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World Journal of Emergency Surgery

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Open Access 01-12-2019 | Wound Infection | Review

Primary resection anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis

Authors: Hosam Halim, Alan Askari, Rebecca Nunn, James Hollingshead

Published in: World Journal of Emergency Surgery | Issue 1/2019

Abstract

Introduction

Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome.

Methods

A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies.

Results

A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38–0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14–1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20–2.78, p = 0.67).

Conclusion

Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.

Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Diseases of the colon and rectum. 2006;49:939–44. https://doi.org/10.1007/s10350-006-0578-2.CrossRefPubMed

Stollman N, Raskin JB. Diverticular disease of the colon. Lancet (London, England). 2004;363:631–9. https://doi.org/10.1016/S0140-6736(04)15597-9.CrossRef

Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357:2057–66. https://doi.org/10.1056/NEJMcp073228.CrossRefPubMed

Fozard JBJ, Armitage NC, Schofield JB, et al. ACPGBI position statement on elective resection for diverticulitis. Colorectal Dis. 2011;13(Suppl 3):1–11. https://doi.org/10.1111/j.1463-1318.2010.02531.x.CrossRefPubMed

Belmonte C, Klas JV, Perez JJ, et al. The Hartmann procedure. First choice or last resort in diverticular disease? Arch Surg. 1996;131:612–5 discussion 616-7.CrossRef

Berry AR, Turner WH, Mortensen NJ, Kettlewell MG. Emergency surgery for complicated diverticular disease. A five-year experience. Dis Colon Rectum. 1989;32:849–54.CrossRef

Peoples JB, Vilk DR, Maguire JP. Elliott DW Reassessment of primary resection of the perforated segment for severe colonic diverticulitis. Am J Surg. 1990;159:291–3 discussion 294.CrossRef

Regenet N, Pessaux P, Hennekinne S, et al. Primary anastomosis after intraoperative colonic lavage vs. Hartmann’s procedure in generalized peritonitis complicating diverticular disease of the colon. Int J Color Dis. 2003;18:503–7. https://doi.org/10.1007/s00384-003-0512-1.CrossRef

Richter S, Lindemann W, Kollmar O, et al. One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV). World J Surg. 2006;30:1027–32. https://doi.org/10.1007/s00268-005-0439-5.CrossRefPubMed

10.

Saccomani GE, Santi F. Gramegna A Primary resection with and without anastomosis for perforation of acute diverticulitis. Acta Chirurgica Belgica. 1993;93:169–72.PubMed

11.

Schilling MK, Maurer CA, Kollmar O, Büchler MW. Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis. Dis Colon Rectum. 2001;44:699–703 discussion 703–5.CrossRef

12.

Thaler K, Neumann F, Gerö A, Kreuzer W. Utility of appropriate peritonitis grading in the surgical management of perforated sigmoid diverticulitis. Colorectal Dis. 2000;2:359–63. https://doi.org/10.1046/j.1463-1318.2000.00191.x.CrossRefPubMed

13.

Trenti L, Biondo S, Golda T, et al. Generalized peritonitis due to perforated diverticulitis: Hartmann’s procedure or primary anastomosis? Int J Color Dis. 2011;26:377–84. https://doi.org/10.1007/s00384-010-1071-x.CrossRef

14.

Tucci G, Torquati A, Grande M, et al. Major acute inflammatory complications of diverticular disease of the colon: planning of surgical management. Hepato Gastroenterol. 1996;43:839–45.

15.

Tudor RG, Farmakis N, Keighley MR. National audit of complicated diverticular disease: analysis of index cases. Br J Surg. 1994;81:730–2.CrossRef

16.

Vennix S, Lips DJ, Di Saverio S, et al. Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort. Surgical endoscopy. 2016;30:3889–96. https://doi.org/10.1007/s00464-015-4694-8.CrossRefPubMed

17.

Binda GA, Saccomani G, Gramegna A. Emergency surgery of complicated colonic diverticulitis. Acta chirurgica Belgica. 1993;93:253–7.PubMed

18.

Vermeulen J, Akkersdijk GP, Gosselink MP, et al. Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Digestive Surg. 2007;24:361–6. https://doi.org/10.1159/000107719.CrossRef

19.

Wedell J, Banzhaf G, Chaoui R, et al. Surgical management of complicated colonic diverticulitis. Br J Surg. 1997;84:380–3.CrossRef

20.

Drumm J, Clain A. The management of acute colonic diverticulitis with suppurative peritonitis. Ann R Coll Surg Engl. 1984;66:90–1.PubMedPubMedCentral

21.

Gawlick U, Nirula R. Resection and primary anastomosis with proximal diversion instead of Hartmann’s: evolving the management of diverticulitis using NSQIP data. J Trauma Acute Care Surg. 2012;72:807–14quiz 1124. https://doi.org/10.1097/TA.0b013e31824ef90b.CrossRefPubMed

22.

Gooszen AW, Gooszen HG, Veerman W, et al. Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection. Eur J Surg. 2001;167:35–9. https://doi.org/10.1080/110241501750069792.CrossRefPubMed

23.

Hold M, Denck H, Bull P. Surgical management of perforating diverticular disease in Austria. Int J Color Dis. 1990;5:195–9.CrossRef

24.

Mäkelä J, Kiviniemi H, Laitinen S. Prevalence of perforated sigmoid diverticulitis is increasing. Dis Colon Rectum. 2002;45:955–61.CrossRef

25.

Medina VA, Papanicolaou GK, Tadros RR, Fielding LP. Acute perforated diverticulitis: primary resection and anastomosis? Conn Med. 1991;55:258–61.PubMed

26.

Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum. 1985;28:71–5.CrossRef

27.

Binda GA, Karas JR, Serventi A, et al. Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Col Dis. 2012;14:1403–10. https://doi.org/10.1111/j.1463-1318.2012.03117.x.CrossRef

28.

Bridoux V, Regimbeau JM, Ouaissi M, et al. Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am Coll Surg. 2017;225:798–805. https://doi.org/10.1016/j.jamcollsurg.2017.09.004.CrossRefPubMed

29.

Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256:819–26; discussion 826–7. https://doi.org/10.1097/SLA.0b013e31827324ba.CrossRefPubMed

30.

Constantinides VA, Tekkis PP, Athanasiou T, et al. Primary resection with anastomosis vs. Hartmann’s procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum. 2006;49:966–81. https://doi.org/10.1007/s10350-006-0547-9.CrossRefPubMed

31.

Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg. 2014;149:292–303. https://doi.org/10.1001/jamasurg.2013.5477.CrossRefPubMed

32.

Vermeulen J, Lange JF. Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future. World J Surg. 2010;34:587–93. https://doi.org/10.1007/s00268-009-0372-0.CrossRefPubMedPubMedCentral

33.

Gachabayov M, Oberkofler CE. Tuech JJ, et alResection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Col Dis. 2018;20:753–70. https://doi.org/10.1111/codi.14237.CrossRef

34.

Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum. 2004;47:1953–64.CrossRef

35.

Cirocchi R, Trastulli S, Desiderio J, et al. Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colo Dis. 2013;28:447–57. https://doi.org/10.1007/s00384-012-1622-4.CrossRef

36.

Biondo S, Lopez Borao J, Millan M, et al. Current status of the treatment of acute colonic diverticulitis: a systematic review. Col Dis. 2012;14:e1–e11. https://doi.org/10.1111/j.1463-1318.2011.02766.x.CrossRef

37.

Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Col Dis. 2007;22:351–7. https://doi.org/10.1007/s00384-005-0059-4.CrossRef

38.

Isbister WH, Prasad J. Emergency large bowel surgery: a 15-year audit. Int J Col Dis. 1997;12:285–90.CrossRef

39.

Ravo B, Metwall N, Yeh J, et al. Effect of fecal loading with/without peritonitis on the healing of a colonic anastomosis: an experimental study. Eur Surg Res. 1991;23:100–7. https://doi.org/10.1159/000129141.CrossRefPubMed

40.

Smith SR, Connolly JC, Gilmore OJ. The effect of faecal loading on colonic anastomotic healing. Br J Surg. 1983;70:49–50.CrossRef

41.

Mueller MH, Karpitschka M, Renz B, et al. Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis. Int J Col Dis. 2011;26:227–34. https://doi.org/10.1007/s00384-010-1017-3.CrossRef

42.

Richards CH, Roxburgh CSD. Scottish Surgical Research Group (SSRG) Surgical outcome in patients undergoing reversal of Hartmann’s procedures: a multicentre study. Col Dis. 2015;17:242–9. https://doi.org/10.1111/codi.12807.CrossRef

43.

Herzog T, Janot M, Belyaev O, et al. Complicated sigmoid diverticulitis—Hartmann’s procedure or primary anastomosis? Acta Chirurgica Belgica. 2011;111:378–83.CrossRef

Title: Primary resection anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis
Authors: Hosam Halim
Alan Askari
Rebecca Nunn
James Hollingshead
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Wound Infection
Enterostomy
Peritonitis
Enterostomy
Diverticulitis
Published in: World Journal of Emergency Surgery / Issue 1/2019
Electronic ISSN: 1749-7922
DOI: https://doi.org/10.1186/s13017-019-0251-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Primary resection anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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