Primary anastomosis and nonrestorative resection for perforated diverticulitis with peritonitis: meta‐analysis of randomized trials

Abstract

Aim The aim of this meta-analysis was to comparatively evaluate the outcomes of primary anastomosis (PRA) and nonrestorative resection (NRR) as emergency surgery and ostomy reversal in patients with perforated diverticulitis and peritonitis. Methods PubMed, MEDLINE via Ovid, Embase, CINAHL, Cochrane Library and Web of Science databases were systematically searched. Postoperative morbidity following emergency resection was the primary end-point. Quality assessment of the included studies was performed using the Cochrane Quality Assessment Tool including recruitment bias and crossover with intention-to-treat analysis. The Haenszel-Mantel method with odds ratios (OR, 95% CI) and the inverse variance method with mean difference (MD, 95% CI) as effect measures were utilized for dichotomous and continuous outcomes, respectively. Results Four randomized controlled trials totaling 382 patients (180 PRA vs 204 NRR) were included. Morbidity rates following emergency resection did not differ (OR = 0.99, 95% CI 0.65, 1.51; P = 0.95; number needed to treat/harm (NNT) 96). Organ/space surgical site infection rates were 3.3% in PRA vs 11.3% in NRR (OR = 0.29, 95% CI 0.12, 0.74; P = 0.009; NNT = 13). Postoperative morbidity rates following ostomy reversal were significantly lower in PRA (OR = 0.31, 95% CI 0.15, 0.64; P = 0.001; NNT = 7). Pooled ostomy non-reversal rates were 16% in PRA vs 35.5% in NRR (OR = 0.37, 95% CI 0.22, 0.62; P = 0.0001; NNT = 6) with high heterogeneity (I 2 = 63%; s 2 = 8.17). Meta-regression analysis revealed significant negative correlation between the PRA-to-NRR crossover rate and the ostomy non-reversal rate (P = 0.029). Conclusion This meta-analysis found that PRA was associated with better short-and long-term outcomes at the cost of significantly longer operating time at emergency surgery.

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

“…Another recent meta-analysis [ 83 ] found that R-PA was associated with better short- and long-term outcomes at the cost of significantly longer operating time at emergency surgery. No subgroup analyses based on age were made, nor specific studies on elderly patients.…”

Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases

“…The morbidity rates after PRA did not differ from those after NRR; however, postoperative morbidity rates of stoma closure surgery were significantly lower in PRA (12%) than in NRR (27.2%) (OR: 0.31). The non‐reversal rate of stoma in PRA (16%) was lower than that in NRR (35.5%) (OR: 0.37) 71 . Moreover, PRA was associated with better short‐ and long‐term outcomes than NRR.…”

“…The non‐reversal rate of stoma in PRA (16%) was lower than that in NRR (35.5%) (OR: 0.37). 71 Moreover, PRA was associated with better short‐ and long‐term outcomes than NRR.…”

¿Por qué hago Resección Sigmoidea y Anastomosis Primaria en Peritonitis Purulenta de Origen Diverticular?

“…13,14 En la última década, múltiples estudios aleatorizados y metaanálisis han intentado contestar esta pregunta y todos ellos favorecen la realización de la RAP en casos seleccionados. [15][16][17][18][19][20][21] Por ejemplo, el estudio multicéntrico y aleatorizado LADIES (rama DIVA) comparó 133 pacientes sometidos a OH y RAP. 20 A pesar de que no hubo diferencias significativas en la morbimortalidad luego de la operación de emergencia, la tasa de pacientes libres de estoma al año postoperatorio fue significativamente menor en el grupo RAP (RAP: 94,6% vs. OH: 71,7%).…”

“…Además, la incidencia de infección de sitio quirúrgico y morbilidad luego de la reconstrucción del tránsito fue significativamente mayor con la OH. 17 Asimismo, el metaanálisis de Ryan y col. encontró una menor incidencia de sepsis abdominal, morbilidad mayor y mortalidad global luego de la RAP. 21 A pesar de las numerosas publicaciones que intentan demostrar la superioridad de una técnica, muchos estudios presentan sesgo de selección.…”