Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: A retrospective study

doi:10.21203/rs.3.rs-2436217/v1

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Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: A retrospective study

https://doi.org/10.21203/rs.3.rs-2436217/v1

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Background

Intestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC).

Methods

Between January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC.

Results

The median age was 65 years (range: 23–90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma.

Conclusions

Primary suturing or resection with anastomosis of an open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation.

Trial registration: The study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1)and the Danish Data Protection Agency (file number 18/28404). No funding was received.

Secondary peritonitis

Vacuum-assisted closure

Anastomotic leakage

Enteroatmospheric fistula

Open abdomen

Faecal peritonitis due to perforation or anastomotic leakage of the small intestine is a severe condition, with a mortality rate ranging from 10 to 30% (1–5). Intestinal resection to achieve source control and placement of a proximal stoma, with either closure of the distal intestinal segment or the placement of a distal stoma, is the conventional treatment of choice (5–10). A primary anastomosis with a proximal protective diverting loop-ostomy may be an alternative option (11). This strategy involving stoma placement carries a risk of high stoma output, short-bowel syndrome, permanent stoma, or complications to a later reversal (6).

Primary anastomosis/suturing with an open abdomen or damage control surgery with vacuum-assisted closure and secondary anastomosis may be alternative options. The establishment of an open abdomen with vacuum-assisted closure (VAC) was initially introduced in trauma settings to prevent and address the lethal triad of hypothermia, acidosis, and coagulopathy. The technique has increasingly been used to treat secondary peritonitis (2, 12–24). At the scheduled re-laparotomy, it is possible to perform lavage of the abdominal cavity, inspect the intestines and perform necessary additional surgical procedures to prevent serious complications. Enteroatmospheric fistula (EAF) formation and incomplete fascial closure are potential disadvantages (2, 12, 18, 25–31).

This study aimed to assess whether primary anastomosis or suturing was safe in patients with faecal peritonitis caused by a small intestinal perforation or anastomotic leakage using the open abdomen principle with VAC.

Patient information

We performed a retrospective chart review of 20 patients (> 18 years) operated between January 2005 and June 2018 for faecal peritonitis caused by small bowel perforation and treated with primary intestinal resection and anastomosis or primary suturing and subsequent open abdomen with VAC. Patients with perforation of the stomach, duodenum, and colon were excluded. Data retrieved from medical records included age, sex, body mass index (BMI), location and cause of intestinal perforation, duration of VAC treatment, number of VAC changes, the negative pressure applied, 90-day mortality rate and whether the patient had a stoma or not at discharge and 1-year follow-up. In addition, we recorded postoperative complications within 30 days, using the Clavien-Dindo classification index (32).

Surgical Approach

For the open abdomen treatment with VAC, the VAC® Abdominal Dressing System (KCI Vacuum Assisted Closure, San Antonio, TX, USA) was applied with a non-mesh mediated fascial traction technique (27). After covering the intestinal loops with the visceral protective layer, the first layer of foam was placed into the wound and extended 5 cm subperitoneally from the wound edge. Another piece of foam was folded and placed in the laparostoma, allowing the foam to stick out above the abdominal wall, resembling a “shark fin”. We then loosely applied an occlusive drape in 10–15 cm wide strips. The fascial edges were simultaneously approximated manually towards the midline while applying negative pressure. The negative pressure applied was to the discretion of the operating surgeon. Dressings were changed within approximately 48 hours, depending on clinical conditions. Fascial closure was commenced as early as possible depending on the clinical and paraclinical parameters, either in one or repeated sessions with interrupted nonabsorbable sutures (Prolene 2 − 0, Ethicon, New Jersey, United States) (27).

Statistical analysis

Continuous data were presented as medians and ranges and compared using the Wilcoxon rank-sum test. Categorical data are presented as counts and proportions with binomial 95% confidence intervals (CI) and were compared by Fisher’s exact test, using Stata software version 17.0 (StataCorp LP®, Texas, USA). A p-value less than 0.05 was considered statistically significant.

Twenty consecutive patients were included. The median age was 65 years (range: 23–90 years). Twelve patients were female (60%). The intestinal perforation was iatrogenic after previous gynaecological or gastrointestinal surgery in 16 cases, ileus in two cases, blunt trauma in one case, and an ischaemic perforation in one patient. Seventeen patients were treated with resection and primary anastomosis and three with suturing of the perforation.

VAC treatment was continued for a median of 4 days (range: 1–12 days). Following secondary closure of the abdomen, three patients (16%) required one or more additional laparotomies due to suspected or confirmed complications (Table 2).

Table 1

Demographics, location and cause of intestinal perforation, type of repair, negative pressure with VAC in patients with and without anastomotic leakage.
		Anastomotic leakage N = 5	No anastomotic leakage N = 15	p-value
Gender	Female	3	9	0.69
Gender	Male	2	6
Age years median [range]		64 [54–73]	66 [23–90]	0.85
BMI	BMI > 30	2	0	0.053
BMI	BMI < 30	3	15
Cause of peritonitis	Secondary to abdominal or gynaecological surgery	5	11
	Ileus	0	2
	Ischaemia	0	1
	Trauma	0	1
Vacuum, negative pressure (mmHg) median [range]		75 [25–75]	50 [25–75]	0.81

Table 2

Postoperative surgical complications in patients according to the Clavien-Dindo classification (7). Multiple complications may have occurred in the same patient.
Clavien-Dindo classification	2	3a	3b	4a, 4b and 5
Fascial dehiscence	0	0	3	0
Wound infection	0	1	1	0
Intra-abdominal abscess	1	1	3	0
Enteroatmospheric fistula	0	0	3	0
Anastomotic leakage	0	0	2	3
Stoma complication	0	0	1	0

Leak occurred in five cases (20%) at a median of 5 days after primary surgery (range: 2–10 days). There were neither significant differences in VAC treatment duration nor in VAC pressure between patients with and without leakage. In one patient, the leakage was re-sutured with no subsequent leakage. The remaining four patients received a stoma. Four patients died within 90 days postoperatively (20%; 95% CI 6%-44%). None of these four patients experienced leakage. The causes of death were sepsis with multi-organ failure in one case, and three died from pulmonary complications. Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma.

In all patients, the fascia was closed after VAC termination. Three patients (15%) were re-operated for fascial dehiscence. Three patients developed EAF (15%). One of the patients with EAF had an anastomotic leakage. There were no significant differences in negative pressure used for patients developing EAF compared to those without (with EAF median 75 (25;75), without EAF 50 (25;75), p = 0.65). All EAFs were initially treated with resection and anastomosis, with a recurrence in all. No bleeding, stroke, acute myocardial infarction, pulmonary embolism, or deep vein thrombosis were observed in any patients.

The principle of suture or primary anastomosis and open abdomen with VAC treatment was feasible but had a high risk of anastomotic leakage and EAF formation after small intestinal perforation. The 90-day mortality rate of 20% was comparable with other reports on patients with secondary peritonitis treated with intestinal resection and proximal ostomy (1, 2).

After primary suturing or anastomosis, the leakage rate was high (25%). Another concern was related to the frequent development of EAF in 15% of cases, which was preceded by leakage in only one case. A systematic review of different negative pressure techniques including commercial negative pressure kits, VAC-pack, negative pressure with sequential closure, Bogota Bag and Artificial Burr in the open abdomen reported a higher incidence of EAF formation in septic patients than non-septic patients (12.1% vs. 3.7%) (33). A prospective analysis of the International Register of Open Abdomen (IROA) by Coccolini et al. included 649 patients treated with an open abdomen, and 51.2% of the patients were diagnosed with peritonitis (34). EAF occurred in 12% of the peritonitis group but this incidence did not differ significantly from that in the control group without peritonitis. In another cohort study of 43 patients treated with VAC due to secondary peritonitis, an EAF rate of 37% was reported (30).

Pipariya et al. studied 50 patients with secondary peritonitis treated with primary repair/resection and compared this cohort with 50 patients who had undergone repair/resection with proximal stoma formation (35). Non-traumatic perforation was the most common aetiology (61%) and most often confined to the terminal ileum (73%). The leak rate in the primary repair/resection group was 8%, and in the stoma group, approximately one-third developed stoma complications (prolapse, hernia, necrosis, and retraction). However, a critical study limitation was that patients in the stoma group had more severe peritonitis and were in poorer condition. A comparative study consisting of 30 primary repairs and 30 loop ileostomies after non-traumatic ileal perforation showed an increased rate of postoperative complication in the primary repair group; a further 20% of the primary repairs had a leakage (36).

Primary anastomosis without a diverting stoma has become an accepted treatment modality in colonic perforations with peritonitis due to diverticulitis (37–39). Damage control with a delayed anastomosis at a second look is another approach (40–50).

The outcome after Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with perforated diverticulitis was investigated in two contemporary systematic reviews (51, 52). They showed favourable results for PA in terms of stoma reversal rates, reversal-related morbidity, lower overall persistent stoma rate, decreased morbidity, overall mortality, and major complications. Furthermore, two recent RCTs studying PA and HP in patients with perforated diverticulitis concluded that stoma reversal and 12-month stoma-free survival were significantly improved in the PA group, without showing a significant difference in mortality or morbidity (37, 53). Other randomized trials and systematic reviews have also provided evidence supporting PA (39, 51, 52).

Two recent systematic reviews investigated damage control surgery (DCS) after perforated diverticulitis. They showed that 62.1–73% of patients received colorectal anastomosis at secondary operation, with a leakage rate of 7.3–13% and postoperative mortality of 9–9.2% (41, 48).

Our study limitations include its retrospective design and a relatively long inclusion period. Nevertheless, as the pathophysiology of peritonitis secondary to bowel perforation was similar, irrespective of the underlying cause, we found it relevant to perform this study even though the number of patients was relatively small. Furthermore, a limited number of surgeons performed all treatments at a single centre, making our approach to open abdomen and VAC uniform and comprehensive.

Primary anastomosis or suturing and open abdomen with VAC in patients with faecal peritonitis due to small intestinal perforation are associated with a high risk of anastomotic leakage and EAF formation. Therefore, the approach should only be considered for cases in which exteriorization of the intestine for stoma formation is difficult/impossible or may lead to short-bowel syndrome.

VAC

Vacuum-assisted closure

EAF

Enteroatmospheric fistula

BMI

Body mass index

IROA

International Register of Open Abdomen

Hartmann’s procedure

DCS

Damage control surgery

Ethics approved and consent to participate

The project was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28404).

Consent for publication

Not applicable.

Availability of data and materials

On request, data can be shared in an anonymised form if a data processor agreement is obtained.

Competing interests

The primary investigator and collaborators have no financial interest in the trial.

Funding

No external funding.

Authors' contributions

PR, ROJ, NQ, and MBE designed the trial and drafted the protocol. SM contributed with the statistical design. PR, ROJ, SR, NQ and MBE discussed and critiqued the data and its interpretation. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Hecker A, Uhle F, Schwandner T, Padberg W, Weigand MA. Diagnostics, therapy and outcome prediction in abdominal sepsis: Current standards and future perspectives. Langenbecks Arch Surg. 2014;399(1):11–22.
Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39(4):912–25.
O van R, CW M, KR B, al et. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: A randomized trial. JAMA. 2007;298(8):865–72.
Tridente A, Clarke GM, Walden A, McKechnie S, Hutton P, Mills GH, et al. Patients with faecal peritonitis admitted to European intensive care units: an epidemiological survey of the GenOSept cohort. Intensive Care Med. 2014;40(2):202–10.
Sartelli M, Catena F, Ansaloni L, Coccolini F, Corbella D, Moore EE, et al. Complicated intra-abdominal infections worldwide: The definitive data of the CIAOW Study. World J Emerg Surg. 2014;9(1):37.
Leppäniemi A, Kimball EJ, de Laet I, Malbrain MLNG, Balogh ZJ, de Waele JJ. Management of abdominal sepsis - A paradigm shift? Anaesthesiol Intensive Ther. 2015;47(4):400–8.
Tellor B, Skrupky LP, Symons W, High E, Micek ST, Mazuski JE. Inadequate source control and inappropriate antibiotics are key determinants of mortality in patients with intra-abdominal sepsis and associated bacteremia. Surg Infect (Larchmt). 2015;16(6):785–93.
Sartelli M, Catena F, Abu-Zidan FM, Ansaloni L, Biffl WL, Boermeester MA, et al. Management of intra-abdominal infections: Recommendations by the WSES 2016 consensus conference. World J Emerg Surg. 2017;12:22.
Sartelli M, Chichom-Mefire A, Labricciosa FM, Hardcastle T, Abu-Zidan FM, Adesunkanmi AK, et al. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017;12:29.
Ross JT, Matthay MA, Harris HW. Secondary peritonitis: Principles of diagnosis and intervention. BMJ. 2018;361:k1407.
Steinemann DC, Stierle T, Zerz A, Lamm SH, Limani P, Nocito A. Hartmann’s procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation. Langenbecks Arch Surg. 2015;400(5):609–16.
Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surg. 2014;101(1):e109-18.
Horwood J, Akbar F, Maw A. Initial experience of laparostomy with immediate vacuum therapy in patients with severe peritonitis. Ann R Coll Surg Engl. 2009;91(8):681–7.
Amin AI, Shaikh IA. Topical negative pressure in managing severe peritonitis: A positive contribution? World J Gastroenterol. 2009;15(27):3394–7.
Tolonen M, Mentula P, Sallinen V, Rasilainen S, Bäcklund M, Leppäniemi A. Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience. J Trauma Acute Care Surg. 2017;82(6):1100–1105.
Wondberg D, Larusson HJ, Metzger U, Platz A, Zingg U. Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: Low primary closure rate. World J Surg. 2008;32(12):2724–9.
Plaudis H, Rudzats A, Melberga L, Kazaka I, Suba O, Pupelis G. Abdominal negative-pressure therapy: A new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature. Ann Intensive Care. 2012;2:(S1).
Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, et al. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg. 2015;10:35.
Perez D, Wildi S, Demartines N, Bramkamp M, Koehler C, Clavien PA. Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis. J Am Coll Surg. 2007;205(4)586–92.
Fortelny RH, Hofmann A, Gruber-Blum S, Petter-Puchner AH, Glaser KS. Delayed closure of open abdomen in septic patients is facilitated by combined negative pressure wound therapy and dynamic fascial suture. Surg Endosc. 2014;28(3):735–40.
Schmelzle M, Alldinger I, Matthaei H, Aydin F, Wallert I, Eisenberger CF, et al. Long-term vacuum-assisted closure in open abdomen due to secondary peritonitis: a retrospective evaluation of a selected group of patients. Dig Surg. 2010;27(4):272–8.
Mutafchiyski VM, Popivanov GI, Kjossev KT, Chipeva S. Open abdomen and VAC; in severe diffuse peritonitis. J R Army Med Corps. 2016;162(1):30–4.
Pliakos I, Papavramidis TS, Mihalopoulos N, Koulouris H, Kesisoglou I, Sapalidis K, et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: A clinical trial. Surgery. 2010;148(5):947–53.
Rausei S, Amico F, Frattini F, Rovera F, Boni L, Dionigi G. A review on vacuum-assisted closure therapy for septic peritonitis open abdomen management. Surg Technol Int. 2014;25:68–72.
Demetriades D, Salim A. Management of the open abdomen. Surgical Clinics of North America. 2014;94(1):131–53.
Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012;36(3):497–510.
Hougaard HT, Ellebaek M, Holst UT, Qvist N. The open abdomen: Temporary closure with a modified negative pressure therapy technique. Int Wound J. 2014;11(S1).
Trevelyan SL, Carlson GL. Is TNP in the open abdomen safe and effective? J Wound Care. 2009;18(1):24–5.
Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: A word of caution. Colorectal Dis. 2007;9(3):266–8.
Mintziras I, Miligkos M, Bartsch DK. High risk of fistula formation in vacuum-assisted closure therapy in patients with open abdomen due to secondary peritonitis—a retrospective analysis. Langenbecks Arch Surg. 2016;401(5):619–25.
Bradley MJ. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy. JAMA Surg. 2013;148(10):947–54.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg. 2009;250(2):187–96.
Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen. Int J Surg. 2014;12(10):1105–14.
Coccolini F, Ceresoli M, Kluger Y, Kirkpatrick A, Montori G, Salvetti F, et al. Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA). Injury. 2019;50(1):160–66.
Pipariya PR, Menon VA CH. A comparative study of primary vs stoma in emergency surgeries. An institutional experience. Sch J App Med Sci. 2015;3:1326–31.
Mittal S, Singh H, Munghate A, Singh G, Garg A, Sharma J. A comparative study between the outcome of primary repair versus loop ileostomy in ileal perforation. Surg Res Pract. 2014;2014:729018.
Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, et al. Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: A prospective multicenter randomized trial (DIVERTI). J Am Coll Surg. 2017;225(6):798–805.
Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L, et al. Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: A prematurely terminated randomized controlled trial. Colorectal Dis. 2012;14(11):1403–10.
Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256(5):819–26.
Brillantino A, Andreano M, Lanza M, D’Ambrosio V, Fusco F, Antropoli M, et al. Advantages of damage control strategy with abdominal negative pressure and instillation in patients with diffuse peritonitis from perforated diverticular disease. Surg Innov. 2019;26(6):656–61.
Cirocchi R, Popivanov G, Konaktchieva M, Chipeva S, Tellan G, Mingoli A, et al. The role of damage control surgery in the treatment of perforated colonic diverticulitis: A systematic review and meta-analysis. Int J Colorectal Dis. 2021;36(5):867–79.
Inukai K, Usui A, Yamada M, Amano K, Mukai N, Tsunetoshi Y, et al. Open abdominal management for perforative peritonitis with septic shock: A retrospective analysis on usefulness of a standardized treatment protocol. Eur J Trauma Emerg Surg. 2021;47(1):93–8.
Kafka-Ritsch R, Birkfellner F, Perathoner A, Raab H, Nehoda H, Pratschke J, et al. Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV. J Gastrointest Surg. 2012;16(10):1915–22.
Kafka-Ritsch R, Zitt M, Perathoner A, Gasser E, Kaufman C, Czipin S, et al. Prospectively randomized controlled trial on damage control surgery for perforated diverticulitis with generalized peritonitis. World J Surg. 2020;44(12):4098–05.
Perathoner A, Klaus A, Mühlmann G, Oberwalder M, Margreiter R, Kafka-Ritsch R. Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis-a proof of concept. Int J Colorectal Dis. 2010;25(6):767–74.
Sohn M, Agha A, Heitland W, Gundling F, Steiner P, Iesalnieks I. Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis. Tech Coloproctol. 2016;20(8):577–83.
Sohn MA, Agha A, Steiner P, Hochrein A, Komm M, Ruppert R, et al. Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome. Int J Colorectal Dis. 2018;33(7):871–78.
Sohn M, Agha A, Iesalnieks I, Gundling F, Presl J, Hochrein A, et al. Damage control strategy in perforated diverticulitis with generalized peritonitis. BMC Surg. 2021;21(1):135.
Tartaglia D, Costa G, Camillò A, Castriconi M, Andreano M, Lanza M, et al. Damage control surgery for perforated diverticulitis with diffuse peritonitis: Saves lives and reduces ostomy. World J Emerg Surg. 2019;14(1):19.
Zizzo M, Castro Ruiz C, Zanelli M, Bassi MC, Sanguedolce F, Ascani S, et al. Damage control surgery for the treatment of perforated acute colonic diverticulitis: A systematic review. Medicine. 2020;99(48):e23323.
Lambrichts DP, Edomskis PP, van der Bogt RD, Kleinrensink GJ, Bemelman WA, Lange JF. Sigmoid resection with primary anastomosis versus the Hartmann’s procedure for perforated diverticulitis with purulent or fecal peritonitis: A systematic review and meta-analysis. Int J Colorectal Dis. 2020;35(8):1371–86.
Ryan OK, Ryan ÉJ, Creavin B, Boland MR, Kelly ME, Winter DC. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann’s procedure for the management of acute perforated diverticulitis with generalised peritonitis. Tech Coloproctol. 2020;24(6):527–43.
Lambrichts DPV, Vennix S, Musters GD, Mulder IM, Swank HA, Hoofwijk AGM, et al. Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): A multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol. 2019;4(8):599–10.

No competing interests reported.

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Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: A retrospective study

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Abstract

Background

Materials And Methods

Patient information

Surgical Approach

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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