Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial. (February 2022)

• Record Type: Journal Article
• Authors: Edomskis, Pim P.; Hoek, Vincent T.; Stark, Pieter W.; Lambrichts, Daniël P.V.; Draaisma, Werner A.; Consten, Esther C.J.; Bemelman, Willem A.; Lange, Johan F.
• Is Part Of: International journal of surgery. Volume 98(2022)
• Publication Date: 2022-02
• Subjects: HP Hartmann's procedure -- PA primary anastomosis; Complicated diverticulitis -- Hartmann's procedure -- Primary anastomosis -- Stoma free rate -- Surgery -- long-term;therapy; Surgery -- Periodicals; Surgical Procedures, Operative -- Periodicals; 617.005
• DOI: 10.1016/j.ijsu.2021.106221
• Languages: English
• ISSNs: 1743-9191

Abstract

Abstract: Background: The aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis. Methods: Data were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality. Results: Three years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538–3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5–22.5) versus HP 17 days (IQR 12.5–27.5)), p = 0.025). Conclusion: Long-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias. Highlights: Regarding long term outcome Primary anastomosis is the preferred choice for patient with purulent and/or fecal peritonitis. Hartmann's procedure has a worse stoma free rate, overall hospitalization and more parastomal hernias. Hartmann's procedure should be avoided in haemodynamically stable and immunocompetent patients.