methodological quality are currently available, well-de- to2008[34].
signedRCTsarerequiredtobetterassesstheeffectsofan A total of 573,244 adults underwent emergency ap-
antibiotic-based approach in conservative treatments of pendectomies during this 3-year period. Overall, 65.2%
uncomplicatedacuteappendicitis. of all appendectomies were performed laparoscopically.
Given this controversy, the appendectomy remains Use of the laparoscopic approach increased 23.7% from
the treatment of choice for acute appendicitis. Non- 58.2% in 2006 to 72% in 2008. In the context of acute
operative antibiotic treatment may be used as an alterna- non-perforated appendicitis, LAs featured lower overall
tive treatment for specific patients for whom surgery is complication rates, lower in-hospital mortality rates, and
contraindicated. a shorter mean length of hospitalization compared to
Both open and laparoscopic appendectomies are vi- theopenprocedure.
able approachestosurgicaltreatmentofacute appen- Routine use of intraoperative irrigation for appen-
dicitis(Recommendation 1A). dectomies does not prevent intra-abdominal abscess
Several randomized trials have compared the diagnos- formation, adds extra costs, and may be avoided
tic and therapeutic advantages of laparoscopic and con- (Recommendation 2B).
ventional open appendectomies in the treatment of acute Recently a retrospective review of 176 consecutive ap-
appendicitis. pendectomies, open (39%) and laparoscopic (61%), at a
Whilethe trials demonstrated areductionin wound in- university affiliated tertiary care facility from July 2007
fections for the laparoscopic appendectomy group, they to November 2008 investigated routine use of intraope-
also exhibited a threefold increase in intra-abdominal rative irrigation for appendectomies. The results did not
abscesses. show decrease in postoperative intra-abdominal abscess
In2010,Sauerlandetal.updatedapreviouslypublished with use of intraoperative irrigation. Thirteen patients
meta-analysis comparing the diagnostic and therapeutic developed postoperative abscess: 11 with irrigation, two
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without irrigation. Ten of 13 patients who developed ab- instead demonstrate that the procedure is unnecessary
scess were perforated; nine with irrigation and one with- in 75%-90% of cases [40-42]. The results of a review by
out [35]. Andersonn and Petzold [41] based primarily on retro-
Patients with periappendiceal abscesses should be spective studies supported the practice of nonsurgical
treated with percutaneous image-guided drainage. treatment without interval appendectomies in patients
(Recommendation 1B). with appendiceal abscesses or phlegmon. Appendiceal
Current evidence demonstrates that an interval abscesses or phlegmon were found in 3.8% of patients
appendectomy is not routinely necessary following with appendicitis. Nonsurgical treatment failed in 7.2%
initial non-operative treatment of complicated ap- of these cases, and abscess drainage was required in
pendicitis. However, interval appendicectomies should 19.7%. Immediate surgery was associated with higher
alwaysbeperformedforpatientswithrecurrentsymp- morbidity rates compared to nonsurgical treatment. Af-
toms(Recommendation2B). ter successful nonsurgical treatments, malignancy and
For patients with acute appendicitis presenting with serious benign diseases were detected in 1.2% and 0.7%
abscesses,theoptimalmanagement strategy issomewhat ofcases,respectively,during follow-upanalyses.
controversial. Following successful conservative treatment, interval
Percutaneous drainage to address periappendiceal abs- appendicectomies were only performed for patients with
cesses results in fewer complications and shorter overall recurrent symptoms. In patients over 40 years of age,
hospitalization[36-38]. other pathological causes of right iliac masses could be
In 2010, a meta-analysis was published comparing con- excluded by means of further investigation (colonoscopy
servativetreatment(i.e.,antibiotictherapy+/−percutante- andcomputerized tomographyscans).
ousabscessdrainage)toappendectomiesinthetreatment Studies investigatinginterval appendectomies after con-
of complicated appendicitis (cases exhibiting abscesses or servative treatment of appendiceal masses are typically
phlegmon)[39]. retrospective in nature. The risk of recurrence of symp-
17 studies (16 non-randomized/retrospective and 1 toms is only 7.2%, which suggests that appendectomies
non-randomized/prospective) reported clinical data for may not be routinely necessary [29]. Due to significant
1572 patients: 847 patients received conservative treat- variabilitybetweenstudiesandtheirretrospectivenatures,
ment and 725 underwent acute appendectomies. Con- additionalstudiesareneededtoconfirmthesefindings.
servative treatment was associated with significantly
fewer complications, wound infections, abdominal/pelvic
abscesses, ileal/bowel obstructions, and additional follow- Diverticulitis
up surgeries. No significant differences were found in the Patients with uncomplicated acute diverticulitis
overall length of hospitalization or in the duration of should be treated with antibiotic therapy to address
intravenous antibiotic infusion. Overall, several clinical gram-negative and anaerobic pathogens (Recommen-
studies demonstrated that there were significantly fewer dation2C).
complications in the conservative treatment group than The routine use of antibiotics for patients with un-
therewereintheappendectomygroup. complicated acute diverticulitis is a point of controversy
The authors concluded that conservative treatment inthemedical community.
of complicated appendicitis was associated with decrea- In 2011, a systematic review was published overview-
sed complication rates and fewer repeat surgeries (“re- ing antibiotic use in cases of uncomplicated diverticulitis
operations”) compared to traditional appendectomies, [43]. Relevant data regarding the use of antibiotics in
while both treatments featured comparable lengths of mild or uncomplicated cases of diverticulitis were sparse
hospitalization. and of poor methodological quality. There was no con-
Traditional management is initially conservative fol- crete evidence to support the routine use of antibiotics
lowed by interval appendectomies performed after reso- inthetreatment ofuncomplicateddiverticulitis.
lution ofthemass. Recently a prospective, multicenter, randomized trial
Recently, the efficacy of interval appendicectomies has involving 10 surgical departments in Sweden and 1 in
been called into question, and there is disagreement in Iceland investigated the use of antibiotic treatment in
the medical community regarding whether or not the cases of acute uncomplicated diverticulitis. Antibiotic
procedure is appropriate for adults with appendiceal treatment for acute uncomplicated diverticulitis neither
abscesses. The main dispute involves the recurrence and accelerated recovery nor prevented complications or re-
complication rates following interval appendectomies as currence[44].
well as the procedure’s ability to address underlying ma- However, even in the absence of evidence support-
lignancy. The literature provides little evidence that an ing the routine use of antibiotics for patients with un-
interval appendicectomy is routinely necessary; findings complicated acute diverticulitis, we recommend adequate
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antimicrobial coverage for gram-negative and anaerobic were resolved with conservative treatment, such an inva-
microorganisms. sive procedure following a favorable response to nonin-
Mild cases ofuncomplicated acute diverticulitis should vasive methods has serious implications and should be
be treated in an outpatient setting. Outpatient treatment madeonanindividualbasis[52-55].
of uncomplicated acute diverticulitis depends on the Acute diverticulitis has a low rate of recurrence and
condition and compliance of the patient as well as his or rarely progresses to more serious complications, and as
her availability for follow-up analysis. The treatment such, elective surgery to prevent recurrence and develop-
involves orally administered antibiotics to combat gram- mentoffurthercomplicationsshouldbeusedsparingly.
negative and anaerobic bacteria. If symptoms persist or To investigate recurrence rates and post-operative
worsen, the patient should be admitted for more aggres- complications following conservatively managed diver-
sive inpatient treatment. ticulitis, Eglinton et al. retrospectively analyzed clinical
Hospitalized patients with uncomplicated acute diver- datafromallpatientswithdiverticulitisadmittedtotheir
ticulitis should be treated with intravenous fluids and department from 1997 to 2002 [56]. After an initial epi-
antibioticinfusion. sode of uncomplicated diverticulitis, only 5% of patients
The clinical value of antibiotics in the treatment of went on to develop the complicated form of the disease.
acuteuncomplicatedleft-sideddiverticulitisispoorlyun- Complicated diverticulitis recurred in 24% of patients,
derstood by the medical community and therefore me- compared to a recurrence rate of 23.4% in those with
ritsfurtherstudy. uncomplicated diverticulitis. Recurrence typically occur-
The grade and stage of diverticulitis are determined by redwithin12monthsoftheinitialepisode.
clinical severity and Hinchey classification of disease, Recently, Makela et al. published a review of 977 pa-
and used to identify patents likely to fail medical man- tients admitted for acute diverticulitis during a 20-year
agement or require surgery. Hinchey's classification pro- period [57]. The authors found that even with 2 or more
vides a means of consistent classification of severity of previous admissions for acute diverticulitis, sigmoid re-
disease for clinical description and decision making. Per- sectionremainedunjustifiablyexcessive.
foration with operative findings of purulent peritonitis Elective surgery is recommended for patients with
correspondstoHincheystageIII,andfeculentperitonitis pelvic abscesses treated by means of percutaneous
to Hinchey stage IV. Stage I and Stage II refer to inflam- drainage due to the poor long-term outcomes of
matory phlegmonandparacolicabscesses[45]. conservative treatment. However, minor mesocolic
Systemic antibiotic treatment alone is usually the abscesses that typically resolve when treated con-
most appropriate treatment for patients with small servatively are not always grounds for surgical inter-
(<4 cm in diameter) diverticular abscesses; image- vention(Recommendation1B).
guided (ultrasound- or CT-guided) percutaneous drai- Given the poor outcomes of pelvic abscesses asso-
nage is suggested for patients with large diverticular ciated with acute left-sided colonic diverticulitis, percu-
abscesses(>4cmindiameter)(Recommendation2B). taneous drainage followed by secondary colectomy is
For patients with diverticulitis complicated by peridi- recommended [58].
verticular abscesses, the size of an abscess is an import- In the event of a colectomy performed to address
ant factor in determining the proper course of action diverticular disease, a laparoscopic approach is ap-
and in deciding whether or not percutaneous drainage is propriatefor selectpatients(Recommendation 1B).
theoptimalapproach [46]. Laparoscopic colectomies may have some advanta-
Patients with small pericolicabscesses(<4cmindiam- ges over open colectomies, including less post-operative
eter)withoutgeneralizedperitonitis(HincheyStage1)can pain,fewercosmeticconsiderations,andashorteraverage
be treated conservatively with bowel rest and broad- lengthof hospitalization.However,thereappearstobeno
spectrumantibiotics[47]. significant difference in early or late complication rates
For patients with peridiverticular abscesses larger than betweenthelaparoscopicandopenprocedures[59,60].
4cmindiameter,observationalstudies indicatethatCT- The cost and outcome of the laparoscopic approach
guided percutaneous drainage is the treatment of choice areboth comparable tothose oftheopenresection[61].
[48-51]. Laparoscopic surgery is recommended for elderly pa-
Recommendations for elective sigmoid colectomy tients [62] and appears to be safe for select patients with
following recovery from acute diverticulitis should be complicated diverticulitis [63].
made onacase-by-case basis(Recommendation1C). Emergency surgery is required for patients with
Theroleofprophylacticsurgeryfollowingconservatively acute diverticulitis associated with diffuse peritonitis
manageddiverticulitisremainsunclearandcontroversial. as well as for patients with acute diverticulitis whose
Although elective resection is often recommended af- initial non-operative management has failed (Recom-
ter single episodes of complicated acute diverticulits that mendation1B).
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Hartmann’s resection is recommended in the event of from 2002 to 2007 in the United States. A total of
severe acute diverticulitis with generalized, purulent, or 99,259 patients underwent urgent surgery for acute di-
fecal peritonitis as well as for patients with poor prog- verticulitis during these years [Primary anastomosis with-
nostic criteria. In the event of diffuse peritonitis, resec- out diversion: 39.3%; Hartman's procedure (HP): 57.3%
tion with primary anastomosis and peritoneal lavage is a and primary anastomosis with proximal diversion (PAD):
suitable approach for patients with promising prognostic 3.4%].TheoverallcomplicationratewaslowerinthePAD
criteria or for those whose non-operative management groupcomparedwiththeHPgroup(PAD:39.06%vs.HP:
ofacute diverticulitis hasfailed. 40.84%; p=0.04). Patients in the HP group had a shorter
Hartmann’s procedure has historically been the stand- mean length of stay (12.5 vs.14.4 days, p<0.001) and
ardtreatmentfor complicated acute diverticulitis [64]. lower mean hospital costs (USD 65,037 vs. USD 73,440,
However, bowel reconstruction following Hartmann’s p<0.01) compared with the PAD group. Mortality was
procedure requires additional surgeries, which many pa- higherintheHPgroup(4.82vs.3.99%,p=0.03).
tients cannot undergo due to complicated medical con- PAD improved outcomes compared with HP, and
ditions; therefore, many of these patients remain with should be considered in patients who are deemed candi-
permanent stoma [65]. datesfortwo-stageoperationsforacutediverticulitis.
The optimal approach for treating left colonic per- Laparoscopic peritoneal lavage with placement of
foration is a one-stage procedure involving primary drainage tubes is a safe approach for cases of perfo-
anastomosis. rateddiverticulitis(Recommendation 2B).
In an emergency setting, intraoperative lavage of the Several case series and prospective studies have de-
colon and primary anastomosis are safe procedures for monstrated that laparoscopic peritoneal lavage is a safe
addressing complicated diverticulitis, though Hartmann’s alternative to conventional management in the treat-
procedureisstillrecommendedforcasesofdiffuseorfe- ment of perforated diverticulitis with diffuse purulent
cal peritonitis, immunocompromised patients, or patients peritonitis[76-79].
experiencingsepticshockandmultiorganfailure[66]. Recently aretrospective population studyused anIrish
Many studies have demonstrated that, for select pa- national database to identify patients acutely admitted
tients, primary anastamosis can be safely performed in with diverticulitis, was published. Demographics, proce-
thepresenceoflocalizedordiffuse peritonitis[67]. dures, comorbidities, and outcomes were obtained for
Primary anastomosis is not recommended for patients theyears1995 to2008[80].
inhigh-risk categories [67-73]. Two thousand four hundred fifty-five patients under-
In 2010,Tabbara et al. reviewed the medical records of went surgery for diverticulitis, of whom 427 underwent
194 patients with complicated acute diverticulitis from laparoscopic lavage. Patients selected for laparoscopic
1996 to 2006 who required a colectomy within 48 hours lavage had lower mortality (4.0% vs 10.4%, p<0.001),
of hospitaladmission [74]. complications (14.1% vs 25.0%, p<0.001), and length of
The independent criteria predictive of eventual resec- stay (10 days vs 20 days, p<0.001) than those requiring
tion with primary anastomosis included the following: laparotomy/resection. Patients older than 65 years were
age less than 55 years, period between hospital admission more likely to die (OR 4.1, p<0.001), as were those with
and surgery lasting longer than 4 hours, and a Hinchey connective tissue disease (OR 7.3, p<0.05) or chronic
scoreofIorII. kidneydisease(OR 8.0,p<0.001).
There were patients featuring many of these indicators
of primary anastomosis who instead underwent fecal di- Coloniccarcinomaperforation
version. The conditions and characteristics of these Patients with perforated colonic carcinoma represent the
patients were comparable to those of the primary anasto- highest riskcasesofcolonicperforation [81].
mosis patients, yet the former group experienced poorer Treatments for perforated colonic carcinoma should
clinicaloutcomesthanthelatter. both stabilize the emergency condition of the perito-
In the event of either intraoperative difficulty or extra- nitis and fulfil the technical objectives of oncological
peritonealanastomosis, a diverting loop ileostomyfollow- intervention(Recommendation1B).
ingresectionandprimaryanastomosis ,maysuggestedfor Treating perforated colorectal cancer is a complicated
high-riskpatientswhoarehemodynamicallystable;inthis procedure and the prognosis is rarely straightforward.
case, high risk is defined by immunosuppression, fecal Colorectal cancer-induced perforation is considered an
peritonitis,and/orASAgradeIV[71]. advanced stage disease due to the potential for periton-
Masoomi et al. [75] using the National Inpatient Sam- eal dissemination of tumor cells throughout the site of
ple database, examined the clinical data of patients who perforation[82].
underwent an urgent open colorectal resection (sigmoi- Thestage ofillness,proximity oftheperforationtothe
dectomy or anterior resection) for acute diverticulitis tumor, and the number of metastatic lymph nodes are
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positively correlated with reduced procedural and cancer- arerecommendedtoimprovetheprognosisofpatients
freesurvivalrates[83]. presentingwithHVIs(Recommendation1C).
Hartmann's procedure has been widely accepted as an Hollow Viscus Injuries (HVIs) are associated with sig-
effective means of treating carcinoma of the left colon nificant rates of morbidity and mortality. HVIs can oc-
(with adequate R0 resection) in certain emergency sce- cur by means of penetrating injury or blunt trauma, but
narios [84]. they are less common in patients who have experienced
A diverting ileostomy is recommended when anasto- blunt trauma than they are in those who have suffered a
mosis isperformedfor high-riskpatients. penetrating injury. In patients who have experienced
blunt trauma, an accurate and timely diagnosis is often a
Colonicperforationfollowingcolonoscopy difficultundertaking.
Early detection and prompt treatment are essential Several mechanisms of bowel injury have been docu-
in optimizing the treatment of colonic post-colonos- mented in the wake of blunt abdominal trauma. The
copy perforations. Patients presenting with such most common injury is the posterior crushing of the
perforationsshouldundergoimmediatesurgical inter- bowel segment between the seat belt and vertebra or
vention, which typically involves primary repair or re- pelvis. It results in local lacerations of the bowel wall,
section(Recommendation1B). mural and mesenteric hematomas, transection of the
Recently, the frequency of colonic perforation has in- bowel, localized devascularization, and full-thickness con-
creased due to routinely performed advanced therapeu- tusions. Devitalization of the areas of contusion may sub-
ticendoscopy. sequentlyresultinlateperforation.
Over the last decade, many advancements have been An important determinant of morbidity in patients
streamlined to better address these perforations, yet there with HVIs appears to bethe interim time between injury
are nodefinitive guidelines for their optimal management and surgery. Only expeditious evaluation and prompt
[85]. surgical action can improve the prognosis of these pa-
Choosing a conservative or surgical approach depends tients[96].
onavarietyofclinical factors[86]. Older age, elevated Abdominal Abbreviated Injury
Conservative management is typically used to treat Scores, significant extra-abdominal injuries, and delays
patients in stable clinical condition without any signs of exceeding 5 hours between admission and laparotomy
peritonitis. In published literature, fewer than 20% of were identified as significant risk factors predictive of
patients with colonoscopy-related perforations were suc- patientmortality [97].
cessfully treated withanon-surgicalapproach[87-89]. Colonic non-destructive injuries should be primar-
Although select patients may be responsive to non- ily repaired. Although Delayed Anastomosis (DA) is
operative therapy, most cases warrant prompt surgical suggested for patients with Destructive Colon In-
intervention to minimize the extent of intraperitoneal juries (DCI) who must undergo a Damage Control
contamination, thereby facilitating a single-step proced- Laparotomy (CDL), this strategy is not suggested for
ure that will likely reduce post-operative complications highriskpatients(Recommendation2C).
[88]. Management pathway of colonic injury has been
Further, timely intervention (shortened timeframe bet- evolving over last three decades. There has been gen-
ween perforation and treatment) results in improved pa- eral agreement that injury location does not affect the
tient outcome[90-92]. outcome.
An early laparoscopic approach is a safe and effec- SharpandColl.stratified469consecutivepatientswith
tive treatment for colonoscopy-related colonic perfo- full thickness penetrating colon injuries for 13 years
ration(Recommendation1C). by age, injury location and mechanism, and severity
Laparoscopic surgery is a prudent compromise that of shock.
minimizes the risks of invasive surgery as well as those 314 (67%) patients underwent primary repair and 155
ofinsufficientlyaggressivenon-operativetherapy[93,94]. (33%) underwent resection. Most injuries involved the
If the area of perforation cannot be localized laparo- transverse colon (39%), followed by the ascending colon
scopically, the surgeon should begin with a laparotomy (26%), the descending colon (21%), and the sigmoid
before proceeding further [95]. colon (14%). Overall, there were 13 suture line failures
(3%) and 72 abscesses (15%). Most suture line failures
Post-traumaticbowelinjuries involved injuries to the descending colon (p=0.06),
The time between incidence and surgery is a signifi- whereasmostabscessesfollowedinjuriestotheascending
cantdeterminantofmorbidityinpatientswithinjuries colon (p=0.37). Injury location did not affect morbidity
to visceral lumens (Hollow Viscus Injuries, HVIs). An ormortalityafterpenetratingcoloninjuries.Fordestructive
expeditiousdiagnosisandpromptsurgicalintervention injuries, operative decisions based on a defined algorithm
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rather than injury location achieved an acceptably low died before definitive repair. Sixty-one patients suffered
morbidity and mortality rate and simplifies management intra-abdominal complications: 35 (17%) abscesses, 15
[98]. (7%) leaks, and 11 (5%) enterocutaneous fistulas. The
Colon injuries in the context of a Damage Control majority of patients with leaks had a delayed anasto-
Laparotomy (DCL) are associated with high complica- mosis. Leak rate increased as one progresses toward the
tion rates and an increased incidence of leakage [99]. left colon (small bowel anastomoses, 3% leak rate; right
Performing a Delayed Anastomosis (DA) during DCL colon, 3%; transverse colon, 20%; left colon, 45%). There
for patients with Destructive Colon Injuries (DCI) who was a significant trend toward higher incidence of leak
require surgical resection is an effective approach with with closure day, with closure after day 5 having a four
complication rates comparable to those of conventional times higher likelihood of developing leak (3% vs. 12%,
laparotomy and primary anastomosis and/or standard p=0.02).
colostomy. However, in the event of extensive damage
with vascular and visceral involvement, the surgical out- Gastroduodenalperforation
come depends largely on the damage control strategy. Surgeryisthetreatmentofchoiceforperforatedpep-
Hollow-organ injury following penetrating trauma tic ulcers. In selected cases (patients younger than
should be transiently managed with suture ligation, sta- 70 years of age without septic shock or peritonitis
ples, or simple suturing of the proximal and distal ends and showing no spillage of water-soluble contrast
of the affected organ, while more definitive repairs (such mediuminagastroduodenogram),non-operativema-
as anastomosis, reconstruction, and colostomy) are ty- nagement may be appropriate. However, if there is
pically deferred to later procedures [100-102]. Small noimprovementofclinicalconditionwithin24hours
bowel or colonic perforations are repaired with sutured of initial non-operative treatment, the patient should
closure. If the bowel requires resection and anastomosis, undergosurgery(Recommendation 1A).
these steps are implemented at a later time and are not Research has shown that surgery is the most effective
performed during initial management; this stepwise ap- means of source control in patients with peptic ulcer
proach allows for better control of intestinal leakage perforations[105-107].
without prolonging surgical time or increasing physio- Patients with perforated peptic ulcers may respond to
logical stress. While the colostomy is a relatively quick conservative treatment without surgery. Such conserva-
procedure, it is not always recommended given that, tive treatment consists of nasogastric aspiration, antibio-
during reanimation, the already edematous abdominal tics, and antisecretory therapy. However, patients older
wall often swells to an even greater size, and the intes- than 70 years of age with significant comorbidities, sep-
tinal loop that is used to create the stoma may become tic shock upon admission, and longstanding perforation
necrotic due to hindered blood supply. Further, these (>24 hours) are associated with higher mortality rates
circumstances can substantially prolong surgical time when non-operativetreatmentisattempted[107-109].
[100-102]. Delaying the time of surgery beyond12 hours after the
In 2011, Ordonez et al. performed a retrospective re- onset of clinical symptoms reduces the efficacy of the
view of patients with penetrating DCI. The authors con- procedure,resultinginpoorerpatientoutcome [110].
cluded that DAs should be performed for all patients Simple closure with or without an omental patch is
presenting with DCI who undergo DCL; however, DAs a safe and effective procedure to address small perfo-
are not recommended for patients with recurrent intra- ratedulcers(<2cm)(Recommendation1A).
abdominal abscesses, severe bowel wall edema and in- In the event of large perforated ulcers, concomitant
flammation, or persistent metabolic acidosis. In these bleeding or stricture, resectional gastroduodenal
patients, a colostomy is a more appropriate alternative surgery may be required. Intraoperative assessment
[103]. enables the surgeon to determine whether or not
In 2011 Burlew et al. [104] reviewed patients requiring resection is the proper course of action (Recom-
an open abdomen after trauma from January 1, 2002 to mendation 1B).
December 31, 2007. Type of bowel repair was stratified Different techniques for simple closure of perforations
as immediate repair, immediate anastomosis, delayed havebeendescribedanddocumentedindetail.
anastomosis, stoma and a combination. In 2010, Lo et al. conducted a study to determine if an
During the 6-year study period, 204 patients suf- omental patch offers any clinical benefit that is not of-
fered enteric injuries and were managed with an open feredbysimple closurealone[111].
abdomen. The study demonstrated that, in terms of leakage rates
Enteric injuries were managed with immediate repair and overall surgical outcome, covering the repaired per-
(58), immediate anastomosis (15), delayed anastomosis forated peptic ulcer with an omental patch did not con-
(96), stoma (10), and a combination (22); three patients vey additional advantages compared to simple closure
