A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann's Procedure for Perforated Left Colonic Diverticulitis with Purulent or Fecal Peritonitis
Document Type
Book Chapter
Publication Date
2019
Find in a Library
Abstract
Objectives
To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis.
Background
The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the two procedures.
Methods
Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from four centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary endpoint was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary endpoints as well as a decreasing accrual rate.
Results
Patient demographics were equally distributed in both groups (Hinchey III: 76% vs. 75% and Hinchey IV: 24% vs. 25%, for HP vs. PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs. 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs. 9% and morbidity 67% vs. 75% in HP vs. PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs. 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs. 20%, P = 0.046), operating time (73 minutes vs. 183 minutes, P < 0.001), hospital stay (6 days vs. 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs. US $24,014) were significantly reduced in the PA group.
Conclusions
This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.
Repository Citation
Ekeh, A. P.
(2019). A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann's Procedure for Perforated Left Colonic Diverticulitis with Purulent or Fecal Peritonitis. 50 Landmark Papers Every Acute Care Surgeon Should Know.
https://corescholar.libraries.wright.edu/surg/798
