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Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials.
Tech Coloproctol. 2018 10; 22(10):743-753.TC

Abstract

INTRODUCTION

The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann's procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis.

METHODS

A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals.

RESULTS

Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14-1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41-4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12-0.96, p = 0.04).

CONCLUSIONS

PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical option in patients with generalised peritonitis due to diverticular perforation.

Authors+Show Affiliations

Department of Surgical Science, University of Perugia, Terni, Italy.Royal Victoria Infirmary, Newcastle upon Tyne, UK. s.afshar@doctors.org.uk.Royal Victoria Infirmary, Newcastle upon Tyne, UK.Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy.Department of Surgery, M Mellini Hospital, Chiari, Italy.Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK.Tift College of Education, Mercer University, Atlanta, USA.Department of General Surgery, San Pietro Polyclinic, Ponte San Pietro, Italy.Emergency Surgery Unit, University of Pisa, Pisa, Italy.Department of General Surgery, Galliera Hospital, Genoa, Italy.

Pub Type(s)

Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

29995173

Citation

Cirocchi, Roberto, et al. "Perforated Sigmoid Diverticulitis: Hartmann's Procedure or Resection With Primary Anastomosis-a Systematic Review and Meta-analysis of Randomised Control Trials." Techniques in Coloproctology, vol. 22, no. 10, 2018, pp. 743-753.
Cirocchi R, Afshar S, Shaban F, et al. Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials. Tech Coloproctol. 2018;22(10):743-753.
Cirocchi, R., Afshar, S., Shaban, F., Nascimbeni, R., Vettoretto, N., Di Saverio, S., Randolph, J., Zago, M., Chiarugi, M., & Binda, G. A. (2018). Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials. Techniques in Coloproctology, 22(10), 743-753. https://doi.org/10.1007/s10151-018-1819-9
Cirocchi R, et al. Perforated Sigmoid Diverticulitis: Hartmann's Procedure or Resection With Primary Anastomosis-a Systematic Review and Meta-analysis of Randomised Control Trials. Tech Coloproctol. 2018;22(10):743-753. PubMed PMID: 29995173.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials. AU - Cirocchi,Roberto, AU - Afshar,Sorena, AU - Shaban,Fadlo, AU - Nascimbeni,Riccardo, AU - Vettoretto,Nereo, AU - Di Saverio,Salomone, AU - Randolph,Justus, AU - Zago,Mauro, AU - Chiarugi,Massimo, AU - Binda,Gian Andrea, Y1 - 2018/07/11/ PY - 2018/03/21/received PY - 2018/06/25/accepted PY - 2018/7/12/pubmed PY - 2019/4/23/medline PY - 2018/7/12/entrez KW - Anastomosis, Surgical KW - Colectomy KW - Diverticulitis, Colonic KW - Peritonitis KW - Surgical Stomas SP - 743 EP - 753 JF - Techniques in coloproctology JO - Tech Coloproctol VL - 22 IS - 10 N2 - INTRODUCTION: The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann's procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis. METHODS: A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals. RESULTS: Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14-1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41-4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12-0.96, p = 0.04). CONCLUSIONS: PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical option in patients with generalised peritonitis due to diverticular perforation. SN - 1128-045X UR - https://www.unboundmedicine.com/medline/citation/29995173/Perforated_sigmoid_diverticulitis:_Hartmann's_procedure_or_resection_with_primary_anastomosis_a_systematic_review_and_meta_analysis_of_randomised_control_trials_ L2 - https://dx.doi.org/10.1007/s10151-018-1819-9 DB - PRIME DP - Unbound Medicine ER -