Abstract
ABSTRACT Background: The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. Aim: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. Method: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann’s procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. Results: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. Conclusion: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.
Highlights
Diverticular disease is a common gastrointestinal disease and found in one third of people over 60 in the Western world[4]
The objective of this systematic review with meta-analysis was to study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment, through the evaluation of mortality, postmorbidity surgery and ostomy non-reversion rates
The question to be answered by the research was structured based on the acronym PICO: (P) patients included were adults over 18, who underwent emergency surgical treatment for perforated diverticulitis of the left colon; (I) analyzed intervention was resection with primary anastomosis (AP) with or without protective ostomy; (C) the primary anastomosis would be compared to the Hartmann procedure; (O) the results compared would be mortality and morbidity in urgent and reversal operations, in addition to the rate of non-reversion of the ostomy
Summary
Diverticular disease is a common gastrointestinal disease and found in one third of people over 60 in the Western world[4]. About 25% of patients with acute diverticulitis require emergency intervention, and the standardized treatment for the perforated form with fecal or purulent peritonitis (Hinchey III and IV classification) is emergency surgery[4,24]. Several studies suggest that resection with primary anastomosis (AP) is the same as the Hartmann procedure in terms of postoperative mortality and morbidity[11]. The objective of this systematic review with meta-analysis was to study the results after the Hartmann vs resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment, through the evaluation of mortality, postmorbidity surgery and ostomy non-reversion rates
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