Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann's procedure for the management of acute perforated diverticulitis with generalised peritonitis

O K Ryan; Éanna J Ryan; B Creavin; M R Boland; M E Kelly; D C Winter

doi:10.1007/s10151-020-02172-2

Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann's procedure for the management of acute perforated diverticulitis with generalised peritonitis

Tech Coloproctol. 2020 Jun;24(6):527-543. doi: 10.1007/s10151-020-02172-2. Epub 2020 Mar 2.

Authors

O K Ryan¹, Éanna J Ryan^{2

3}, B Creavin^{1

4}, M R Boland⁴, M E Kelly^{1

4}, D C Winter^{1

4}

Affiliations

¹ University College Dublin School of Medicine and Medical Science, Dublin, Ireland.
² University College Dublin School of Medicine and Medical Science, Dublin, Ireland. eannaryan@rcsi.com.
³ Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland. eannaryan@rcsi.com.
⁴ Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

PMID: 32124112
DOI: 10.1007/s10151-020-02172-2

Abstract

Background: Surgical strategies for acute perforated diverticulitis with generalised peritonitis remain controversial. This study aimed to meta-analyse trials comparing primary resection and anastomosis (PRA) to Hartmann's procedure (HP) for Hinchey III/IV diverticulitis.

Methods: A systematic literature search was conducted to identify observational studies and randomised control trials (RCTs) of patients with Hinchey III/IV diverticulitis undergoing sigmoidectomy that compared PRA to HP. The methodological quality of the included studies was assessed systematically (Newcastle-Ottawa, Jadad and Cochrane risk of bias scores) and a meta-analysis was performed.

Results: After removal of duplicates, 12 studies including 4 RCTs were identified. The analysis included 918 patients, of whom 367 (39.98%) underwent PRA. Both the initial stoma rate (risk ratio [RR] persistent stoma 0.43, 95% confidence interval [CI] 0.26, 0.71, p = 0.001; I² = 99%, p < 0.0001) and the rate of permanent stoma after combining the first (emergency surgery) and second (stoma reversal) procedures were lower in the PRA group. There was no difference in in 30-day mortality; however, PRA resulted in a reduction in overall mortality as well as major complications after the initial operation (RR 0.67, 95% CI 0.46, 0.97, p = 0.03; I² = 22%, p = 0.26), stoma reversal (RR 0.48, 95% CI 0.26, 0.92, p = 0.03; I² = 0%, p = 0.58) and when combining both procedures (RR 0.67, 95% CI 0.51, 0.88, p = 0.005; I² = 0%, heterogeneity p = 0.58). A subgroup analysis of stoma reversal rates using data from only RCTs were consistent (RR permanent stoma, 0.33, 95% CI 0.13, 0.85, p = 0.02; I² = 77%, p = 0.004) with the findings of the overall analysis.

Conclusions: This meta-analysis demonstrates that PRA used in the management of haemodynamically stable patients with Hinchey grade III/IV diverticulitis leads to a lower overall persistent stoma rate, with reduced morbidity compared with the traditional management.

Keywords: Diverticulitis; Hartmann’s procedure; Meta analysis; Primary resection and anastomosis; Stoma reversal.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Anastomosis, Surgical
Colostomy
Diverticulitis*
Diverticulitis, Colonic* / complications
Diverticulitis, Colonic* / surgery
Humans
Intestinal Perforation* / etiology
Intestinal Perforation* / surgery
Peritonitis* / etiology
Peritonitis* / surgery
Treatment Outcome