Multicentre, randomized clinical trial of primary <i>versus</i> secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis

Zeitoun, Guy; Laurent, Alexis; Rouffet, F; Jm, Hay; Fingerhut, Abe; Paquet, J-C; Peillon, Christophe

doi:10.1046/j.1365-2168.2000.01552.x

Cited by 178 publications

(114 citation statements)

References 22 publications

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“…Although the superiority of an approach with primary resection has been established in multicenter randomized studies over the traditional threestage treatment (diversion, resection, and reanastomosis) [1], the indication to perform a primary anastomosis versus an end-colostomy (Hartmann's procedure; HP) is still under debate.…”

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confidence: 99%

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case‐matched Control Study

et al. 2007

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Background The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann's operation (HP) was compared in a case-matched control study. Methods Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). Results Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p = 0.001), with significantly fewer complications (23% versus 66%, p = 0.02), and lower severity (7% versus 33%, p = 0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p = 0.45) and complication severity (18% versus 24%, p = 0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p = 0.003, 17 versus 28 days, p < 0.001). Conclusions Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessary.How to manage acute left-sided colon perforation remains controversial, as no study providing a high level of evidence is currently available. Although the superiority of an approach with primary resection has been established in multicenter randomized studies over the traditional threestage treatment (diversion, resection, and reanastomosis) [1], the indication to perform a primary anastomosis versus an end-colostomy (Hartmann's procedure; HP) is still under debate.Acute colonic perforation, mostly caused by diverticulitis [2][3][4], is associated with high rates of mortality (up to 20%) and morbidity (up to 60%) [3,5]. The prevalence of diverticular disease is increasing in Western countries, as approximately one-third of the population is affected by the sixth decade of life, and half by the ninth decade [6,7]. Diverticulitis occurs in 10%-25% of patients with diverticulosis [8], and

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confidence: 99%

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case‐matched Control Study

et al. 2007

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“…The multiple variable logistic regression analysis estimated odds ratios and 95% confidence intervals for days from admission for each outcome adjusted for confounders. The solution to the regression equation was used to predict the average probability of each outcome for each day following admission (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). Average predicted values for each day were plotted to show the trend over 1 -20 days.…”

Section: Discussionmentioning

confidence: 99%

“…Diverticulitis complicated by pericolic or pelvic abscess may be treated with intravenous antibiotics and possible image guided drain placement (6). Patients with peritonitis require emergent surgical resection (6,8).…”

Section: Introductionmentioning

confidence: 99%

Impact of Operative Delay on Sepsis and Mortality in Patients with Acute Diverticulitis

et al. 2017

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Background: Ideal operative timing for non-emergent, acute diverticulitis (AD) remains unclear. Medical management is initially attempted to convert a high risk urgent surgery to a less morbid elective surgery, or to avoid surgery altogether. A large proportion of patients will fail medical treatment and require colectomy. Objectives: To evaluate the effect of operative delay on sepsis and mortality in patients with AD. Methods: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent colectomy with a primary diagnosis of diverticulitis between 2005 and 2014 were included. Multiple patient variables were analyzed to see their combined effect on death and sepsis. Patients undergoing surgical intervention on hospital day 0, emergent cases and those with preoperative sepsis were excluded. The impact of operative delay on mortality and sepsis was evaluated using day from admission as the predictor of the primary outcomes. Secondary outcomes included urinary tract infection (UTI), pneumonia (PNA), need for blood transfusion, septic shock, return to the operating room, length of stay (LOS), readmission, wound dehiscence, and surgical site infections (SSI). Frequency of patient variables was recorded and a multiple variable logistic regression analysis was performed to control for possible confounders. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for primary and secondary outcomes. Results: 32,399 patients underwent colectomy for AD on hospital day 1 -20. Adjusted for other factors, days to operation was found to be a significant predictor for death (OR = 1.038, 95% CI 1.020 -1.057; P < 0.0001) and sepsis (OR = 1.051, 95% CI, 1.035 -1.067; P < 0.0001). Each day in which surgical intervention was delayed was associated with a 3.8% increased risk of mortality and 5.1% increased risk of sepsis. Delay of surgery was also associated with an increased risk of blood transfusion, return to the operating room and increased LOS. Conclusions: Delaying operation for patients with AD has a significant impact on sepsis and mortality. While non-operative approaches may be attempted, with each additional day operative therapy is delayed there is a significant increase in the risk of morbidity and mortality. This data suggests that surgeons should pursue operative therapy earlier in the hospital course to improve patient outcomes.

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“…One of the first published reviews of emergency surgery for perforated diverticular disease reported improved mortality and morbidity when the colon was resected compared with procedures in which the colon was left in the abdomen [30]. A subsequent randomized trial reported that primary resection was associated with significantly lower rates of postoperative peritonitis and early re-operation when compared with initial suture of the perforation and diverting colostomy followed by secondary sigmoid resection [31].…”

Section: Primary Anastomosis Versus Hartmann's Proceduresmentioning

confidence: 99%

Management of Acute Diverticulitis and its Complications

Welbourn

Hartley

2014

Indian J Surg

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Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.

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Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis

Abstract: Primary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.

Cited by 178 publications

References 22 publications

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case‐matched Control Study

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case‐matched Control Study

Impact of Operative Delay on Sepsis and Mortality in Patients with Acute Diverticulitis

Management of Acute Diverticulitis and its Complications

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