• Sergio A Acuna, Trevor Wood, Tyler R Chesney, Fahima Dossa, Steven D Wexner, Fayez A Quereshy, Sami A Chadi, and Nancy N Baxter.
• Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
• Dis. Colon Rectum. 2018 Dec 1; 61 (12): 1442-1453.

BackgroundThe traditional approach for perforated diverticulitis, the Hartmann procedure, has considerable morbidity and the challenge of stoma reversal. Alternative procedures, including primary resection and anastomosis and laparoscopic lavage, have been proposed but remain controversial.ObjectiveThe purpose of this study was to compare operative strategies for perforated diverticulitis.Data SourcesMEDLINE, Embase, Cochrane Library, and the grey literature were searched from inception to October 2017.Study SelectionWe included randomized clinical trials evaluating operative strategies for perforated diverticulitis.InterventionsHartmann procedure, primary resection and anastomosis, and laparoscopic lavage were included.Main Outcome MeasuresData were independently extracted by 2 investigators. Risk of bias was evaluated using the Cochrane risk-of-bias tool. Pooled risk ratios for major complications, reoperation, and mortality were determined using random-effects models.ResultsSix trials including 626 patients with perforated diverticulitis were identified. Laparoscopic lavage and sigmoidectomy had comparable rates of early reoperation and postoperative mortality; major complications (Clavien-Dindo >IIIa) were more frequent after laparoscopic lavage (RR = 1.68 (95% CI, 1.10-2.56); 3 trials, 305 patients). Comparing approaches for sigmoidectomy, primary resection and anastomosis had similar rates of major complications (RR = 0.88 (95% CI, 0.49-1.55); 3 trials, 255 patients) and postoperative mortality (RR = 0.58 (95% CI, 0.20-1.70); 3 trials, 254 patients) compared with the Hartmann procedure. However, patients who underwent primary resection and anastomosis were more likely to be stoma free at 12 months compared with the Hartmann procedure (RR = 1.40 (95% CI, 1.18-1.67); 4 trials, 283 patients) and to experience fewer major complications related to the stoma reversal procedure (RR = 0.26 (95% CI, 0.07-0.89); 4 trials, 186 patients).LimitationsThere were no limitations to this study.ConclusionsLaparoscopic lavage is associated with increased risk of major complications versus primary resection for Hinchey III diverticulitis. The lower rate of stoma reversal and higher rate of complications after the Hartmann procedure suggest primary resection and anastomosis as the optimal management of perforated diverticulitis.

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