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In this multicenter, randomized trial comparing primary peritoneal drainage with laparotomy for the management of perforated necrotizing enterocolitis in preterm infants with birth weights less than 1500 g, there were no significant differences between groups in mortality at 90 days, dependence on total parenteral nutrition at 90 days, or length of the hospital stay in surviving infants. These data do not support an advantage of either primary peritoneal drainage or laparotomy over the alternative approach among preterm infants with perforated necrotizing enterocolitis. This trial compared primary peritoneal drainage with laparotomy for the management of perforated necrotizing enterocolitis in preterm infants. There were no significant differences between groups in mortality at 90 days, dependence on total parenteral nutrition at 90 days, or length of the hospital stay in surviving infants. Necrotizing enterocolitis is a severe inflammatory disorder of the intestine occurring in premature infants. It is a major cause of death and morbidity in neonates. 1 In contrast to the improvements during the past 30 years in the outcomes of many conditions affecting premature infants, the mortality rate of 30 to 50 percent for babies with intestinal perforation due to necrotizing enterocolitis remains essentially unchanged. 2 The standard approach to patients with perforated intestine, necrotic intestine, or both is surgical resection of the involved bowel with the creation of intestinal stomas. In a critically ill premature infant, this entails substantial risks. Primary . . .

Background This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann’s procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis. Methods A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P  < 5 % was considered statistically significant in this study. Results A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann’s for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs . 6.7 ± 2.2 days, P  < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %. Conclusions Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

Background Perforated diverticulitis is a condition associated with substantial morbidity. Recently published reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomised study has published any results. Methods DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional Hartmann's Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpoints consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patients are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient is included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally, placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months. A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40). Discussion HP is associated with a high rate of complication. Not only does the primary operation entail complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe, minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer re-operations, decreased morbidity, mortality, costs and increased quality of life. Trial registration British registry (ISRCTN) for clinical trials ISRCTN82208287 http://www.controlled-trials.com/ISRCTN82208287

ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

ObjectivesPerforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed.DesignEndoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III–V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists’ discretion.ResultsEMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III–V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III–V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014).ConclusionsIn this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III–V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification.Trial registration numberNCT01368289; results.

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist’s skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Objective To delineate gestational age (GA)-dependent pathophysiology of necrotizing enterocolitis-associated intestinal perforation (NEC-IP) and establish precision management protocols. Methods A single-center retrospective cohort study (2013–2023) included 66 preterm (< 37 weeks) and 38 term (≥ 37 weeks) neonates with NEC-associated perforations. Outcomes included anatomical distribution, microbiological profiles, management disparities, and prognoses. Results Preterm infants exhibited significantly higher rates of twin gestation (43.9% vs 7.9%, p  = 0.003), antenatal steroid exposure (43.9% vs 2.6%, p  < 0.001), and preoperative fasting rate (33.3% vs 7.9%, p  = 0.009) compared to term infants. Preterm infants demonstrated Gram-positive bacteremia (83.3%) with Gram-negative peritoneal predominance (83.9%), alongside significantly lower leukocyte counts (Stage 2:12.6 vs 14.9 × 10⁹/L, Stage 3: 9.1 vs 11.1 × 10⁹/L, both p  < 0.05), platelet levels (all stage), and hemoglobin levels (Stage 1:125.1 vs 141.6 × 10 12 /L, p  = 0.004). Term infants showed Gram-positive peritoneal dominance (76.2%) with classic peritonitis signs (hematochezia 68.4%, abdominal tenderness 55.3%). Lleal perforations predominated in preterms (69.7% vs 21.1%, p  < 0.001), whereas colonic involvement was prevalent in terms (63.1%). Prolonged parenteral nutrition in preterms (27.0 vs 20.0 days, p  = 0.009) correlating with prolonged hospitalization (38.4 ± 9.7 vs 23.5 ± 8.1 days; p  < 0.001), achieved higher enteral tolerance (151.7 vs 134.2 ml/kg/d, p  = 0.009). There was no case dead in initial admission. Rehospitalization and mortality rates in readmission were comparable (term 73.7 vs preterm 60.6%, p = 0.177;1% vs 2%; p  = 0.653). Although weight at discharge in term group was higher compared to preterm infants (2.5 ± 0.4 vs 3.5 ± 0.6 kg; p  < 0.001), while weight velocity was similar between two groups (18.3 ± 7.5 vs 16.6 ± 9.6 g.kg⁻ 1 ·d⁻ 1 ; p  = 0.312). Conclusion GA-specific NEC-IP mechanisms mandate: (1) preterm-focused ileal exploration & Gram-negative coverage, (2) term-focused retroperitoneal debridement & Gram-positive control, and (3) GA-stratified diagnostic framework integrating clinical signs and imaging. This precision approach reduces missed perforations and surgical delays.

Aim To identify factors predicting the failure of non-operative treatment in acute complicated colonic diverticulitis. Material and methods Consecutive patients hospitalized for non-operative treatment of acute complicated diverticulitis of the sigmoid colon between 2009 and 2015 were included in this retrospective analysis. Complicated disease was defined as the presence of extraluminal air or fluid collection within a computed tomography (CT) scan. The primary endpoint of the study was the need for emergent sigmoidectomy. The direction of perforation was assessed by CT scan and divided into 2 main groups: perforation towards the small bowel and perforation in other directions (abdominal wall, pelvic wall, retroperitoneum, urogenital organs). Results A total of 140 patients were included. Of these patients, 25 patients did not respond to non-operative treatment and underwent rescue surgery (18%). CT revealed perforations towards the small bowel in 28 patients, 19 of whom did not respond to non-operative treatment (68%); in contrast, 6 of 112 (5%) patients with perforation in other directions experienced treatment failure. By multivariate analysis, perforation towards the small bowel (hazard ratio 75.0; 95% CI, 13.7–409.7, p  < 0.001) was associated with a significantly increased risk for a failure of non-operative management. The only other risk factor was the presence of an intra-abdominal abscess. Diverticular perforation towards the small bowel is associated with a very high risk for emergency sigmoidectomy due to failed non-operative treatment. Conclusion Diverticular perforation towards the small bowel is associated with a very high risk for emergency sigmoidectomy due to failed non-operative treatment.

Purpose Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are severe gastrointestinal complications of prematurity. The clinical presentation and treatment of NEC and SIP (peritoneal drain vs laparotomy) can overlap; however, the pathogenesis is distinct. Therefore, a patient initially treated for SIP can subsequently develop NEC. This phenomenon has only been described in case reports, and no risk factor evaluation exists. We evaluate clinical characteristics, risk factors, and outcomes of patients treated for a distinct episode of NEC after SIP. Methods We performed a retrospective review of very low birth weight (<1500 g) neonates who presented with pneumoperitoneum between 07/2004 and 09/2022. Data was obtained from two separate neonatal intensive care units that were part of the same institution. Patients with an initial preoperative, intraoperative, or pathological diagnosis of NEC were excluded. Patients with an intraoperative diagnosis of SIP or preoperative diagnosis of SIP successfully treated with a peritoneal drain (PD) were evaluated. Patients subsequently treated (medically or surgically) for NEC after SIP were then compared to SIP-alone patients. Clinical characteristics included demographics, gestational age (GA), birth weight (BW), perinatal risk factors (chorioamnionitis, steroids, indomethacin), postoperative feeding regimen, and length of stay (LOS) were compared. Results Of the 278 patients included, 31 (11.2%) patients had NEC after SIP. There was no difference in GA (25 weeks vs 25 weeks, p  = 0.933) or BW (760 g vs 735 g, p  = 0.370) between NEC after SIP vs SIP alone cohorts, respectively. Twenty (64%) of NEC after-SIP patients were previously treated with LP. NEC after SIP occurred with a median onset of 56 days. Pneumatosis was the most frequent (81%) presenting symptom and 12 (39%) patients had hematochezia. Four (12.9%) patients required LP for NEC and all had NEC intraoperatively and on pathology. A majority (77.4%) of patients were on breast milk (BM) at time of NEC diagnosis. NEC after SIP patients had lower maternal age at delivery (29.0 vs 25.0, p  = 0.055) and the incidence of NEC after LP (primary or failed drain) was higher than PD alone (16.7% vs 6.2%, p  = 0.007). NEC after SIP patients had longer LOS (135 vs 81, p  < 0.001). Conclusion We report an 11.2% incidence of NEC at a median of 56 days following successful treatment of SIP, resulting in increased LOS. SIP patients are a high-risk cohort and protocols to prevent this phenomenon should be investigated.

Perforation during colonoscopy is a rare but well recognized complication with significant morbidity and mortality. We aim to systematically review the currently available literature concerning care and outcomes of colonic perforation. An algorithm is created to guide the practitioner in management of this challenging clinical scenario. A systematic review of the literature based on PRISMA-P guidelines was performed. We evaluate 31 articles focusing on findings over the past 10 years. Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity. Reliable conclusions are limited by the nature of the data available – mainly single institution, retrospective studies. Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy when compared to diagnostic colonoscopy and the sigmoid as the most common site of perforation. Mortality appears driven by pre-existing conditions. Treatment must be tailored according to the patient's comorbidities and clinical status as well as the specific conditions during the colonoscopy that led to the perforation. •Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity.•Reliable conclusions are limited by the nature of the data available – single institution, retrospective studies.•Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy and the sigmoid as the most common site of perforation.•Mortality appears driven by pre-existing conditions.•Treatment must be tailored according to patient's comorbidities and clinical status.