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Meta-analysis of surgical strategies in perforated left colonic diverticulitis with generalized peritonitis

  • Systematic Reviews and Meta-analyses
  • Published:
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Abstract

Purpose

Surgical strategies for perforated diverticulitis (Hinchey stages III and IV) remain controversial. This systematic review aimed to compare the outcome of primary anastomosis, Hartmann procedure and laparoscopic lavage.

Methods

A systematic literature search was conducted through Medline, Embase, Cochrane Central Register and Health Technology Assessment Database to identify randomized and non-randomized controlled trials involving patients with perforated left-sided colonic diverticulitis comparing different surgical strategies. The methodological quality of the included studies was assessed systematically (Grading of Recommendations, Assessment, Development and Evaluation) and a meta-analysis was performed.

Results

After screening 4090 titles and abstracts published between 1958 and January 2018, 148 were selected for full text assessment. Sixteen trials (7 RCTs, 9 non-RCTs) with 1223 patients were included. Mortality rates were not significantly different between Hartmann procedure and primary anastomosis for Hinchey III and IV, neither in the meta-analysis of three RCTs (RR 2.03 (95% CI 0.79 to 5.25); p = 0.14, moderate quality of evidence) nor in the meta-analysis of six observational studies (RR 1.53 (95% CI 0.89 to 2.65); p = 0.13, very low quality of evidence). However, stoma reversal rates were significantly higher in the primary anastomosis group (RR 0.73 (95% CI 0.58 to 0.98); p = 0.008, moderate quality of evidence). Meta-analysis of four RCTs showed no significant difference between laparoscopic lavage for Hinchey III compared to sigmoid resection neither for mortality (RR 1.07 (95% CI 0.65 to 1.76); p = 0.79, moderate quality of evidence) nor for major complications (RR 0.86 (95% CI 0.69 to 1.08); p = 0.20, moderate quality of evidence).

Conclusions

This systematic review suggests similar rates of complications but higher rates of colonic restoration after primary anastomosis compared to Hartmann procedure in perforated diverticulitis with generalized peritonitis (Hinchey III and IV). Results in laparoscopic lavage for Hinchey III are not superior to primary resection. However, further studies with a careful interpretation of the meaning of re-interventions are required.

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Abbreviations

ASA:

American Society of Anaesthesiologists

GRADE:

Grading of Recommendations, Assessment, Development and Evaluation

HP:

Hartmann procedure

LL:

Laparoscopic lavage

LOS:

Length of hospital stay

PA:

Primary anastomosis

RCT:

Randomized controlled trial

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Acknowledgements

We would like to thank Angela Munson and Christa Bosshard or her assistance and proofreading of the manuscript.

Author information

Authors and Affiliations

  1. Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401, Winterthur, Switzerland

    Sina Schmidt, Tarek Ismail, Christopher Soll & Stefan Breitenstein

  2. Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland

    Milo A. Puhan

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  1. Sina Schmidt
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  4. Christopher Soll
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Contributions

Dr. med. Sina Schmidt, Dr. med. Tarek Ismail, Dr. med. Christopher Soll, and Prof. Dr. med. Stefan Breitenstein: study conception and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, and critical revision of manuscript. Prof. Dr. med. Milo A. Puhan: study conception and design, analysis and interpretation of data, drafting of manuscript, and critical revision of manuscript.

Corresponding author

Correspondence to Sina Schmidt.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This manuscript is a meta-analysis; it does not contain any procedures involving human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all participants involved in this study.

Additional information

Sina Schmidt and Tarek Ismail shared first authorship.

Electronic supplementary material

Suppl. Fig. 1

Analysis of 6 observational studies comparing Hartmann Procedure with primary anastomosis (PDF 13 kb)

Suppl. Fig. 2

Analysis of overall morbidity of three observational studies comparing laparoscopic lavage with resection (res.) (PDF 10 kb)

Suppl. Fig. 3

Search Strategy (PDF 51 kb)

Suppl. Table 1

Description of included studies (PDF 200 kb)

Suppl. Table 2

Outcome results of included studies (PDF 13 kb)

Suppl. Table 3b

a: Quality Assessment of included studies comparing Hartmann Procedure with primary anastomosis (randomized controlled trials and observational studies). b: Quality Assessment of included studies comparing colonic resection (Hartmann Procedure or primary anastomosis) with laparoscopic lavage (randomized controlled trials and observational studies) (PDF 51 kb)

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Schmidt, S., Ismail, T., Puhan, M.A. et al. Meta-analysis of surgical strategies in perforated left colonic diverticulitis with generalized peritonitis. Langenbecks Arch Surg 403, 425–433 (2018). https://doi.org/10.1007/s00423-018-1686-x

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  • DOI: https://doi.org/10.1007/s00423-018-1686-x

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