Abstract
Introduction
The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann’s procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis.
Methods
A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals.
Results
Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14–1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41–4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12–0.96, p = 0.04).
Conclusions
PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical option in patients with generalised peritonitis due to diverticular perforation.
Similar content being viewed by others
References
Cirocchi R, Afshar S, Di Saverio S, Popivanov G, De Sol A, Gubbiotti F, Tugnoli G, Sartelli M, Catena F, Cavaliere D, Tabola R, Fingerhut A, Binda GA (2017) A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine. World J Emerg Surg 12:14. https://doi.org/10.1186/s13017-017-0120-y
Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B, Italian Society of C, Rectal S (2015) Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 19(10):615–626. https://doi.org/10.1007/s10151-015-1370-x
Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF (2014) Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 57(3):284–294. https://doi.org/10.1097/DCR.0000000000000075
Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, Di Saverio S, Ulrych J, Kluger Y, Ben-Ishay O, Moore FA, Ivatury RR, Coimbra R, Peitzman AB, Leppaniemi A, Fraga GP, Maier RV, Chiara O, Kashuk J, Sakakushev B, Weber DG, Latifi R, Biffl W, Bala M, Karamarkovic A, Inaba K, Ordonez CA, Hecker A, Augustin G, Demetrashvili Z, Melo RB, Marwah S, Zachariah SK, Shelat VG, McFarlane M, Rems M, Gomes CA, Faro MP, Junior GA, Negoi I, Cui Y, Sato N, Vereczkei A, Bellanova G, Birindelli A, Di Carlo I, Kok KY, Gachabayov M, Gkiokas G, Bouliaris K, Colak E, Isik A, Rios-Cruz D, Soto R, Moore EE (2016) WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 11:37. https://doi.org/10.1186/s13017-016-0095-0
ACPGBI (2014) Commissioning guide: colonic diverticular disease. RCS
Krukowski ZH, Matheson NA (1984) Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 71(12):921–927
Vermeulen J, Coene PP, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GH, Weidema WF, Lange JF (2009) Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one-stage procedure? Colorectal Dis 11(6):619–624. https://doi.org/10.1111/j.1463-1318.2008.01667.x
Breitenstein S, Kraus A, Hahnloser D, Decurtins M, Clavien PA, Demartines N (2007) Emergency left colon resection for acute perforation: primary anastomosis or Hartmann’s procedure? A case-matched control study. World J Surg 31(11):2117–2124. https://doi.org/10.1007/s00268-007-9199-8
Hold M, Denck H, Bull P (1990) Surgical management of perforating diverticular disease in Austria. Int J Colorectal Dis 5(4):195–199
Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, Fazio VW, Aydin N, Darzi A, Senapati A (2006) Primary resection with anastomosis vs. Hartmann’s procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 49(7):966–981. https://doi.org/10.1007/s10350-006-0547-9
Cirocchi R, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A, Noya G, Liu L (2013) Treatment of Hinchey stage III–IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 28(4):447–457. https://doi.org/10.1007/s00384-012-1622-4
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62(10):1006–1012. https://doi.org/10.1016/j.jclinepi.2009.06.005
Higgins JPT, Green S (2011) Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration
Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, Grieder F, Gelpke H, Decurtins M, Tempia-Caliera AA, Demartines N, Hahnloser D, Clavien PA, Breitenstein S (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256(5):819–826. https://doi.org/10.1097/SLA.0b013e31827324ba discussion 826 – 817.
Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L, Bergamaschi R, Study Group on D (2012) Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis 14(11):1403–1410. https://doi.org/10.1111/j.1463-1318.2012.03117.x
Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, Schwarz L, Mege D, Sielezneff I, Sabbagh C, Tuech JJ (2017) Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2017.09.004
Zingg U, Pasternak I, Dietrich M, Seifert B, Oertli D, Metzger U (2010) Primary anastomosis vs Hartmann’s procedure in patients undergoing emergency left colectomy for perforated diverticulitis. Colorectal Dis 12(1):54–60. https://doi.org/10.1111/j.1463-1318.2008.01694.x
Constantinides VA, Tekkis PP, Senapati A, Association of Coloproctology of Great Britain I (2006) Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 93(12):1503–1513. https://doi.org/10.1002/bjs.5402
Abbas S (2007) Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 22(4):351–357. https://doi.org/10.1007/s00384-005-0059-4
Salem L, Flum DR (2004) Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 47(11):1953–1964
Aydin HN, Tekkis PP, Remzi FH, Constantinides V, Fazio VW (2006) Evaluation of the risk of a nonrestorative resection for the treatment of diverticular disease: the Cleveland Clinic diverticular disease propensity score. Dis Colon Rectum 49(5):629–639. https://doi.org/10.1007/s10350-006-0526-1
Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, Coene PP, Weidema WF, Lange JF (2007) Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Dig Surg 24(5):361–366. https://doi.org/10.1159/000107719
Casal Nunez JE, Ruano Poblador A, Garcia Martinez MT, Carracedo Iglesias R, Del Campo Perez V (2008) [Morbidity and mortality after a Hartmann operation due to peritonitis originating from a sigmoid diverticulum disease (Hinchey grade III–IV)]. Cir Esp 84(4):210–214
Aydin HN, Remzi FH, Tekkis PP, Fazio VW (2005) Hartmann’s reversal is associated with high postoperative adverse events. Dis Colon Rectum 48(11):2117–2126. https://doi.org/10.1007/s10350-005-0168-8
Regenet N, Pessaux P, Hennekinne S, Lermite E, Tuech JJ, Brehant O, Arnaud JP (2003) Primary anastomosis after intraoperative colonic lavage vs. Hartmann’s procedure in generalized peritonitis complicating diverticular disease of the colon. Int J Colorectal Dis 18(6):503–507. https://doi.org/10.1007/s00384-003-0512-1
Auguste L, Borrero E, Wise L (1985) Surgical management of perforated colonic diverticulitis. Arch Surg 120(4):450–452
Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC (2008) Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 95(1):97–101. https://doi.org/10.1002/bjs.6024
Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA, Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW, Boermeester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA, Ladies trial c (2015) Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 386(10000):1269–1277. https://doi.org/10.1016/S0140-6736(15)61168-0
Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, Korner H, Dahl FA, Oresland T, Group SS (2015) Laparoscopic lavage vs primary resection for acute perforated diverticulitis: The Scandiv Randomized Clinical Trial. JAMA 314(13):1364–1375. https://doi.org/10.1001/jama.2015.12076
Angenete E, Thornell A, Burcharth J, Pommergaard HC, Skullman S, Bisgaard T, Jess P, Lackberg Z, Matthiessen P, Heath J, Rosenberg J, Haglind E (2016) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: The First Results From the Randomized Controlled Trial DILALA. Ann Surg 263(1):117–122. https://doi.org/10.1097/SLA.0000000000001061
Afshar S, Kurer MA (2016) Laparoscopic peritoneal lavage for perforated diverticulitis: are we any further forward? Colorectal Dis 18(10):937–938. https://doi.org/10.1111/codi.13404
Galbraith N, Carter JV, Netz U, Yang D, Fry DE, McCafferty M, Galandiuk S (2017) Laparoscopic lavage in the management of perforated diverticulitis: a contemporary meta-analysis. J Gastrointest Surg. https://doi.org/10.1007/s11605-017-3462-6
Cirocchi R, Di Saverio S, Weber DG, Tabola R, Abraha I, Randolph J, Arezzo A, Binda GA (2017) Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis. Tech Coloproctol 21(2):93–110. https://doi.org/10.1007/s10151-017-1585-0
Ceresoli M, Coccolini F, Montori G, Catena F, Sartelli M, Ansaloni L (2016) Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials. World J Emerg Surg 11(1):42. https://doi.org/10.1186/s13017-016-0103-4
Angenete E, Bock D, Rosenberg J, Haglind E (2017) Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis—a meta-analysis. Int J Colorectal Dis 32(2):163–169. https://doi.org/10.1007/s00384-016-2636-0
Silva MA, Ratnayake G, Deen KI (2003) Quality of life of stoma patients: temporary ileostomy versus colostomy. World J Surg 27(4):421–424. https://doi.org/10.1007/s00268-002-6699-4
Amelung FJ, Van ‘t Hullenaar CP, Verheijen PM, Consten EC (2017) Ileostomy versus colostomy: which is preferable?. Nederlands tijdschrift voor geneeskunde 161(0):D788
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
There is no funding to declare by any of the authors.
Rights and permissions
About this article
Cite this article
Cirocchi, R., Afshar, S., Shaban, F. et al. Perforated sigmoid diverticulitis: Hartmann’s procedure or resection with primary anastomosis—a systematic review and meta-analysis of randomised control trials. Tech Coloproctol 22, 743–753 (2018). https://doi.org/10.1007/s10151-018-1819-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-018-1819-9