Advertisement

Techniques in Coloproctology

, Volume 22, Issue 10, pp 743–753 | Cite as

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

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

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.

Keywords

Diverticulitis, Colonic Peritonitis Colectomy Anastomosis, Surgical Surgical Stomas 

Introduction

The surgical management of perforated sigmoid diverticulitis with generalised peritonitis is a challenging and evolving issue [1]. Currently, resectional surgery is the treatment of choice, as recommended by most guidelines [2, 3, 4, 5]. Hartmann’s procedure (HP) has been the standard approach for decades. This was solidified in the surgical psyche after the seminal paper by Krukowski et al. in 1984 [6]. However, restoration of intestinal continuity after HP is associated with significant morbidity and mortality [7]. A large proportion (30–60%) of patients never undergo a reversal procedure [7, 8, 9]. This has led to the suggestion of resection with primary anastomosis (PA) as an alternative approach, with or without a covering ileostomy. A number of systematic review and meta-analyses have been published comparing these two approaches [10, 11]. However, there has been no consensus.

We performed a systematic review of the literature to compare HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis.

Materials and methods

A systematic literature search was performed on MEDLINE, Embase, SCOPUS and Web of Science for publications up to March 2018. We considered only randomized controlled trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed [12] (Fig. 1).

Fig. 1

PRISMA flow diagram

The keywords used in the search were ‘colon perforation’ OR ‘peritonitis’ AND ‘diverticulitis’ and their combinations. We also manually searched the references of identified articles and relevant reviews. No language restrictions were applied.

Titles, abstracts and full texts of articles were evaluated independently by two authors (RC and RT). The same two authors independently performed the extraction of data from included articles. Any disagreements between the two authors were resolved by the senior author (GB).

The primary outcomes sought were the postoperative hospital mortality rate after the index intervention, the overall postoperative mortality rate after the index intervention and stoma reversal operation combined, as well as the permanent stoma rate.

The secondary outcomes sought were the postoperative morbidity rate after the index intervention, the overall postoperative morbidity rate after the index intervention and the stoma reversal operation combined, and the rate of postoperative intra-abdominal abscess after the index intervention, anastomotic leak rate, unplanned returns to theatre, length of hospital stay and cost-analysis.

The assessment of methodological quality was performed independently by two authors (RC and RT). Risk of bias was assessed using methods described in the Cochrane Handbook for Systematic Reviews of Interventions [13]. As there were only three included studies, we did not perform a funnel plot for analysis.

Statistical analysis

This meta-analysis was conducted using the Review Manager (RevMan Version 5.3) computer program (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). The outcomes were pooled with a random-effects model with Mantel–Haenszel method to estimate risk ratios and their 95% confidence intervals. For continuous variables Weighted Mean Difference (WMD) and 95% confidence intervals were calculated. Heterogeneity was assessed using I2 statistics. We considered an I2 value exceeding 50% to be indicative of significant heterogeneity. A protocol for this meta-analysis was registered on PROSPERO (http://www.crd.york.ac.uk/prospero): CRD42017078566.

Results

The PRISMA flow diagram for the systematic review is presented in Fig. 1. The initial search yielded 1,204 potentially relevant articles. After removal of duplicates, screening titles/abstracts for relevance and assessment for eligibility, 41 studies were selected for analysis of full text. Of these, 38 were excluded because they were not RCTs. Three RCTs were included in this systematic review and meta-analysis (Table 1). The three included RCTs, encompassing 254 patients reported results comparing sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV).

Table 1

Characteristics of the RCTs included

Study

Nation—participating centers

Registration on Clinical Trial.gov

Estimated sample size: number patients

Enrolling time in the study

Patients screened (n)

Patients randomised (n)

Randomisation

ITT (n) (%)

Patients lost during 1 year follow-up after emergency surgery (n) (%)

PA (n)

HP (n)

Bridoux et al. [16]

Multicenter: France

NCT 00692393

246

2008–2012

NR

102

50

52

Yes

0

Oberkofler et al. [14]

Multicenter: Switzerland

NCT 1239927

136

2006–2009

83

62

32

30

Yes

0

Binda et al. [15]

Multicenter: Italy, Norway, Turkey, USA, Poland, Slovenia, Israel

NCT 1239927

600

2001–2010

NR

90

34

56

Yes

4 (4.4%)

PA primary anastomosis, HP Hartmann procedure, ITT intention to treat, n number, NR not reported, RCT randomised controlled trial

Characteristics of the studies

The three RCTs were multicentre studies conducted in Italy, France, Switzerland, Norway, Turkey, Poland, Slovenia, Israel and the USA, between 2001 and 2012. All the include studies were registered at ClinicalTrials.gov. All conducted power analyses, but none met the sample sizes suggested for those analyses. The inclusion criteria were perforated sigmoid diverticulitis with Hinchey III and IV generalised peritonitis. The exclusion criteria were Hinchey I and II, evidence of malignancy, clinical state which prevented patient’s participation (septic shock or multi-visceral failure) and the lack of consent (Table 2).

Table 2

Inclusion and exclusion criteria

Study

Inclusion criteria

Exclusion criteria

Bridoux et al. [16]

Left-sided perforated diverticulitis with Hinchey III and IV generalized peritonitis

Physical states which prevented patient’s participation (septic shock or multi-visceral failure) failure to sign consent

Oberkofler et al. [14]

Left-sided perforated diverticulitis with Hinchey III and IV generalized peritonitis

Hinchey I and II evidence of metastasis failure to sign consent

Binda et al. [15]

Left-sided perforated diverticulitis with Hinchey III and IV generalized peritonitis

Failure to sign consent peritonitis secondary to perforated diverticulitis of right colon

The total number of screened patients was only reported by Oberkofler et al. [14]. They reported 83 patients who were screened with a suspected diagnosis of generalised peritonitis from complicated colonic diverticulitis. Of those, 62 were included for randomisation (74.7%). Overall, 1.6% of the randomised patients were lost to follow-up (4 out of 254 patients).

The characteristics of the patients [sex, age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, Hinchey stage III/IV, Mannheim Peritonitis Index] were not significantly different between the two groups in any of the included studies, where reported (Tables 3, 4). Only two of the studies reported the level of expertise of the surgeons and the timing of the surgery (Table 4). Although none of the studies defined a ‘permanent’ stoma, all patients who did not have bowel continuity restored were followed up for at least 1 year. Therefore, stomas not reversed within 1 year of the index intervention are considered ‘permanent’ stomas for the purposes of this analysis.

Table 3

Patient characteristics

Study

Sex (M/F)

n. pts

P value

Age, years (median, range)

P value

BMI, kg/m2 (mean, range)

P value

ASA class

N (%)

P value

Hinchey stage III/IV

n. pts

P value

PA

HP

PA

HR

PA

HR

PA

HR

PA

HR

Bridoux et al. [16]

28/22

23/29

0.234

61 (25–93)

61.5 (29–92)

0.445

26.1 (20–43)

26.8 (19.3–44.6)

0.541

ASA > 1–45 (90%)

ASA > 1–43 (83%)

0.283

42/8

40/12

0.235

Oberkofler et al. [14]

12/20

9/21

0.598

72 (60–83)

74 (61–81)

0.652

24 (23–28)

24 (22–29)

0.987

ASA I–III—24 (75%)

ASA IV—8 (25%)

ASA I–III—22 (73%)

ASA IV—8 (27%)

1.000

24/8

23/7

1.000

Binda et al. [15]

22/12

27/29

0.190

63.5 ± 2.2a

65.7 ± 1.8a

0.481

NR

NR

NR

NR

NR

NR

30/4

45/11

0.394

PA primary anastomosis, HP Hartmann procedure, n. pts number of patients, BMI body mass index, ASA American Society of Anesthesiologists, NR not reported

aMean ± SD

Table 4

Operative details

Author – year of publication

MPI score, median (range)

P value

First surgeon resident, n. pts (%)

P value

Night surgery, n. pts (%)

P value

C-reactive protein (mg/L), median (IQR)

P value

PA

HP

PA

HR

PA

HR

PA

HR

Bridoux et al. [16]

26 (16–39)

27 (20–43)

0.060

24 (48%)

23 (45.1%)

0.770

19 (38%)

22 (43%)

0.599

NR

NR

NR

Oberkofler et al. [14]

24 (19–28)

22 (16–28)

0.886

4 (12%)

6 (20%)

0.502

NR

NR

NR

194 (67–291)

236 (136–307)

0.105

Binda et al. [15]

11.4 ± 0.6a

12.7 ± 0.6a

0.145

NR

NR

NR

15 (44%)

36 (64%)

0.083

NR

NR

NR

PA primary anastomosis, HP Hartmann procedure, MPI = Mannheim peritonitis index, n. pts number of patients, NR not reported

aMean ± SD

The summary of the quality assessment of the included studies is shown in Fig. 2. The principal limitation of these trials was the small sample size. Lack of blinding was also a significant limitation. The risk for blinding of outcome assessment (detection bias) was unclear, since none of the studies described detail of any measures used to blind the outcome assessors from knowledge of which intervention a participant received. An intention-to-treat analysis was performed in all of the studies. The surgical procedures were not standardised and there was considerable heterogeneity in the use of a covering stoma in the PA group (all patients in the study by Binda et al. [15]; 46% in the study by Bridoux et al. [16]; and 30% in the study by Oberkofler et al. [14]).

Fig. 2

Methodological quality assessment of the included studies

Primary outcomes

There was no statistically significant difference in the rate of postoperative hospital mortality after the index intervention (RR = 0.63, 95% CI 0.23–1.70). Similarly, there was no statistically significant difference in the cumulative rate of postoperative hospital mortality after the index intervention and the stoma reversal operation (RR = 0.52, 95% CI 0.20–1.35). There was no statistically significant difference in the permanent stoma rate (RR = 0.40, 95% CI 0.14–1.16). (Fig. 3a–c).

Fig. 3

Forest plots of pooled outcomes. a Postoperative hospital mortality rate after index intervention. b Overall postoperative mortality rate after index intervention and stoma reversal operation. c Permanent stoma rate (covering ileostomy or end colostomy). d Postoperative morbidity rate after index intervention. e Overall postoperative morbidity rate after index intervention and stoma reversal operation. f Postoperative intra-abdominal abscess after index intervention. g Overall anastomotic leak rate after index intervention and stoma reversal operation. h Unplanned returns to theatre after the index intervention. i Overall unplanned returns to theatre after the index intervention and stoma reversal operation. j Length of hospital stay after the index intervention

Secondary outcomes

There was no statistically significant difference in the rate of postoperative morbidity after the index intervention (RR = 1.05, 95% CI 0.85–1.30). Similarly, there was no statistically significant difference in the cumulative rate of postoperative morbidity after the index intervention and the stoma reversal operation combined (RR = 0.96, 95% CI 0.71–1.30). Patients in the PA group had a 66% lower risk of a postoperative intra-abdominal abscess than the patients in the HP group (RR = 0.34, 95% CI 0.12–0.96). See Fig. 3d–f.

The pooled rate of cumulative anastomotic leak rate after index intervention including stoma reversal operation (Fig. 3g) was lower in HP group (5/138, 3.6%) than PA group (6/116, 5.2%), however, this difference was not statistically significant (RR = 1.42, 95% CI 0.41–4.87).

Binda et al. reported a single anastomotic leak in PA group after the index intervention (n = 34) who was converted to a HP [15]. Oberkofler et al. also reported a single anastomotic leak in the PA group after the index intervention (n = 32), but did not report how this was managed [14]. Bridoux et al. reported two patients with anastomotic leaks in the PA group after the index intervention (n = 50), one patient was converted to a HP and the other was treated with a colonic stent [16]. Bridoux et al. reported one patient with an anastomotic leak in the reversal of ileostomy after PA group (n = 32) without detail of their management and one patient who required drainage of abdominal abscess in the reversal of HP group (n = 33), although it is not clear whether this resulted from an anastomotic leak [16]. Binda et al. only report the anastomotic leaks that needed re-operation: one in the in the reversal of ileostomy after PA group (n = 22) and two in the reversal of HP group (n = 34) [15]. Oberkofler et al. reported no anastomotic leaks in the reversal of ileostomy after PA group (n = 26) and two anastomotic leaks in the reversal of HP group (n = 15) without detail of their management [14].

Only two of the studies reported unplanned returns to theatre after the index procedure [15, 16]. Oberkofler et al. grouped this outcome with organ failure under Clavien-Dindo grades IIIb-V complications [14]. The pooled rate was lower in the PA group (3/84, 3.6%) compared with the HP group (5/108, 4,6%). However, this difference was not statistically significant (RR 0.71, 95% CI 0.17–2.91) (Fig. 3h).

Overall unplanned returns to theatre after the index intervention and stoma reversal operation combined was reported by two of the studies. The pooled rate was lower in PA group (5/84, 6%) than HP group (9/108, 8.3%), however, this difference was not statistically significant (Fig. 3i).

Length of hospital stay was similar in the HP and PA groups in the two of the included studies where it was reported (WMD − 4.31 days, 95% CI − 10.92–2.30)—See Fig. 3j [14, 16]. Cost-analysis was performed by one of the included studies [14], which reported similar costs for both groups after the index intervention, stoma reversal operation and with all procedures combined.

Discussion

In this meta-analysis of all currently available RCTs comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis, we found no significant difference between PA and HP in terms of postoperative morbidity and mortality after the index procedure or cumulatively after inclusion of the stoma reversal surgery. Despite two out of the three trials reporting a lower permanent stoma rate in the PA arm [14, 16], the difference in permanent stoma rates was not statistically significant in our meta-analysis. While none of the three studies found a significant difference in postoperative intra-abdominal abscess rates, a pooled analysis showed a reduced incidence in the PA arm. The reasons for this are unclear, but we speculate it may be related to rectal stump leakage in the HP group, which is not specifically reported in any of the included studies. The rectal stump leak rate after HP for perforated diverticulitis in the literature is reported to be around 2–3% [17, 18]. Other possible reasons are changes in the intraoperative conduct such as carrying out a more thorough intraoperative lavage. This finding warrants further investigation as the understanding of the reasons may lead to improvement of postoperative outcome after either PA or HP.

The management of complicated sigmoid diverticulitis is controversial. The literature is dominated by nonrandomised studies, the majority of which are retrospective [10, 18, 19, 20]. Selection bias in such studies impedes generalisability of the findings [20]. One prospective study identified predictors of patients undergoing HP instead of PA were BMI > 30 kg m−2, Mannheim peritonitis index > 10, operative urgency (emergency/urgent compared to elective) and Hinchey grade III and IV [21]. This is the most likely explanation for the higher mortality and morbidity reported after HP compared to PA in observational studies [22, 23]. Therefore, although data from such nonrandomised studies show that PA is a feasible option in selected patients, RCTs are required to guide practice. To date, only the three RCTs included in this meta-analysis exist [14, 15, 16].

Most of the available guidelines recommend resection surgery in perforated diverticulitis; however, they do not give a clear preference for either PA or HP [2, 3, 4, 5]. The World Society of Emergency Surgery (WSES) 2016 guidelines advise HP for managing generalised peritonitis in critically ill patients and in patients with multiple comorbidities [4]. However, they also advise that in clinically stable patients with no co-morbidities, PA with or without a diverting stoma may be performed [4]. The American Society of Colon and Rectal Surgeons (ASCRS) 2014 practice parameters recommend that “following resection, the decision to restore bowel continuity must incorporate patient factors, intraoperative factors and surgeon preference” [3]. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Royal College of Surgeons (RCS) 2014 guidance on colonic diverticular disease states that both HP and PA with or without a covering stoma are potential options and the decision as to which to utilise should be made on an individual patient basis [5]. Reversal of HP is viewed by most surgeons as a more complex procedure with a higher risk of adverse events when compared to closure of a covering ileostomy [7, 24]. In our meta-analysis the cumulative morbidity and mortality were similar after PA and HP. It has to be borne in mind that in the included RCTs restoration of bowel continuity was largely dependent on surgeon and patients’ choice. Therefore, selection bias may have been a factor. In previous nonrandomised studies, the reported rates of restoration of bowel continuity is usually higher after PA (80–90%) [8, 20], when compared to HP (40–70%) [7, 8, 9]. These figures are very similar to those reported in the RCTs included in this meta-analysis [14, 15, 16].

Interestingly, 67% of patients in the PA arms of the study by Bridoux et al. avoided a covering stoma [16]. This constituted deviation from the study protocol. All but one of the fifteen patients who did not have a covering stoma, had Hinchey III peritonitis and the morbidity was low in this select group. Previous studies have demonstrated that PA without a covering ileostomy is feasible; however, it can be associated with a significant rate of complications (24–84%) [9, 25, 26]. The covering ileostomy in the PA group was mandatory in the study by Binda et al. [15]. The aim was to create a more homogeneous group and to avoid confounding factors. In practice the decision to perform a covering ileostomy after a PA conducted in the emergency setting is based on a variety of factors including: the hydro-pneumatic leak test, perceived viability of the anastomosis and other intraoperative variables. Identifying patients undergoing PA who could safely avoid a covering stoma is an area for further research.

All RCTs included in this review had a small sample size. They were all terminated early and did not reach their target sample size because of difficulties in recruitment. Binda et al. achieved under a third of their calculated sample size over a lengthy 9-year recruitment period with an average of less than one patient recruited per participating centre per year [15]. Recruitment in the emergency surgical setting carries inherent logistical difficulties. Oberkofler et al. were also advised to stop the trial after an interim safety analysis that reported significantly more serious complications with stoma reversal after HP than after PA (20 vs 0%) [14]. Bridoux et al. achieved less than half their calculated sample size [16]. The authors’ point to the uptake of laparoscopic peritoneal lavage to treat Hinchey III during their recruitment period, resulting in some surgeons not being willing to randomise patients to resection surgery, as a potential factor. Interest in laparoscopic peritoneal lavage rose after the publication of a large prospective series by Myers et al. in 2008 showing good outcomes [27]. More recently reports from three RCTs on laparoscopic peritoneal lavage have been published [28, 29, 30]. The interpretation of data from these RCTs has been the subject of some debate [31], resulting in a number meta-analysis, some with opposing conclusions [32, 33, 34, 35].

All included trials were at high risk of bias. Despite the randomised design of the included studies, selection bias is still a potential concern. The higher number of patients recruited in the HP arm (n = 56) compared to PA (n = 34) in the study by Binda et al. suggests protocol violation and selection bias [15]. The higher proportion of patients with Hinchey IV in HP arm (20%) compared to PA arm (12%) in this study further points to this possibility. Oberkofler et al. report that around a half of all potentially eligible patients presenting to the recruiting units were not assessed for eligibility either because of the surgeons’ disagreement about enrolment or the patient declining to participate [14]. Bridoux et al. did not record the number of patients excluded at the request of the Ethics Committee, but recognised the potential for selection bias as a limitation of their study [16]. This suggests a possible lack of equipoise, reversion to surgeons’ preference and selection bias during the conduct of the RCTs included in this review. However, the extent of such biases is difficult to quantify. The tendency for critically ill patients with more severe pathology to have a HP is a recognised phenomenon [21, 22]. Moreover, PA and HP are rather different in terms of technical complexity and expertise required. HP is generally viewed as a faster and simpler index procedure [15]. The surgeon with less expertise may be more inclined to perform HP rather than PA.

None of the included RCTs were blinded, which also introduces risk of bias. Blinding of patients, surgeons or researchers is problematic in this setting. It is difficult to envisage a practical and effective solution to this problem.

None of the studies in our meta-analysis included quality of life (QOL) data. Both ileostomy and colostomy result in significant QOL impairment [36]. Ileostomies are generally better tolerated, although they can lead to complications, including dehydration and renal impairment [36, 37]. Given that a proportion of patients with colostomy and ileostomy did not have bowel continuity restored, the impact on QOL is an important consideration when evaluating the merits of each surgical approach.

Statistical heterogeneity was low for all our outcomes of interest, except postoperative morbidity rate after index intervention including the stoma reversal operation and permanent stoma rate. The reasons for higher statistical heterogeneity in the latter two outcomes of interest are unknown, but are likely to be related to clinical differences between the studies due to patient factors, definitions of morbidity and surgeons’ preferred practice for reversal of stomas.

The participants in the Oberkofler et al. study were on average around a decade older (mean age 73) than in the other two studies (mean age 61 and 65 in the studies by Bridoux et al. and Binda et al., respectively). The majority of patients had Hinchey III and the remainder had Hinchey IV disease, which was consistent across the included studies (mean range from 76–83%). The surgical interventions were not standardised and grades of operating surgeons varied significantly. All procedures were performed by a laparotomy in the study by Bridoux et al. [16]. In the study by Binda et al. 11.8% of PA and 5.4% HP procedures were performed laparoscopically [15]. Oberkofler et al. did not state if any of the procedures were laparoscopic.

Conclusions

PA and HP seem to be equivalent in terms of most outcomes of interest with a lower intra-abdominal abscess rate after the index procedure favouring PA. However, given the significant limitations of the included RCTs, these findings may not be applicable to all patients presenting with perforated sigmoid diverticulitis and generalised peritonitis. There is a need for well-designed and implemented RCTs with sufficient statistical power to address this question.

Notes

Compliance with ethical standards

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.

References

  1. 1.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    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 CrossRefPubMedGoogle Scholar
  3. 3.
    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 CrossRefPubMedGoogle Scholar
  4. 4.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    ACPGBI (2014) Commissioning guide: colonic diverticular disease. RCSGoogle 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(12):921–927CrossRefGoogle Scholar
  7. 7.
    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 CrossRefPubMedGoogle Scholar
  8. 8.
    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 CrossRefPubMedGoogle Scholar
  9. 9.
    Hold M, Denck H, Bull P (1990) Surgical management of perforating diverticular disease in Austria. Int J Colorectal Dis 5(4):195–199CrossRefGoogle Scholar
  10. 10.
    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 CrossRefPubMedGoogle Scholar
  11. 11.
    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 CrossRefPubMedGoogle Scholar
  12. 12.
    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 CrossRefGoogle Scholar
  13. 13.
    Higgins JPT, Green S (2011) Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane CollaborationGoogle Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    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 CrossRefPubMedGoogle Scholar
  16. 16.
    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 CrossRefPubMedGoogle Scholar
  17. 17.
    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 CrossRefPubMedGoogle Scholar
  18. 18.
    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 CrossRefPubMedGoogle Scholar
  19. 19.
    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 CrossRefPubMedGoogle Scholar
  20. 20.
    Salem L, Flum DR (2004) Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 47(11):1953–1964CrossRefGoogle Scholar
  21. 21.
    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 CrossRefPubMedGoogle Scholar
  22. 22.
    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 CrossRefPubMedGoogle Scholar
  23. 23.
    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):210–214CrossRefGoogle Scholar
  24. 24.
    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 CrossRefPubMedGoogle Scholar
  25. 25.
    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 CrossRefPubMedGoogle Scholar
  26. 26.
    Auguste L, Borrero E, Wise L (1985) Surgical management of perforated colonic diverticulitis. Arch Surg 120(4):450–452CrossRefGoogle Scholar
  27. 27.
    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 CrossRefPubMedGoogle Scholar
  28. 28.
    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 CrossRefPubMedGoogle Scholar
  29. 29.
    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 CrossRefPubMedGoogle Scholar
  30. 30.
    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 CrossRefPubMedGoogle Scholar
  31. 31.
    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 CrossRefPubMedGoogle Scholar
  32. 32.
    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 CrossRefPubMedGoogle Scholar
  33. 33.
    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 CrossRefPubMedGoogle Scholar
  34. 34.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    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 CrossRefPubMedGoogle Scholar
  36. 36.
    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 CrossRefPubMedGoogle Scholar
  37. 37.
    Amelung FJ, Van ‘t Hullenaar CP, Verheijen PM, Consten EC (2017) Ileostomy versus colostomy: which is preferable?. Nederlands tijdschrift voor geneeskunde 161(0):D788PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Roberto Cirocchi
    • 1
  • Sorena Afshar
    • 2
    Email author
  • 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

Personalised recommendations