Jemds.

com Original Research Article

ASSOCIATION OF PERFORATION PERITONITIS IN EXTRAPERITONEAL SURGERY- AN UNRELATED

COMPLICATION
Saleem Tahir1, Shariq Ahmad2

1Associate Professor, Department of Surgery, Eras Lucknow Medical College and Hospital, Lucknow.
2Senior Resident, Department of Surgery, Eras Lucknow Medical College and Hospital, Lucknow.
ABSTRACT
BACKGROUND
The aim of this study is to discuss and emphasise the occurrence of perforated diverticular disease as an unrelated complication in
extraperitoneal surgery.
Objective- 35 patients are reported here where perforation of colonic diverticulum took place in 7 patients after an
extraperitoneal surgery and emphasising the unrelated complication.

MATERIALS AND METHODS

The study comprised of 35 patients of extraperitoneal surgery and the incidence of perforation recorded in total patients.

RESULTS
Perforation of colonic diverticula was observed in 7 patients who underwent extraperitoneal surgery.
Observation- Perforation of colonic diverticula is multifactorial and the incidence has increased in patients undergoing surgery
with multiple factors.

CONCLUSION
Spontaneous perforation of sigmoid diverticula is multifactorial and the differential diagnosis of an unrelated complication in
extraperitoneal surgeries should be kept in mind based on the clinical symptomology.

KEYWORDS
Perforation Peritonitis in Extraperitoneal Surgery.
HOW TO CITE THIS ARTICLE: Tahir S, Ahmad S. Association of perforation peritonitis in extraperitoneal surgery- an unrelated
complication. J. Evolution Med. Dent. Sci. 2017;6(20):1632-1635, DOI: 10.14260/Jemds/2017/357
BACKGROUND All the routine investigations done preoperatively were
Diverticular disease has an increasing incidence in western within normal limits and the patients were declared fit in pre-
countries, which can be explained by an increasing elderly anaesthetic check-up.
population and also the relatively low-fibre diet of Western
culture. Fifty percent of the population over 50 years of age RESULTS
have diverticulosis, and it is estimated that acute 7 of the 35 patients developed symptoms of bowel
diverticulitis will develop in 15 - 20% of these cases.(1) obstruction in the post-operative period.
Complicated diverticular disease carries significant morbidity The patients developed distension of abdomen and
and mortality. These were influenced by patient-related features of peritonitis in the post-operative period from Day
factors. Because of high mortality and morbidities, it is 5 to Day 16.
suggested the need to target a specific group of patients for Exploratory laparotomies of all patients revealed sigmoid
early diagnosis and prophylactic management. perforation in 5 patients, perforation of descending colon in 1
patient and caecal perforation in 1 patient.
MATERIALS AND METHODS In 4 of the above patients, there were multiple diverticula
The study was conducted in Eras Medical College, Lucknow. in whole of the colon including sigmoid and caecum.
It was done on 35 patients over a period of 2 years. Temporary ileostomy was done in 6 patients and
All the patients were above 40 years of age and planned caecostomy was done in 1 patient.
for elective renal surgeries; 14 patients were planned for Post laparotomy mortality was found in 1 patient, while
elective open nephrectomy, 6 of left side and 8 of right side; others responded well in the post-operative period.
21 patients were planned for PCNL, 13 of right side and 8 of All the other patients of the 35 were discharged
left side. uneventfully.
25 patients gave a history of constipation previously,
Financial or Other, Competing Interest: None.
while others did not have any altered bowel and bladder
Submission 26-01-2017, Peer Review 23-02-2017,
Acceptance 01-03-2017, Published 09-03-2017. habits.
Corresponding Author: The association was 71.2% with respect to all the cases
Dr. Saleem Tahir, with preop constipation. All the patients who had signs and
Associate Professor, symptoms of perforation had history of constipation.
Department of Surgery,
Colonoscopy was not done preoperatively in any of the
Eras Lucknow Medical College & Hospital,
Lucknow-226003, Uttar Pradesh, India. patients.
E-mail: [email protected] The diagnosis of perforation was made on post-operative
DOI: 10.14260/jemds/2017/357 chest x-ray suggesting gas under diaphragm and inter-bowel
fluid on ultrasonogram.

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Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Age 46 62 55 65 69
Type of surgery Right PCNL Left nephrectomy Right nephrectomy Right PCNL Left nephrectomy
Post-operative constipation Present Absent Present Present Absent
Findings Descending colon Sigmoid
Sigmoid perforation Sigmoid perforation Caecal perforation
on exploratory laparotomy perforation perforation
Table 1

Pre- and Post-operative Blood Values

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Pre Post Pre Post Pre Post Pre Post Pre Post
Hb (gm%) 11.1 10.9 12 12.2 13.1 12.6 10.8 11 10.7 10.4
TLC (/mm3) 7300 11000 9200 14300 6000 7400 8200 7350 12000 10900
S. K+ (mEq/L) 3.8 2.7 4.1 3.4 4.4 3.6 3.5 2.8 4.3 3.9
S. Bilirubin (mg%) 0.4 0.6 0.9 1.1 0.9 0.7 1.1 1 0.3 0.6

The preoperative and postoperative haemoglobin levels

were within normal limits, but there was found to be a
decrease in serum potassium levels in the post-operative
period indicating that post-operative ileus may have caused
the rupture of the diverticula spontaneously. The pre- and
post-operative TLC and serum bilirubin levels were
insignificant. But the TLC increased when there were features
of peritonitis from POD 6 to POD 16. In all the above cases
during the extraperitoneal first surgery, care was taken not to
breach the peritoneum and no iatrogenic bowel injury was
registered. Respiratory complications and long-term steroid
use was ruled out in all of these patients except one who had
a history of bronchial asthma and was on bronchodilators for
10 years.

Association of Peritonitis and Renal Surgeries

DISCUSSION
Observation Nephrectomy PCNL
Acute postoperative perforated diverticulitis has been
Total cases with perforation 5 2
associated with cardiac surgery or renal transplant surgery.(2)
Postoperative constipation 18 7
Sigmoid perforation 3 2 The pathogenesis of postoperative diverticulitis is
Age > 60 years 7 11 multifactorial in nature. Its high incidence may be common in
Use of bronchodilators 1 none older age group patients undergoing surgery. Low-fibre diets
may also have a role in the pathogenesis of perforated
Percentage of patients who underwent nephrectomy diverticulitis, as they can lead to diverticulosis and chronic
developing peritonitis 35.70%. Percentage of patients who constipation. In the postoperative period, there may be
underwent PCNL developing peritonitis 5.80%. The worsening constipation due to bed rest, opiate analgesics,
association of symptoms of peritonitis with nephrectomy was anaesthetics and the surgery itself. Another theory in the
significant unrelated to the side of the surgery. Age had an pathogenesis of diverticular perforation suggests that it is
association of 70% with development of peritonitis with age
due to intestinal mucosal ischaemia induced by hypotension,
being > 60 years. There was also significant association of
low-flow states, the use of vasoconstricting drugs, and
constipation in terms of development of peritonitis. In all the
microthrombi or emboli.(3) Increased collagenase activity
patients developing peritonitis history of on and off
after surgery with resulting collagen breakdown in thin-
constipation with irregular bowel habits was present. None of
walled diverticula, is suggested to be a contributing factor to
the patients were found to be using corticosteroids for the
long time with no history of bronchial asthma and any other postoperative perforation.(4)
respiratory illness. The clinical presentation of diverticulitis depends on the
location of the affected diverticulum, the severity of the
Diverticular Perforation inflammatory process and the presence of complications.

Presenting Complaints include the following-

Left lower quadrant pain (70% of patients).
Change in bowel habits.
Nausea and vomiting.
Constipation.
Diarrhoea.
Flatulence.
Bloating.

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Physical findings in patients with diverticulitis mirror the bowel disease and irritable bowel syndrome. The main aim is
severity of the inflammation and the presence of avoidance of complication, mainly stricture and perforation.
complications as follows. The prognosis if detected early is favourable and mortality is
In simple diverticulitis, localised abdominal tenderness in low.
the area of the affected diverticula and fever.
Left lower quadrant tenderness is most common, as most CONCLUSION
diverticula occur in the sigmoid colon. Spontaneous perforation of sigmoid diverticula is
Right lower quadrant tenderness, mimicking acute multifactorial and the differential diagnosis of an unrelated
appendicitis can occur in right-sided diverticulitis. complication in extraperitoneal surgeries should be kept in
In complicated diverticulitis with abscess formation a mind based on the clinical symptomology. The perforation of
tender palpable mass, elderly patients and some patients colonic diverticula has been observed previously in surgeries
taking corticosteroids may have unremarkable findings, even such as cardiac bypass and renal transplantation, but
in the presence of severe diverticulitis, findings in patients perforation in routine elective surgeries warrant a keen
with peritonitis due to free perforation are as follows. history taking and thorough investigation in all suspected
Generalised tenderness with rebound and guarding on patients planned for even extraperitoneal elective surgeries.
abdominal examination, the abdomen may be distended and Perforation has been linked to Non-Steroidal Anti-
tympanic to percussion, bowel sounds can be diminished or Inflammatory Drug (NSAID) use in case-control studies.
absent, the fibre content of the diet plays a large role in the Glucocorticoids may increase this risk. Steroids also may
pathogenesis of diverticular disease. Fibre has been found to mask symptoms and delay appropriate therapy. Because of
be protective. Most fibre in the human diet is of plant origin this, NSAIDs and glucocorticoids should be used with caution
and this type of fibre binds water and salt in the colon, in patients who have known diverticular disease or in
leading to bulkier and more voluminous stools. Therefore, patients who are at risk. Diffuse purulent or faecal peritonitis
fibre decreases the frequency of contractions and prevents an is the most dramatic complication, which still has a high risk
exaggerated form of segmentation. In addition, dietary fibre of mortality and morbidity. Surgical risk is related to clinical
influences the content of colonic bacterial flora, forms the conditions, duration of peritonitis, age of patient and
main substrate for bacterial carbohydrate fermentation and comorbidities. Thus, it is not possible to state a univocal
produces energy-yielding substrates-short-chain fatty approach, although Hartmanns procedure keeps being the
acidsfor growth and maintenance of colonic cellular first choice.(5) But still the treatment of primary resection
function. Consequently, a fibre-deficient diet increases the with or without a diversion colostomy is debatable. The
chances of intense, more frequent segmentation, thus initial assessment of patients with suspected acute
predisposing to herniation of mucosa by allowing isolated diverticulitis is comprised of a thorough history and physical
increases of intraluminal pressure. examination including abdominal, rectal and pelvic
examinations. Useful initial examinations may include a
Summary complete blood cell count, urinalysis and flat and upright
The case series includes 35 patients of extraperitoneal abdominal radiography. If the clinical picture is clear enough
surgery including PCNL and nephrectomy. Perforation to diagnose diverticulitis, no other tests are indicated. For
peritonitis was observed in 5 patients that underwent confirmation other tests such as Computed Tomography (CT),
surgery. Laparotomy in all of these patients revealed water-soluble contrast enema, endoscopy and ultrasound
ruptured colonic diverticula. In all of these patients, there may be performed. In particular, the differential diagnosis of
was no significant association with any of the risk factors and colorectal cancer should also be kept in mind. A barium
hence the need for preoperative colonoscopy was enema examination should be avoided in acute presentations
unwarranted. On close history taking of the previous in patients with suspected acute diverticulitis and localised
incidence revealed episodes of altered bowel habits in some peritoneal signs because of a possible extravasation of
of the patients. However, postoperative constipation, use of barium into the peritoneal cavity, which can increase the
asthmatic drugs and associated comorbidities played morbidity and mortality related to barium-induced chemical
important factors. Henceforth, the important points from this peritonitis. In the emergency setting, water-soluble enemas
study revealed that bowel pathology, especially colonic are safer. There are several important points regarding
diverticula may be considered in all cases of extraperitoneal surgical technique. From a technical standpoint, the resection
surgeries if the patient presents with post-operative should be carried proximally to the compliant bowel and
abdominal distension and features of peritonitis more so if extend distally to the upper rectum. After sigmoid colectomy,
the patient is associated with certain risk factors. The an important predictor of recurrence is a colosigmoid rather
management in these patients should be aimed at early than colorectal anastomosis. The proximal margin of
diagnosis and aggressive management, which includes either resection should be in an area of pliable colon without
a diversion procedure or resection and anastomosis. hypertrophy or inflammation. Resection of the diseased colon
Followup of these patients must be regularly done with must be the desired goal along with removal of the entire
colonoscopy and maintenance of a high-fibre diet with thickened colonic segment(s), but not necessarily all the
reduction of episodes of constipation. The use of proximal diverticula-bearing colon. Laparoscopic colectomy
corticosteroids and opioids must be under strict control of is appropriate in select patients and has advantages over
the physician. Most cases detected early can be treated open laparotomy including less pain, smaller incisions and
conservatively and on bowel rest. Surgical management is shorter recovery. There is no increase in early and late
done in severe cases or patients with peritonitis. The complications and cost and outcome are comparable with
differential diagnosis involves carcinoma colon, inflammatory those of open resection.

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