It is very fashionable nowadays to systematically review and meta-analyse every topic even when there are only very few trials out. A recent example is the bombardment of systematic reviews on the management of purulent perforated diverticulitis [1,2,3,4]. In a few years nearly 10 reviews have been published, all with different interpretation of the data from the LOLA, SCANDIV and DILALA trials [5,6,7]. So, every reader can find a review with conclusions that will suit him or her.
This review by Cirocchi et al. [8] is also based on only 3 trials, all underpowered and ended prematurely. The overall conclusion is that a Hartmann’s is comparable to primary anastomosis for perforated diverticulitis be it Hinchey III or IV in terms outcomes of interest. The paper is interesting to read though, because the issues in this field of research are very well discussed. The most important problem stated, is that the 3 trials have been confounded by selection of patients that were included. The randomized trial by Binda et al. [9] included 56 Hartmann’s and only 34 primary anastomosis . This suggests that patients were in the end not considered suitable for primary anastomosis.
Examples of patients that will not be in the trials are the hemodynamically unstable patients, patients on immunosuppressants or those who had pelvic radiation therapy. It is also very likely, that if the surgeon on call was not a colorectal surgeon, patients were not considered eligible for inclusion.
As long as the potentially eligible patients who for whatever reason were not randomized, are not accounted for, the external validity of the studies is very low.
Surprisingly, the stoma rate at the end of follow-up was not significantly different. This was due to the results of Binda et al. [9] whose study probably suffered from the largest inclusion bias.
The DIVA trial randomized all patients with fecal peritonitis from the LADIES trial [10] to primary anastomosis vs. Hartmann, addressing this very topic. Patient enrollment and minimum follow-up are concluded and results will follow soon.
The Hartmann’s procedure is mostly done open both in and outside trials. A significant number of these patients will develop incisional hernias [11, 12]. Incisional hernia repair significantly increases the extent and operative risk of reversing a Hartmann’s and might be an important reason for not reversing. The situation is different with a laparoscopic Hartmann’s procedure with extraction via a Pfannentsiel incision or at the stoma site. The absence of an incisional hernia together with the probability of fewer adhesions are most likely reasons why more laparoscopic Hartmann’s are closed as described by Vennix et al. [13].
A laparoscopic Hartmann’s might be a great alternative to a primary anastomosis particularly if hemodynamic instability exists, if the patients is immunocompromised or has had prior radiotherapy. There is of course the technical issue for those who do not feel comfortable with a laparoscopic procedure.
Otherwise, the true Hinchey III patients can have laparoscopic lavage, favorable Hinchey IV’s resection and primary anastomosis and all others with risk factors a laparoscopic Hartmann’s. No trial can determine whether this is the proper approach . National registries where all patients are accounted for or cross-sectional population based studies should solve this research question.
References
Angenete E, Bock D, Rosenberg J, Haglind E (2017) Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis—a meta-analysis. Int J Colorectal Dis 32(2):163–169. https://doi.org/10.1007/s00384-016-2636-0
Ceresoli M, Coccolini F, Montori G, Catena F, Sartelli M, Ansa- loni L (2016) Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials. World J Emerg Surg 11(1):42. https://doi.org/10.1186/s13017-016-0103-4
Galbraith N, Carter JV, Netz U, Yang D, Fry DE, McCafferty M, Galandiuk S (2017) Laparoscopic lavage in the management of perforated diverticulitis: a contemporary meta-analysis. J Gastrol Intest Surg. https://doi.org/10.1007/s11605-017-3462-6
Cirocchi R, Di Saverio S, Weber DG, Tabola R, Abraha I, Ran- dolph J, Arezzo A, Binda GA (2017) Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis. Tech Coloproctol 21(2):93–110. https://doi.org/10.1007/s10151-017-1585-0
Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA, Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW, Boer- meester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA, Ladies trial c (2015) Laparoscopic peritoneal lavage or sig- moidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 386(10000):1269–1277. https://doi.org/10.1016/S0140-6736(15)61168-0
Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, Korner H, Dahl FA, Oresland T, Group SS (2015) Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the scandiv randomized clinical trial. JAMA 314(13):1364–1375. https://doi.org/10.1001/jama.2015.12076
Angenete E, Thornell A, Burcharth J, Pommergaard HC, Skull- man S, Bisgaard T, Jess P, Lackberg Z, Matthiessen P, Heath J, Rosenberg J, Haglind E (2016) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg 263(1):117–122. https://doi.org/10.1097/SLA.0000000000001061
Cirocchi R, Afshar S, Shaban F, Nascimbeni R, Vettoretto N, Saverio SD, Randolph J, Zago M, Chiarugi M, Binda GA (2018) Perforated sigmoid diverticulitis: Hartmann’s procedure or resection with primary anastomosis—a systematic review and meta-analysis of randomised control trials. Tech Coloproctol. https://doi.org/10.1007/s10151-018-1819-9
Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L, Bergamaschi R, Study Group on D (2012) Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis 14(11):1403–1410. https://doi.org/10.1111/j.1463-1318.2012.03117.x
Swank HA, Vermeulen J, Lange JF, Mulder IM, van der Hoeven JA, Stassen LP, Crolla RM, Sosef MN, Nienhuijs SW, Bosker RJ, Boom MJ, Kruyt PM, Swank DJ, Steup WH, de Graaf EJ, Weidema WF, Pierik RE, Prins HA, Stockmann HB, Tollenaar RA, van Wagensveld BA, Coene PP, Slooter GD, Consten EC, van Duijn EB, Gerhards MF, Hoofwijk AG, Karsten TM, Neijenhuis PA, Blanken-Peeters CF, Cense HA, Mannaerts GH, Bruin SC, Eijsbouts QA, Wiezer MJ, Hazebroek EJ, van Geloven AA, Maring JK, D’Hoore AJ, Kartheuser A, Remue C, van Grevenstein HM, Konsten JL, van der Peet DL, Govaert MJ, Engel AF, Reitsma JB, Bemelman WA, Dutch Diverticular Disease (3D) Collaborative Study Group (2010) The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 10:29. https://doi.org/10.1186/1471-2482-10-29
Pogacnik JS, Messaris E, Deiling SM, Connelly TM, Berg AS, Stewart DB, McKenna KJ, Poritz LS, Koltun WA (2014) Increased risk of incisional hernia after sigmoid colectomy for diverticulitis compared with colon cancer. J Am Colloid Surg 218(5):920–928. https://doi.org/10.1016/j.jamcollsurg.2014.01.050. Epub 2014 Feb 19
Connelly TM, Tappouni R, Mathew P, Salgado J, Messaris E (2015) Risk factors for the development of an incisional hernia after sigmoid resection for diverticulitis: an analysis of 33 patients, operative and disease-associated factors. Am Surg 81(5):492–497
Vennix S, Lips DJ, Di Saverio S, van Wagensveld BA, Brokelman WJ, Gerhards MF, van Geloven AA, van Dieren S, Lange JF, Bemelman WA (2016) Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort. Surg Endosc. 30(9):3889–3896. https://doi.org/10.1007/s00464-015-4694-8. Epub 2015 Dec 17
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The author declares that he has no conflict of interest.
Ethical approval
For this type of study ethical approval is not required.
Informed consent
For this type of study formal consent is not required.
Rights and permissions
About this article
Cite this article
Bemelman, W.A. Perforated sigmoid diverticulitis: Hartmann’s procedure or resection with primary anastomosis. Tech Coloproctol 22, 739–740 (2018). https://doi.org/10.1007/s10151-018-1881-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-018-1881-3