Abstract
PurposeThe optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann’s procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence.MethodsA systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs).ResultsFrom a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients.ConclusionAlthough between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann’s procedure in selected patients with Hinchey III or IV diverticulitis.
Highlights
Up to 35% of patients with acute diverticulitis present with complicated disease, such as perforation with purulent or fecal peritonitis (Hinchey III or IV) [1,2,3,4]
For the non-randomized studies, the NewcastleOttawa Scale (NOS) and methodological index for nonrandomized studies (MINORS) scores ranged between 6–9 and 13–18, respectively
Postoperative morbidity related to the reversal procedure was assessed in four studies (Fig. 4c), being the four included trials, which showed a significant difference in favor of primary anastomosis (PA) (PA 14/118 (11.9%) vs. Hartmann’s procedure (HP) 34/126 (27%); odds ratios (ORs) 0.33, 95% CI 0.16, 0.69; NNT 7)
Summary
Up to 35% of patients with acute diverticulitis present with complicated disease, such as perforation with purulent or fecal peritonitis (Hinchey III or IV) [1,2,3,4]. Previous studies have found PA to be associated with higher stoma reversal rates and another important potential benefit of PA is the option to avoid a defunctioning ileostomy in selected cases [8,9,10,11]. PA has the potential benefit to decrease patient burden, lower associated healthcare costs, and improve patient-reported outcomes [14]. In the light of increased incidence and admission rates of perforated diverticulitis, a critical appraisal of treatment strategies and their outcomes is an important step towards consensus on its optimal surgical approach [15]. The aim of this systematic review and metaanalysis was to assess outcomes of HP and PA (with or without ileostomy) for perforated diverticulitis with purulent or fecal peritonitis
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