Prospectively Randomized Controlled Trial on Damage Control Surgery for Perforated Diverticulitis with Generalized Peritonitis

To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis. The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure. Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed. A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively. Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL). Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers. PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates. After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures. Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.

Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial

Hartmann's Procedure vs Primary Anastomosis with Diverting Loop Ileostomy for Acute Diverticulitis: Nationwide Analysis of 2,729 Emergency Surgery Patients

BackgroundSeveral studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost‐related outcomes were rarely reported. The present study aimed to evaluate costs and cost‐effectiveness within the DIVA arm of the Ladies trial.MethodsThis was a cost‐effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12‐month follow‐up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention‐to‐treat principle. Main outcomes were incremental cost‐effectiveness (ICER) and cost–utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma‐free or incremental quality‐adjusted life‐years respectively.ResultsOverall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €–8126 (–14 660 to –1592). The ICER was €–39 094 (95 per cent bias‐corrected and accelerated (BCa) c.i. –1213 to –116), indicating primary anastomosis to be more cost‐effective. The ICUR was €–101 435 (BCa c.i. –1 113 264 to 251 840).ConclusionPrimary anastomosis is more cost‐effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p= 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p= 0.001), and increased operation time (105 vs. 84min., p= 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p< 0.001). Complication rate (44 vs. 24%, p= 0.092), mortality (12 vs. 0%, p= 0.061), overall number of surgeries (3.4 vs. 2.4, p= 0.017), enterostomy rate (76 vs. 36%, p= 0.001), and length of hospital stay (25 vs. 18.8days, p= 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p= 0.005) and with fungal infection (100 vs. 49%, p= 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p< 0.001), enterostomy rate (81 vs. 48%, p= 0.017), and anastomotic leakage (29 vs. 6%, p= 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p= 0.014). Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Non-restorative resection (NRR) is the most common procedure for perforated diverticulitis, but frequently leads to permanent stoma and morbidity related to stoma reversal. For selected patients, primary anastomosis (PRA) is another option. Damage control surgery (DCS) may be an alternative, potentially offering a greater likelihood of stoma-free discharge. We compared DCS to conventional surgical treatment in terms of stoma-free discharge and postoperative complications. This single center trial compared patients treated before and after the introduction of a new treatment algorithm based on DCS. The prospective study group underwent surgery from 2022 to 2024, following implementation of a DCS-based treatment algorithm. The retrospective control group underwent operation from 2020 to 2022 (pre-algorithm). The primary outcome was stoma presence at 12 months. Secondary outcomes included stoma at discharge, complications, length of hospitalization, costs, and complications after stoma reversal. In the control group, 29/30 patients (97%) underwent NRR. In the study group, 22/26 (85%) underwent DCS, among these 4/22 (18%) required conversion to NRR, and 18/22 (82%) achieved anastomosis during the second-look. Demographics, length of hospitalization, post-operative complications, and complications after stoma reversal were similar. The control group exhibited higher rates of stoma at 12 months (37% vs. 8%, P = 0.003). Multivariate analysis revealed that treatment before the algorithm was independently associated with increased stoma presence at 12 months (Hazard ratio 10.65, P = 0.013). DCS appears to be a safe and effective strategy, yielding significantly lower rates of stoma at 12 months compared to conventional treatment for perforated diverticulitis.

To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis. 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 2 procedures. Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 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 end point was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary end points as well as a decreasing accrual rate (NCT01233713). 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. This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Diverticulitis poses a significant public health burden, particularly among older adults (65 years and older). Hartmann's procedure (HP) and primary anastomosis with proximal diversion (PAPD) are the most common surgeries performed, although comparative studies do not highlight older adults. We analyzed days alive and at home (DAAH), a patient-centered outcome, for 6 months (DAAH 6Mo ) after diverticulitis surgery, as well as non-home discharge rate. We hypothesized that PAPD recipients would have decreased DAAH 6Mo and increased non-home discharge compared with HP. A retrospective cohort study of community-dwelling Medicare beneficiaries undergoing HP vs PAPD was performed. The primary outcome DAAH 6Mo was calculated by subtracting total inpatient, emergency department, and mortality days from 180, beginning with the day of admission. HP and PAPD patients were matched using 2-stage greedy matching (4:1 ratio). Generalized estimating equations were used to calculate incidence rate ratios (IRRs) and 95% CIs. A total of 1,368 participants were included; ultimately, 553 HP were matched with 215 PAPD patients. Baseline characteristics and unweighted DAAH 6Mo (144.5 HP vs 144.4 PAPD) were similar between matched groups. In generalized estimating equation models, HP was associated with a nonsignificant increase in DAAH 6Mo compared with PAPD (IRR 1.04, 95% CI 0.99 to 1.08), and a statistically insignificant 9% increase in non-home discharge probability (odds ratio 1.09, 95% CI 0.78 to 1.53). Results were similar for the DAAH 6Mo outcome when limited to urgent or emergent admissions (IRR 1.00, 95% CI 0.94 to 1.05). Postoperative DAAH 6Mo do not significantly differ for adults aged 65 years and older after HP or PAPD for diverticulitis. Either surgical option can be considered in both emergent and nonemergent situations, allowing the decision to be tailored to surgeon expertise and patient preferences.

Hartmann's procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience. From January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP. A total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation. RPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert—A systematic review and meta-analysis

Gangrenous sigmoid volvulus has a significant impact on morbidity and mortality. This study was conducted to compare sigmoid resection and primary anastomosis (RPA) with sigmoid resection and end colostomy (Hartmann's procedure) for gangrenous sigmoid volvulus. A systematic review and meta-analysis study design was employed to summarize retrospective cohort, prospective cohort, and randomised control trial studies published from inception to march 31, 2023. Searching was performed on Medline, CINAHAL, Web of Science, Google Scholar, the Cochrane Library, and ClinicalTrials.gov to locate eligible articles. Data searching, selection and screening, quality assessment of the included articles, and data extraction were done by two separate reviewers. RevMan 5.4 software with a fixed-effect Mantel-Haenszel model and Stata version 14 were used to analyze the data. The protocol registered on PROSPERO registration website (CRD42023413367). Ten cohort studies and one randomised control trial with 724 patients were found; all of them were rated as being of moderate quality. The overall mortality after RPA was 15% (95%CI: 11-19%), and after Hartmann's procedure it was 19% (95%CI: 15-23%). Resection and primary anastomosis (RPA) for gangrenous sigmoid volvulus had slightly lower mortality rate than stoma (OR=0.98(95%CI: 0.68-1.42), p=0.07, I2=43%), which had no statistically significant difference. Resection and primary anastomosis (RPA) had a slightly higher morbidity rate than Hartmann's procedure (OR=1.01(95%CI: 0.66-1.55), p=0.30, I2=18%), which had no statistically significant difference. Sigmoid resection and primary anastomosis (RPA) and Hartmann's procedure had no significant differences in mortality and morbidity for the treatment of gangrenous sigmoid volvulus. Choice of the intervention for gangrenous sigmoid volvulus should be individualized with consideration of different detrimental factors.

Tu1754 Rectal Prolapse Repair: Laparoscopic or Perineal Approach?

Background: The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. Aim: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. Method: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann’s procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. Results: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. Conclusion: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

Perforated diverticulitis is a critical surgical emergency that demands immediate attention and intervention. Damage control surgery (DCS) has emerged as an alternative to traditional approaches for managing physiologically unstable and critically ill patients. This systematic review includes 16 articles published between 2015 and 2025, covering randomized controlled trials, observational cohorts, case reports, and guidelines. The inclusion and exclusion criteria focused on human studies published in English that addressed managing perforated diverticulitis with DCS. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines were used to guide article selection, which was further refined using standardized appraisal tools such as A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), the Newcastle-Ottawa Scale (NOS), Joanna Briggs Institute Checklists (JBI), the Cochrane Risk of Bias (RoB) tool, the Appraisal of Guidelines for Research and Evaluation II (AGREE II), and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). This review highlights DCS as an effective approach for managing perforated diverticulitis. Patient management with DCS showed significant improvement compared to traditional methods such as Hartmann’s procedure. Physiological stabilization reduced complications such as stoma formation and improved anastomosis rates, as supported by the included studies. The findings suggest that DCS reduces morbidity and mortality, lowers the need for a stoma, and enhances bowel continuity in patients with perforated diverticulitis. Several studies also employed negative pressure therapy for temporary abdominal closure. The main prognostic factors identified were ongoing peritonitis and hemodynamic instability, which characterize critically ill patients. These findings underscore the importance of prioritizing patient stability and controlling disease severity at the outset, before proceeding to definitive therapy once the patient is stable. Further high-quality, multicenter studies with larger sample sizes are needed to develop standardized treatment guidelines.