What is the appropriate care for a transgender patient with perforated diverticulitis?

Management of Perforated Diverticulitis in Transgender Patients

Transgender patients with perforated diverticulitis should be managed identically to cisgender patients using the same evidence-based surgical and medical protocols, as gender identity does not alter the pathophysiology or treatment approach for this life-threatening surgical emergency. 1

Initial Assessment and Resuscitation

Immediate priorities include:

• Aggressive fluid resuscitation, hemodynamic monitoring, and correction of electrolyte abnormalities before surgical intervention 2
• Broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms (Meropenem, Doripenem, Imipenem/cilastatin, or Eravacycline) initiated immediately 2
• CT with IV contrast to confirm perforation, assess extent of peritonitis, and identify free air or abscess formation 3
• Laboratory assessment including white blood cell count, C-reactive protein, and procalcitonin to gauge severity 3

Surgical Decision Algorithm

The surgical approach depends entirely on hemodynamic stability and extent of peritonitis:

For Hemodynamically Stable Patients with Diffuse Peritonitis:

• Primary resection with anastomosis (with or without diverting stoma) is recommended for stable patients without significant comorbidities 3, 2
• Emergency laparoscopic sigmoidectomy may be performed only if technical expertise and equipment are available, though conversion rates range 0-19% 1
• Hartmann's procedure remains the safer option in most real-world scenarios, particularly with fecal peritonitis or multiple comorbidities 2, 4

For Hemodynamically Unstable Patients or Those in Septic Shock:

• Damage control surgery is the recommended approach according to the World Journal of Emergency Surgery 1, 3
• Initial operation focuses on source control: limited resection or closure of perforation with peritoneal lavage and temporary abdominal closure 1, 3
• Patient transferred to ICU for physiological optimization 1
• Second-look operation performed 24-48 hours later for bowel reconstruction when stabilized 1, 3
• This staged approach achieves bowel continuity restoration in 76-84% of patients 3

Critical Pitfalls to Avoid

Do not attempt non-operative management in patients with large amounts of distant free gas or clinical peritonitis—failure rates approach 57-60% 1, 2

Do not perform primary anastomosis in unstable patients or those with fecal peritonitis, as mortality increases significantly 2, 5

Do not rely on laparoscopic lavage as definitive treatment—this approach has unacceptably high reoperation rates and should only be considered in highly selected patients 1, 2

Antibiotic Duration

• 4 days of antibiotics if source control is adequate and patient is immunocompetent and non-critically ill 3, 2
• Up to 7 days for immunocompromised or critically ill patients, guided by clinical response and inflammatory markers 3, 2

Special Considerations for Transgender Patients

Hormone therapy considerations:

• Continue gender-affirming hormone therapy perioperatively unless specific contraindications exist (no evidence suggests discontinuation improves surgical outcomes)
• Estrogen therapy may theoretically increase thrombotic risk—ensure appropriate VTE prophylaxis as with any patient on estrogen
• Testosterone therapy does not require modification for emergency surgery

Anatomical considerations:

• Prior gender-affirming surgeries do not alter sigmoid anatomy or diverticular disease management
• Standard surgical approaches and techniques apply regardless of prior pelvic surgeries

Outcomes and Prognosis

• Overall mortality for perforated diverticulitis with damage control surgery is approximately 9.8% 3
• Anastomotic leak rates of approximately 13% occur after staged procedures 3
• Mortality is significantly higher (26%) with colostomy and drainage alone compared to resection (7%) 5
• Stoma reversal after Hartmann's procedure is achieved in approximately 76% of surviving patients 1