Primary anastomosis for perforated left colonic diverticulitis has a significantly higher rate of stoma reversal than Hartmann’s procedure

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Key study points:

1. Patients receiving primary anastomosis for perforated left colonic diverticulitis had a higher rate of stoma reversal than those receiving a Hartmann’s procedure.

Primer: One of the most common complications of acute diverticulitis is perforation of the left colon. This leads to spillage of bowel contents into the peritoneum and the development of either purulent or fecal peritonitis, eventually progressing to sepsis. There are conflicting guidelines as to the appropriate surgical management of a colonic perforation in this scenario: immediate resection of the diseased segment of colon and establishing an end colostomy, also known as the Hartmann procedure (HP), versus resection of the diseased segment of colon and establishing a primary anastomosis (PA). The advantage of the HP is shorter operating time and no risk of anastomotic breakdown. However, the patient must undergo an additional procedure to eventually reverse the colostomy. The use of a diverting stoma is usually undertaken in both techniques, but even this step confers no clear advantage. There is a lack of clear evidence for either procedure in the context of an acute colonic perforation, especially since prior studies had inherent selection bias in that sicker patients usually received the HP. This study hoped to answer definitely which procedure is more efficacious.

 Background reading:

1. Young-Fadok TM. Diverticular disease of the Colon 2012.

2. Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg. 2007;245:94–103.

This [multicenter, randomized, controlled ] study involved 62 patients from 4 different institutions who presented with acute left-sided colonic perforation from 2006-2009. Patients were randomized to either receive the HP or PA with diverting ileostomy and all patients had a planned ostomy reversal procedure scheduled for 3 months post-operatively. The primary end-point of the study was the overall complication rate. The overall complication rate were similar between the two study groups (80% for HP and 84% for PA, p = .813). Furthermore, there were no significant differences in morbidity and mortality after the initial procedure. However, the stoma reversal rate after PA with diverting ileostomy was significantly higher (90% PA vs 57% HP, p = .005). This finding led to the early discontinuation of the trial.

In sum: This trial examined the effectiveness of two standard surgical procedures for treatment of a perforated left colon secondary to diverticulitis. While the overall complication rates were similar for the Hartmann Procedure and Primary Anastomosis with Diverting Ileostomy, and there were no significant differences in morbidity and mortality after the initial procedures, PA was found to have a much higher rate of stoma reversal than HP. Since sicker patients tend to receive the HP, selection bias present in previous retrospective studies had been cited as the reason why HP results were inferior to PA. This randomized controlled trial has corrected sufficiently for this potential bias. It should be noted that this study was limited to primary anastomosis with accompany diverting ileostomy, and does not answer the question of whether or not a diverting ileostomy is necessary. There also still exists the most novel approach of laparoscopic suturing of the perforation with accompanying abdominal washout that was not compared in this present study.

Click to read the study in [Annals of Surgery]

By [AH]

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