Perforated sigmoid diverticulitis: Hartmann’s procedure or resection with primary anastomosis—a systematic review and meta-analysis of randomised control trials

  • Roberto Cirocchi
  • Sorena Afshar
  • Fadlo Shaban
  • Riccardo Nascimbeni
  • Nereo Vettoretto
  • Salomone Di Saverio
  • Justus Randolph
  • Mauro Zago
  • Massimo Chiarugi
  • Gian Andrea Binda



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.


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.


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).


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.


Diverticulitis, Colonic Peritonitis Colectomy Anastomosis, Surgical Surgical Stomas 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


There is no funding to declare by any of the authors.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Roberto Cirocchi
    • 1
  • Sorena Afshar
    • 2
  • Fadlo Shaban
    • 2
  • Riccardo Nascimbeni
    • 3
  • Nereo Vettoretto
    • 4
  • Salomone Di Saverio
    • 5
  • Justus Randolph
    • 6
  • Mauro Zago
    • 7
  • Massimo Chiarugi
    • 8
  • Gian Andrea Binda
    • 9
  1. 1.Department of Surgical ScienceUniversity of PerugiaTerniItaly
  2. 2.Royal Victoria InfirmaryNewcastle upon TyneUK
  3. 3.Department of Medical and Surgical SciencesUniversity of BresciaBresciaItaly
  4. 4.Department of SurgeryM Mellini HospitalChiariItaly
  5. 5.Department of Colorectal SurgeryAddenbrooke’s HospitalCambridgeUK
  6. 6.Tift College of EducationMercer UniversityAtlantaUSA
  7. 7.Department of General SurgerySan Pietro PolyclinicPonte San PietroItaly
  8. 8.Emergency Surgery UnitUniversity of PisaPisaItaly
  9. 9.Department of General SurgeryGalliera HospitalGenoaItaly

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