Evidence-Based Surgery for Complicated Diverticular Disease

Abstract

et al., with mortality rates ranging between 5–25% for PAD and 10–20% for HP [1–4]. Limitations of these studies are the small sample sizes and the retrospective nature which inherently introduces bias. Age, physical status and severity of disease differ among the trials and between study groups [1–4]. In many studies healthier patients were more likely to undergo PAD resulting in a better outcome. In the present population-based study, almost 57,000 patients who underwent HP were compared to 3,361 patients after PAD. In contrast to previous reports, the PAD group had more comorbidities as compared to the HP group, which is interesting. Mortality after PAD was significantly lower than after HP. Although the odds ratio is not very high (1.30; 95% CI 1.03–1.65), the conclusion of the authors that PAD must be regarded as a realistic and probably treatment of choice is likely to be valid. The authors clearly mention the limitations of their study including the lack of information on the severity of the acute diverticulitis of the included patients (Hinchey classification). During the study period another 39,000 patients with complicated diverticulitis were treated with bowel resection and primary anastomosis without diversion. Likely these were patients with a lower severity of disease (mild and localized peritonitis) in whom diverThe p aper by Masoo mi and colleagues [this issue, pp. 315–320] reports on the surgical management of complicated diverticular disease. The study shows that after a sigmoid resection, creation of a primary anastomosis with diversion (PAD) has, in the short term, at least an equal outcome as compared to Hartmann’s procedure (HP), which is still regarded by many surgeons as the golden standard. Mortality rates were 4.0 and 4.8% respectively; complications were seen in about 40% of patients in both groups. Controversy still exists about the preferred treatment for complicated diverticulitis. Fear of anastomotic leakage deters many surgeons from performing primary anastomosis. Hence, HP is frequently performed to avoid the risk of anastomotic leakage and the possible devastating sequelae. Restoration of bowel continuity after HP is not without risks and most of times requires a re-laparotomy. In patients where a primary anastomosis is created, bowel diversion proximal to the anastomosis is thought to reduce the clinical consequences of anastomotic dehiscence [1]. Restoration of the continuity of gastrointestinal tract can usually be performed at a later stage by a local procedure and laparotomy can usually be avoided. Earlier studies that have addressed this surgical dispute found similar results as the present study of Masoomi