Ivan Facile1, Raffaele Galli1, Alberto Posabella2,3, Raoul André Droeser2,3, Pavlo Dinter2, Robert Rosenberg1, Markus Von Flüe2,3, Daniel Christian Steinemann4,5. 1. Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland. 2. Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland. 3. Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland. 4. Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland. daniel.steinemann@unibas.ch. 5. Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland. daniel.steinemann@unibas.ch.
Abstract
PURPOSE: The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann's procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. METHODS: Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. RESULTS: Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06-0.96, p = .044). CONCLUSIONS: In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.
PURPOSE: The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann's procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. METHODS: Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. RESULTS: Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06-0.96, p = .044). CONCLUSIONS: In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.
Authors: Daniël P V Lambrichts; Sandra Vennix; Gijsbert D Musters; Irene M Mulder; Hilko A Swank; Anton G M Hoofwijk; Eric H J Belgers; Hein B A C Stockmann; Quirijn A J Eijsbouts; Michael F Gerhards; Bart A van Wagensveld; Anna A W van Geloven; Rogier M P H Crolla; Simon W Nienhuijs; Marc J P M Govaert; Salomone di Saverio; André J L D'Hoore; Esther C J Consten; Wilhelmina M U van Grevenstein; Robert E G J M Pierik; Philip M Kruyt; Joost A B van der Hoeven; Willem H Steup; Fausto Catena; Joop L M Konsten; Jefrey Vermeulen; Susan van Dieren; Willem A Bemelman; Johan F Lange Journal: Lancet Gastroenterol Hepatol Date: 2019-06-06
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