Septic Perforated Diverticulitis in a Steroid-Dependent Patient
A 67-year-old man with type 2 diabetes, BMI 34, and COPD on prednisone 10 mg daily presents after 36 hours of left lower quadrant pain, fever to 39.1°C, and confusion. He is tachycardic at 126/min and hypotensive at 86/50 mmHg after 2 L of crystalloid; lactate is 4.8 mmol/L. CT shows Hinchey IV sigmoid diverticulitis with free air and fecal contamination. At laparotomy there is 1.5 L of feculent fluid, a 3-cm perforation, and friable, inflamed sigmoid colon; he is on norepinephrine. The splenic flexure is mobile, the rectum is healthy, and the patient is coagulopathic with a temperature of 35.4°C. The anesthesia team reports worsening acidosis and increasing vasopressor requirement.
1. What is the most appropriate operative strategy at this point, and why would you reject a primary stapled anastomosis even with a proximal diversion?
Read the worked answer
Resect, do not anastomose. The patient has septic shock, chronic steroid exposure, feculent peritonitis, hypothermia, coagulopathy, and worsening acidosis-all factors that make a fresh colorectal anastomosis unsafe even with a proximal diverting ileostomy. A primary anastomosis still carries a leak risk that would be poorly tolerated, and constructing an ileostomy adds time in an unstable patient. The safest damage-control operation is a sigmoid resection with a stapled rectal stump and an end colostomy, leaving the abdomen open with a temporary closure after generous lavage. A mucous fistula is optional and can be difficult in a short stump. Plan a re-look at 24–48 hours for reassessment and delayed fascial closure. If the patient were physiologically stable with minimal contamination, primary anastomosis with diverting ileostomy could be considered, but not here.
2. On postoperative day 1 the patient remains on norepinephrine, has a 4 L positive fluid balance, bladder pressure 22 mmHg, and rising peak airway pressures. What is your assessment and management?
Read the worked answer
Bladder pressure 22 mmHg with new organ dysfunction is intra-abdominal hypertension bordering on abdominal compartment syndrome. The temporary closure is likely too tight, and the patient has a large positive fluid balance. First, verify the measurement and treat reversible contributors: deepen sedation, consider neuromuscular blockade, drain the stomach and bladder, and avoid further fluid loading. If bladder pressure remains above 20 mmHg with organ dysfunction, open the temporary closure in the ICU or operating room and use a negative-pressure dressing without fascial closure. Do not try to close the fascia. Excess crystalloid should be avoided; use vasopressors and diuresis when hemodynamically appropriate. If abdominal perfusion pressure remains low, decompressive laparotomy is indicated. Reassess daily.
3. Six weeks later he is stable and asks about reversing the stoma. What conditions must be met, and what surveillance is required?
Read the worked answer
Before reversal, confirm that he has recovered from sepsis and is nutritionally replete, that the rectal stump is healthy and the anal sphincter competent, and that there is no distal obstruction. A colonoscopy through the stoma or rectum should exclude a proximal neoplasm, since diverticulitis can mask cancer. CT can assess the rectal stump and any hernia. Reversal is usually considered at 3–6 months, after inflammation has subsided; a stapled colorectal anastomosis is typical. Counsel about leak, stricture, and the possibility of a temporary ileostomy. If he has ongoing steroid use, optimize it and consider the risk of poor healing. Surveillance after reversal follows colorectal cancer screening guidelines.