What is the best course of treatment for an elderly female patient with a colon perforation, free air, subcutaneous emphysema, and a perisigmoid collection, who does not currently show signs or laboratory results indicative of sepsis?

Management of Elderly Female with Colon Perforation, Free Air, Subcutaneous Emphysema, and Perisigmoid Collection Without Sepsis

This patient requires urgent surgical intervention with source control despite the absence of overt sepsis, as colon perforation with free air and subcutaneous emphysema indicates ongoing contamination that will inevitably progress to life-threatening peritonitis if not addressed surgically. 1, 2

Why Surgery is Mandatory in This Case

The presence of free intraperitoneal air combined with subcutaneous emphysema indicates a significant perforation with ongoing gas leak that has tracked through tissue planes—this is not a sealed, contained process 3, 4, 5. The 2022 WSES guidelines for elderly patients with acute left colonic diverticulitis explicitly state: "In elderly patients with acute left colonic diverticulitis and CT findings of distant intraperitoneal free air and no free fluid (WSES stage 2b), we suggest against non-operative management as a viable option" 1. Your patient exceeds even this threshold by having both free air AND a perisigmoid collection.

The subcutaneous emphysema is particularly concerning as it demonstrates that gas is dissecting through retroperitoneal and fascial planes, which occurs with extraperitoneal or combined intraperitoneal/extraperitoneal perforations—these are associated with larger defects and more extensive contamination 3, 5, 6.

The Absence of Sepsis is Misleading

Do not be falsely reassured by the current absence of septic signs—this represents a narrow window before inevitable clinical deterioration 2, 7. In elderly patients, the inflammatory response may be blunted, and sepsis can develop rapidly once bacterial translocation overwhelms host defenses 1. The WSES guidelines emphasize that "prompt and effective source control surgery" is required for perforated diverticulitis with peritonitis to prevent mortality 1.

Delayed surgical intervention beyond 24 hours after perforation significantly increases complication rates, hospital stays, and mortality 2, 7, 8. Every hour of delay is associated with decreased survival probability 1.

Recommended Surgical Approach

Hartmann's procedure (sigmoid resection with end colostomy) is the procedure of choice for this elderly patient with left-sided perforation and perisigmoid collection 1, 2:

• Hartmann's operation provides definitive source control while avoiding the risk of anastomotic leak in contaminated fields 1
• This approach is specifically recommended for elderly patients with perforated diverticulitis and generalized peritonitis 1
• Primary anastomosis is contraindicated given the presence of abscess, free air, and likely significant contamination 1, 2

If the patient is hemodynamically unstable or develops intraoperative instability, consider damage control surgery with resection, end colostomy, and delayed stoma maturation if open abdomen is required 1.

Laparoscopic approach should be avoided in this setting—the WSES guidelines state: "In elderly patients with acute left colonic diverticulitis and acute peritonitis, we suggest against laparoscopic lavage as the preferred surgical approach due to the higher risk of failure to control the source of sepsis" 1.

Preoperative Management (Immediate, Not Delayed)

While preparing for urgent surgery within hours:

• Broad-spectrum IV antibiotics covering gram-negative, gram-positive, and anaerobic organisms (e.g., piperacillin-tazobactam 4.5g IV or equivalent) 1, 2, 8
• Aggressive fluid resuscitation and correction of electrolyte abnormalities 2
• Nasogastric decompression 2, 7
• CT scan with IV contrast if not already obtained to define the extent of perforation and collections 2, 7

Postoperative Antibiotic Duration

Antibiotics should be continued for 3-5 days after adequate source control 1. The WSES guidelines state: "In elderly patients with complicated diverticulitis a short course of antibiotic therapy (3–5 days) after adequate source control is a reasonable option" 1. Extend to 7 days only if the patient remains critically ill or shows ongoing signs of infection 1, 2, 8.

Why Conservative Management is Contraindicated

Conservative management requires ALL of the following criteria, which your patient does not meet 2, 7, 8:

• ✗ Small, sealed-off perforation (your patient has free air indicating ongoing leak)
• ✗ Localized peritoneal signs only (subcutaneous emphysema indicates extensive dissection)
• ✗ No significant peritoneal contamination (perisigmoid collection present)
• ✗ Hemodynamically stable (may be met, but other criteria are not)

The presence of free intraperitoneal air alone is an absolute contraindication to conservative management in elderly patients 1, 2.

Critical Pitfalls to Avoid

• Do not delay surgery waiting for sepsis to develop—by that point, mortality risk increases exponentially 1, 2, 7
• Do not attempt percutaneous drainage alone for the perisigmoid collection without addressing the perforation source 1
• Do not pursue primary anastomosis in this contaminated field in an elderly patient 1, 2
• Do not be misled by "stable" vital signs—elderly patients may not mount typical inflammatory responses until they decompensate suddenly 1