Perforated diverticulitis: To anastomose or not to anastomose? A systematic review and meta-analysis

Shaban, Fadlo; Carney, Kate; McGarry, Kenneth; Holtham, S

doi:10.1016/j.ijsu.2018.08.009

Cited by 20 publications

(16 citation statements)

References 42 publications

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“…In our series, both rectal stump leakages developed in elderly and frail patients after HP for Hinchey IV diverticulitis. The incidence of anastomotic leak in our study was 4.6% and was similar to that found in the literature [32]. In all these cases, the patients were not immunosuppressed and no intraoperative complications were documented.…”

Section: Discussionsupporting

confidence: 91%

“…In the analysis of his multicenter study, the author complained about the refusal of some surgeons to randomize ill patients, as a result of their skepticism in the applicability of PA in patients with generalized peritonitis [38]. This resulted in poor recruitment and premature termination of the trial, before achieving the planned sample size as highlighted in a meta-analysis by Shaban et al, who stated that the included RCTs were underpowered [32].…”

Section: Discussionmentioning

confidence: 99%

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Short- and long-term outcomes for primary anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Facile¹,

Galli²,

Dinter

et al. 2020

Langenbecks Arch Surg

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Purpose The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. Methods Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. Results Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044). Conclusions In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Short- and long-term outcomes for primary anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Facile¹,

Galli²,

Dinter

et al. 2020

Langenbecks Arch Surg

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“…The present results are generally in line with those from previous meta-analyses. With regard to overall mortality from randomized and observational studies, Gachabayov et al [34] and Shaban et al [35] found PA to be favorable over HP, which was also the case in the present quantitative analysis of mortality within the included observational studies. However, in the subgroup analysis of randomized studies in a b c Fig.…”

Section: Discussionsupporting

confidence: 81%

Sigmoid resection with primary anastomosis versus the Hartmann’s procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis

Lambrichts

Edomskis

Bogt

et al. 2020

Int J Colorectal Dis

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Purpose The 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. Methods A 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). Results From 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, PAwas 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. Conclusion Although 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.

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“…In perforated diverticulitis, for example, there has been no consensus in the management, which is why the Shaban and coauthors [19] felt compelled to perform a systematic review and meta-analysis, particularly because many surgeons choose the Hartmann's procedure to avoid the risk of an anastomotic leak.…”

Section: The Anastomosis In An "Emergency" Setting Scared Of a (Potential)mentioning

confidence: 99%

The Problem of the Colorectal Anastomosis

Ionescu¹

2023

Current Topics in Colorectal Surgery

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Colorectal anastomosis is defined as a surgical procedure in which the colon is attached to the remainder of the rectum after most or some part of it was removed during an intervention. A straight colorectal anastomosis implies a direct attachment, while a J-pouch colorectal anastomosis implies a previous creation of a reservoir, or “pouch” out of bowel material. The problem of colorectal anastomosis safety and outcome is among the most important and persistent issues in colorectal surgery, mainly due to the anastomotic leakage, a threatening and dangerous complication, with an incidence of up to 20% or even more in case of surgical oncology. Various prediction models and anastomosis testing techniques have been described in order to prevent or identify early any possible imperfection of the anastomosis, each with pros and cons. The measures generally used to increase the safety and reliability of the colorectal anastomosis are to evaluate the blood supply of the tissues anastomosed with indocyanine green, or to test the mechanical integrity of the anastomosis for leakage by employing air, methylene blue, or tension.

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Perforated diverticulitis: To anastomose or not to anastomose? A systematic review and meta-analysis

Abstract: Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.

Cited by 20 publications

References 42 publications

Short- and long-term outcomes for primary anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Short- and long-term outcomes for primary anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Sigmoid resection with primary anastomosis versus the Hartmann’s procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis

The Problem of the Colorectal Anastomosis

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