Diseases of the Colon & Rectum

, Volume 49, Issue 7, pp 966–981 | Cite as

Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

  • Vasilis A. Constantinides
  • Paris P. Tekkis
  • Thanos Athanasiou
  • Omer Aziz
  • Sanjay Purkayastha
  • Feza H. Remzi
  • Victor W. Fazio
  • Nail Aydin
  • Ara Darzi
  • Asha Senapati
Article

Purpose

This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis.

Methods

Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed.

Results

Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome.

Conclusions

Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Key words

Systematic review Primary resection and anastomosis Hartmann’s procedure Diverticulitis Diverticular disease 

References

  1. 1.
    Wong, WD, Wexner, SD, Lowry, A,  et al. 2000Practice parameters for the treatment of sigmoid diverticulitis–supporting documentation. The Standards Task Force. The American Society of Colon and Rectal SurgeonsDis Colon Rectum43290297PubMedCrossRefGoogle Scholar
  2. 2.
    Sanderson, ER 1980Henri Hartmann and the Hartmann operationArch Surg115792793PubMedGoogle Scholar
  3. 3.
    Nagorney, DM, Adson, MA, Pemberton, JH 1985Sigmoid diverticulitis with perforation and generalized peritonitisDis Colon Rectum287175PubMedGoogle Scholar
  4. 4.
    Rodkey, GV, Welch, CE 1984Changing patterns in the surgical treatment of diverticular diseaseAnn Surg200466478PubMedGoogle Scholar
  5. 5.
    Zeitoun, G, Laurent, A, Rouffet, F,  et al. 2000Multicentre, randomized clinical trial of primary vs. secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitisBr J Surg8713661374PubMedCrossRefGoogle Scholar
  6. 6.
    Belmonte, C, Klas, JV, Perez, JJ,  et al. 1996The Hartmann procedure. First choice or last resort in diverticular disease?Arch Surg131612615PubMedGoogle Scholar
  7. 7.
    Ling, L, Aberg, T 1984Hartmann procedureActa Chir Scand150413417PubMedGoogle Scholar
  8. 8.
    Wigmore, SJ, Duthie, GS, Young, IE,  et al. 1995Restoration of intestinal continuity following Hartmann’s procedure: the Lothian experience 1987–1992Br J Surg822730PubMedGoogle Scholar
  9. 9.
    Auguste, LJ, Wise, L 1981Surgical management of perforated diverticulitisAm J Surg141122127PubMedCrossRefGoogle Scholar
  10. 10.
    Hiltunen, KM, Kolehmainen, H, Vuorinen, T, Matikainen, M 1991Early water-soluble contrast enema in the diagnosis of acute colonic diverticulitisInt J Colorectal Dis6190192PubMedCrossRefGoogle Scholar
  11. 11.
    Lambert, ME, Knox, RA, Schofield, PF, Hancock, BD 1986Management of the septic complications of diverticular diseaseBr J Surg73576579PubMedGoogle Scholar
  12. 12.
    Dudley, HA, Racliffe, AG, McGeehan, D 1980Intraoperative irrigation of the colon to permit primary anastomosisBr J Surg678081PubMedGoogle Scholar
  13. 13.
    Haglund, U, Hellberg, R, Johnsen, C, Hulten, L 1979Complicated diverticular disease of the sigmoid colon. An analysis of short and long term outcome in 392 patientsAnn Chir Gynaecol684146PubMedGoogle Scholar
  14. 14.
    Salem, L, Flum, DR 2004Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic reviewDis Colon Rectum4719531964PubMedCrossRefGoogle Scholar
  15. 15.
    Hinchey, EJ, Schaal, PG, Richards, GK 1978Treatment of perforated diverticular disease of the colonAdv Surg1285109PubMedGoogle Scholar
  16. 16.
    Moher, D, Cook, DJ, Eastwood, S,  et al. 1999Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analysesLancet35418961900PubMedCrossRefGoogle Scholar
  17. 17.
    Clarke, M, Horton, R 2001Bringing it all together: Lancet-Cochrane collaborate on systematic reviewsLancet3571728PubMedCrossRefGoogle Scholar
  18. 18.
    Stroup, DF, Berlin, JA, Morton, SC,  et al. 2000Meta-analysis ofobservational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies inEpidemiology (MOOSE) groupJAMA28320082012PubMedCrossRefGoogle Scholar
  19. 19.
    Mantel, N, Haenszel, W 1959Statistical aspects of the analysis of data from retrospective studies of diseaseJ Natl Cancer Inst22719748PubMedGoogle Scholar
  20. 20.
    Yusuf, S, Peto, R, Lewis, J,  et al. 1985Beta blockade during andafter myocardial infarction: an overview of the randomized trialsProg Cardiovasc Dis27335371PubMedGoogle Scholar
  21. 21.
    DerSimonian, R, Laird, N 1986Meta-analysis in clinical trialsControl Clin Trials7177188PubMedCrossRefGoogle Scholar
  22. 22.
    Egger, M, Smith, GD 1995Misleading meta-analysisBMJ311753754PubMedGoogle Scholar
  23. 23.
    Egger, M, Davey Smith, G, Schneider, M, Minder, C 1997Bias in meta-analysis detected by a simple, graphical testBMJ315629634PubMedGoogle Scholar
  24. 24.
    Athanasiou, T, Al-Ruzzeh, S, Kumar, P,  et al. 2004Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patientsAnn Thorac Surg77745753PubMedCrossRefGoogle Scholar
  25. 25.
    Alanis, A, Papanicolaou, GK, Tadros, RR, Fielding, LP 1989Primary resection and anastomosis for treatment of acute diverticulitisDis Colon Rectum32933939PubMedGoogle Scholar
  26. 26.
    Blair, NP, Germann, E 2002Surgical management of acute sigmoid diverticulitisAm J Surg183525528PubMedCrossRefGoogle Scholar
  27. 27.
    Crooms, JW, Kovalcik, PJ 1984Obstructing left-sided colon carcinoma. Appraisal of surgical optionsAm Surg501519PubMedGoogle Scholar
  28. 28.
    Drumm, J, Clain, A 1984The management of acute colonic diverticulitis with suppurative peritonitisAnn R Coll Surg Engl669091PubMedGoogle Scholar
  29. 29.
    Gooszen, AW, Gooszen, HG, Veerman, W,  et al. 2001Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resectionEur J Surg1673539PubMedCrossRefGoogle Scholar
  30. 30.
    Gregg, RO 1987An ideal operation for diverticulitis of the colonAm J Surg153285290PubMedCrossRefGoogle Scholar
  31. 31.
    Hold, M, Denck, H, Bull, P 1990Surgical management of perforating diverticular disease in AustriaInt J Colorectal Dis5195199PubMedCrossRefGoogle Scholar
  32. 32.
    Kourtesis, GJ, Williams, RA, Wilson, SE 1988Surgical options in acute diverticulitis: value of sigmoid resection in dealing with the septic focusANZ J Surg58955959Google Scholar
  33. 33.
    Medina, VA, Papanicolaou, GK, Tadros, RR, Fielding, LP 1991Acute perforated diverticulitis: primary resection and anastomosis?Conn Med55258261PubMedGoogle Scholar
  34. 34.
    Peoples, JB, Vilk, DR, Maguire, JP, Elliott, DW 1990Reassessment of primary resection of the perforated segment for severe colonic diverticulitisAm J Surg159291293PubMedGoogle Scholar
  35. 35.
    Regenet, N, Pessaux, P, Hennekinne, S,  et al. 2003Primary anastomosis after intraoperative colonic lavage vs. Hartmann's procedure in generalized peritonitis complicating diverticular disease of the colonInt J Colorectal Dis18503507PubMedCrossRefGoogle Scholar
  36. 36.
    Saccomani, GE, Santi, F, Gramegna, A 1993Primary resection with and without anastomosis for perforation of acute diverticulitisActa Chir Belg93169172PubMedGoogle Scholar
  37. 37.
    Sarin, S, Boulos, PB 1991Evaluation of current surgical management of acute inflammatory diverticular diseaseAnn R Coll Surg Engl73278282PubMedGoogle Scholar
  38. 38.
    Schilling, MK, Maurer, CA, Kollmar, O, Buchler, MW 2001Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysisDis Colon Rectum44699703PubMedCrossRefGoogle Scholar
  39. 39.
    Underwood, JW, Marks, CG 1984The septic complications ofsigmoid diverticular diseaseBr J Surg71209211PubMedGoogle Scholar
  40. 40.
    Wedell, J, Banzhaf, G, Chaoui, R,  et al. 1997Surgical management of complicated colonic diverticulitisBr J Surg84380383PubMedCrossRefGoogle Scholar
  41. 41.
    Zorcolo, L, Covotta, L, Carlomagno, N, Bartolo, DC 2003Safetyof primary anastomosis in emergency colorectal surgeryColorectal Dis5262269PubMedCrossRefGoogle Scholar
  42. 42.
    Nespoli, A, Ravizzini, C, Trivella, M, Segala, M 1993The choice of surgical procedure for peritonitis due to colonic perforationArch Surg128814818PubMedGoogle Scholar
  43. 43.
    Kressner, U, Antonsson, J, Ejerblad, S,  et al. 1994Intraoperative colonic lavage and primary anastomosis – an alternative to Hartmann procedure in emergency surgery of the left colonEur J Surg160287292PubMedGoogle Scholar
  44. 44.
    Maher, M, Caldwell, MP, Waldron, R,  et al. 1996Staged resection or primary anastomosis for obstructing lesions to the left colonIr Med J89138139PubMedGoogle Scholar
  45. 45.
    Koruth, NM, Hunter, DC, Krukowski, ZH, Matheson, NA 1985Immediate resection in emergency large bowel surgery: a 7 year auditBr J Surg72703707PubMedGoogle Scholar
  46. 46.
    Isbister, WH, Prasad, J 1997Emergency large bowel surgery: a 15-year auditInt J Colorectal Dis12285290PubMedCrossRefGoogle Scholar
  47. 47.
    Darby, CR, Berry, AR, Mortensen, N 1992Management variability in surgery for colorectal emergenciesBr J Surg79206210PubMedGoogle Scholar
  48. 48.
    Allen-Mersh, TG 1993Should primary anastomosis and on-table colonic lavage be standard treatment for left colon emergencies?Ann R Coll Surg Engl75195198PubMedGoogle Scholar
  49. 49.
    Smith, SR, Connolly, JC, Gilmore, OJ 1983The effect of fecal loading on colonic anastomotic healingBr J Surg704950PubMedGoogle Scholar
  50. 50.
    Zorcolo, L, Covotta, L, Carlomagno, N, Bartolo, DC 2003Toward lowering morbidity, mortality, and stoma formation in emergency colorectal surgery: the role of specializationDis Colon Rectum4614611467PubMedCrossRefGoogle Scholar

Copyright information

© The American Society of Colon and Rectal Surgeons 2006

Authors and Affiliations

  • Vasilis A. Constantinides
    • 1
  • Paris P. Tekkis
    • 1
    • 4
  • Thanos Athanasiou
    • 1
  • Omer Aziz
    • 1
  • Sanjay Purkayastha
    • 1
  • Feza H. Remzi
    • 2
  • Victor W. Fazio
    • 2
  • Nail Aydin
    • 2
  • Ara Darzi
    • 1
  • Asha Senapati
    • 3
  1. 1.Imperial College of Science, Technology and Medicine, Department of Surgical Oncology and TechnologySt. Mary’s HospitalLondonUnited Kingdom
  2. 2.Department of Colorectal SurgeryThe Cleveland Clinic FoundationClevelandUSA
  3. 3.Department of SurgeryQueen Alexandra HospitalPortsmouthUnited Kingdom
  4. 4.Imperial College London, Department of Surgical Oncology and TechnologySt. Mary’s HospitalLondonUnited Kingdom

Personalised recommendations