International Journal of Colorectal Disease

, Volume 28, Issue 4, pp 447–457 | Cite as

Treatment of Hinchey stage III–IV diverticulitis: a systematic review and meta-analysis

  • Roberto Cirocchi
  • Stefano Trastulli
  • Jacopo Desiderio
  • Chiara Listorti
  • Carlo Boselli
  • Amilcare Parisi
  • Giuseppe Noya
  • Liu Liu
Review

Abstract

Background

This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.

Objective

This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.

Methods

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.

Results

Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann’s procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).

Conclusions

Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

Keywords

Diverticulitis Colonic perforation Peritonitis 

References

  1. 1.
    Weizman AV, Nguyen GC (2011) Diverticular disease: epidemiology and management. Can J Gastroenterol 25:385–389PubMedGoogle Scholar
  2. 2.
    Vermeulen J, Lange JF (2010) Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future. World J Surg 34:587–593PubMedCrossRefGoogle Scholar
  3. 3.
    Hughes ES, Cuthbertson AM, Carden AB (1963) The surgical management of acute diverticulitis. Med J Aust 50(1):780–782PubMedGoogle Scholar
  4. 4.
    Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109PubMedGoogle Scholar
  5. 5.
    Killingback M (1983) Management of perforative diverticulitis. Surg Clin North Am 63:97–115PubMedGoogle Scholar
  6. 6.
    Krukowski ZH, Matheson NA (1984) Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 71:921–927PubMedCrossRefGoogle Scholar
  7. 7.
    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 49:629–639PubMedCrossRefGoogle Scholar
  8. 8.
    Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C et al (2005) The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 100:910–917PubMedCrossRefGoogle Scholar
  9. 9.
    Smithwick RH (1942) Experiences with the surgical management of diverticulitis of the sigmoid. Ann Surg 115:969–985PubMedCrossRefGoogle Scholar
  10. 10.
    Lockhart-Mummery JP (1938) Late results of diverticulitis. Lancet 2:1401–1404CrossRefGoogle Scholar
  11. 11.
    Greif JM, Fried G, McSherry CK (1980) Surgical treatment of perforated diverticulitis of the sigmoid colon. Dis Colon Rectum 23:483–487PubMedCrossRefGoogle Scholar
  12. 12.
    Banerjee S, Leather AJ, Rennie JA, Samano N, Gonzalez JG, Papagrigoriadis S (2005) Feasibility and morbidity of reversal of Hartmann's. Colorectal Dis 7:454–459PubMedCrossRefGoogle Scholar
  13. 13.
    Toorenvliet BR, Bakker RF, Breslau PJ, Merkus JW, Hamming JF (2010) Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Dis 12:179–186PubMedCrossRefGoogle Scholar
  14. 14.
    White SI, Frenkiel B, Martin PJ (2010) A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage. Dis Colon Rectum 53:1537–1541PubMedCrossRefGoogle Scholar
  15. 15.
    Kohler L, Sauerland S, Neugebauer E (1999) Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 13:430–436PubMedCrossRefGoogle Scholar
  16. 16.
    Lee EC, Murray JJ, Coller JA, Roberts PL, Schoetz DJ Jr (1997) Intraoperative colonic lavage in nonelective surgery for diverticular disease. Dis Colon Rectum 40:669–674PubMedCrossRefGoogle Scholar
  17. 17.
    Biondo S, Pares D, Kreisler E, Rague JM, Fraccalvieri D, Ruiz AG et al (2005) Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 48:2272–2280PubMedCrossRefGoogle Scholar
  18. 18.
    Tabbara M, Velmahos GC, Butt MU, Chang Y, Spaniolas K, Demoya M et al (2010) Missed opportunities for primary repair in complicated acute diverticulitis. Surgery 148:919–924PubMedCrossRefGoogle Scholar
  19. 19.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097PubMedCrossRefGoogle Scholar
  20. 20.
    Higgins J, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions. Wiley, ChichesterGoogle Scholar
  21. 21.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e1000100PubMedCrossRefGoogle Scholar
  22. 22.
    Greenland S, Robins JM (1985) Estimation of a common effect parameter from sparse follow-up data. Biometrics 41:55–68PubMedCrossRefGoogle Scholar
  23. 23.
    Mantel N, Haenszel W (1959) Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 22:719–748PubMedGoogle Scholar
  24. 24.
    Friedman HP, Goldberg JD (1996) Meta-analysis: an introduction and point of view. Hepatology 23:917–928PubMedCrossRefGoogle Scholar
  25. 25.
    SIGN guidelines. Available at: http://www.sign.ac.uk/guidelines/fulltext/50/checklist3. Accessed 20 Mar 2009
  26. 26.
    Rangel SJ, Kelsey J, Colby CE, Anderson J, Moss RL (2003) Development of a quality assessment scale for retrospective clinical studies in pediatric surgery. J Pediatr Surg 38:390–396, discussion −6PubMedCrossRefGoogle Scholar
  27. 27.
    Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12PubMedCrossRefGoogle Scholar
  28. 28.
    Chalmers TC, Smith H Jr, Blackburn B, Silverman B, Schroeder B, Reitman D et al (1981) A method for assessing the quality of a randomized control trial. Control Clin Trials 2:31–49PubMedCrossRefGoogle Scholar
  29. 29.
    Egger M (1997) Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634PubMedCrossRefGoogle Scholar
  30. 30.
    Fegiz G, Tonelli F, Rossi P, Di Paola M, De Masi E, Simonetti G (1976) Preservation of the superior hemorrhoidal artery in resection of the colon and rectum. Surg Gynecol Obstet 143:919–925PubMedGoogle Scholar
  31. 31.
    Napolitano AM, Napolitano L, Costantini R, Ucchino S (1996) Innocenti P [Skeletization of the inferior mesenteric artery in colorectal surgery. Current considerations]. G Chir 17:185–189PubMedGoogle Scholar
  32. 32.
    Gooszen AW, Tollenaar RA, Geelkerken RH, Smeets HJ, Bemelman WA, Van Schaardenburgh P et al (2001) Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 88:693–697PubMedCrossRefGoogle Scholar
  33. 33.
    Hoemke M, Treckmann J, Schmitz R, Shah S (1999) Complicated diverticulitis of the sigmoid: a prospective study concerning primary resection with secure primary anastomosis. Dig Surg 16:420–424PubMedCrossRefGoogle Scholar
  34. 34.
    Messinetti S, Giacomelli L, Manno A, Finizio R, Fabrizio G, Granai AV et al (1998) Preservation and peeling of the inferior mesenteric artery in the anterior resection for complicated diverticular disease. Ann Ital Chir 69:479–482, discussion 82–3PubMedGoogle Scholar
  35. 35.
    Urbanavicius L, Pattyn P, de Putte DV, Venskutonis D (2011) How to assess intestinal viability during surgery: a review of techniques. World J Gastrointest Surg 3:59–69PubMedCrossRefGoogle Scholar
  36. 36.
    Binda GA, Arezzo A, Serventi A, Bonelli L, Facchini M, Prandi M et al (2012) Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 99:276–285PubMedCrossRefGoogle Scholar
  37. 37.
    Gooszen AW, Gooszen HG, Veerman W, Van Dongen VM, Hermans J, Klien Kranenbarg E et al (2001) Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection. Eur J Surg 167:35–39PubMedCrossRefGoogle Scholar
  38. 38.
    Hold M, Denck H, Bull P (1990) Surgical management of perforating diverticular disease in Austria. Int J Colorectal Dis 5:195–199PubMedCrossRefGoogle Scholar
  39. 39.
    Regenet N, Pessaux P, Hennekinne S, Lermite E, Tuech JJ, Brehant O et al (2003) Primary anastomosis after intraoperative colonic lavage vs. Hartmann's procedure in generalized peritonitis complicating diverticular disease of the colon. Int J Colorectal Dis 18:503–507PubMedCrossRefGoogle Scholar
  40. 40.
    Richter S, Lindemann W, Kollmar O, Pistorius GA, Maurer CA, Schilling MK (2006) One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV). World J Surg 30:1027–1032PubMedCrossRefGoogle Scholar
  41. 41.
    Schilling MK, Maurer CA, Kollmar O, Buchler MW (2001) Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis. Dis Colon Rectum 44:699–703, discussion −5PubMedCrossRefGoogle Scholar
  42. 42.
    Trenti L, Biondo S, Golda T, Monica M, Kreisler E, Fraccalvieri D et al (2011) Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis? Int J Colorectal Dis 26:377–384PubMedCrossRefGoogle Scholar
  43. 43.
    Finlay IG, Carter DC (1987) A comparison of emergency resection and staged management in perforated diverticular disease. Dis Colon Rectum 30:929–933PubMedCrossRefGoogle Scholar
  44. 44.
    Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G (2009) Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 52:609–615PubMedCrossRefGoogle Scholar
  45. 45.
    Nagorney DM, Adson MA, Pemberton JH (1985) Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 28:71–75PubMedCrossRefGoogle Scholar
  46. 46.
    Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E et al (2007) Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Dig Surg 24:361–366PubMedCrossRefGoogle Scholar
  47. 47.
    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 12:54–60PubMedCrossRefGoogle Scholar
  48. 48.
    Zeitoun G, Laurent A, Rouffet F, Hay J, Fingerhut A, Paquet J et al (2000) Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg 87:1366–1374PubMedCrossRefGoogle Scholar
  49. 49.
    Kronborg O (1993) Treatment of perforated sigmoid diverticulitis: a prospective randomized trial. Br J Surg 80:505–507PubMedCrossRefGoogle Scholar
  50. 50.
    Perathoner A, Klaus A, Muhlmann G, Oberwalder M, Margreiter R, Kafka-Ritsch R (2010) Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis—a proof of concept. Int J Colorectal Dis 25:767–774PubMedCrossRefGoogle Scholar
  51. 51.
    Pasternak I, Dietrich M, Woodman R, Metzger U, Wattchow DA, Zingg U (2010) Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis. Int J Colorectal Dis 25:463–470PubMedCrossRefGoogle Scholar
  52. 52.
    Krukowski ZH (2009) Diverticular disease. In: Phillips RKS (ed) Colorectal surgery: a companion to specialist surgical practice, 3rd edn. Saunders, Edinburgh, p 107–124Google Scholar
  53. 53.
    Practice parameters for sigmoid diverticulitis (2000) The Standards Task Force, American Society of Colon and Rectal Surgeons. Surg Laparosc Endosc Percutan Tech 10:142–148.Google Scholar
  54. 54.
    Mayo WJ, Wilson LB, Griffin HZ (1907) Acquired diverticulitis of the large intestine. Surg Gynecol Obstet 5:8–15Google Scholar
  55. 55.
    Bauer VP (2009) Emergency management of diverticulitis. Clin Colon Rectal Surg 22:161–168PubMedCrossRefGoogle Scholar
  56. 56.
    Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH et al (2006) Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 49:966–981PubMedCrossRefGoogle Scholar
  57. 57.
    Afshar S, Kurer MA (2012) Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis. Colorectal Dis 14:135–142PubMedCrossRefGoogle Scholar
  58. 58.
    Naraynsingh V, Maharaj R, Hassranah D, Hariharan S, Dan D, Zbar AP (2011) Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making? Tech Coloproctol 15:199–203PubMedCrossRefGoogle Scholar
  59. 59.
    Mueller MH, Karpitschka M, Renz B, Kleespies A, Kasparek MS, Jauch KW et al (2011) Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis. Int J Colorectal Dis 26:227–234PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Roberto Cirocchi
    • 1
  • Stefano Trastulli
    • 1
  • Jacopo Desiderio
    • 1
  • Chiara Listorti
    • 1
  • Carlo Boselli
    • 1
  • Amilcare Parisi
    • 2
  • Giuseppe Noya
    • 1
  • Liu Liu
    • 3
  1. 1.Department of General and Oncologic SurgeryUniversity of PerugiaPerugiaItaly
  2. 2.Department of Digestive Surgery and Liver UnitSt. Maria HospitalTerniItaly
  3. 3.Department of SurgeryPrince of Wales Hospital, Chinese University of Hong KongHong KongChina

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