DIVERTI
PubMed • Full text • PDF
Clinical Question
In patients with undergoing emergency sigmoidectomy with purulent/feculent peritonitis, does primary anastamosis with diverting ostomy decrease mortality compared to Hartmann’s procedure (discontinuity with end colostomy)?
Bottom Line
Following emergency colectomy for Hinchey III/IV diverticulitis, primary anastomosis with proximal diversion reduces stoma related morbidity without increasing morbidity in comparison with an end colostomy without anastomosis (Hartmann's procedure).
Major Points
Diverticulitis resulting in sepsis can require emergency sigmoid colectomy for infectious source control [1]. The pathway to restore intestinal continuity in a contaminated field is subject to debate, as contamination and septic shock predispose to anastomotic leak. Historically, this was handled by performing a proximal end colostomy with a distal rectal stump, known as a Hartmann’s procedure. The patient is then brought back at a later date for colostomy reversal and reanastamosis. While this approach is undoubtedly safe in the short-term, it exposes the patient to a second major operation (colostomy reversal), results in a significant amount of permanent colostomys, and exposes the patient to colostomy related morbidity.
To reduce end-colostomy related morbidity, an alternative approach is primary anastomosis with proximal diversion (either via loop colostomy or ileostomy. This protects the new anastomosis and represents a lower risk second operation, as reversing loop ileostomies can usually be done locally via the stoma site without full midline laparotomy and peritoneal entry. The anastomosis and diversion approach has demonstrated promising results, although it has historically been challenging to randomize [2].
DIVERTI represents the first prospective, multicenter, randomized trial in emergent diverticulitis. Although DIVERTI trial ultimately proved underpowered and failed to show the specific improvement in mortality, it did demonstrate a 30% absolute risk reduction in definitive stoma with the primary anastamosis group. Subsequent studies have supported this study, finding higher rates fo 12 month stoma free survival [3]. Meta-analysis data has supported a lower mortality in the primary with the primary anastomosis approach [4].
Guidelines
- The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis
- Following resection, the decision to restore bowel continuity should incorporate patient factors, intraoperative factors, and surgeon preference. 1B Recommendation [5]
Design
- N=102 (52 Hartmann Pouch, 50 primary anastamosis)
- Setting: 7 sites tertiary centers/affiliated centers in France
- Mean follow-up: 18 months
- Enrollment: June 2008 - May 2012
- Analysis: Intention-to-treat, T-test, Mann-Whitey, Fisher’s exacted, chi-squared as dictated by data
- Stoma reversal analysis excluded patients without stoma
- Primary outcome: Rate of mortality after primary anastomosis , ostomy reversal
Population
Inclusion Criteria
- adults > 18 years old
- Hinchey stage III (purulent) or IV (feculant) peritonitis
- clinical assessment, CT, laparotomy confirming diagnosis of diverticulitis
Exclusion Criteria
- unable to provide consent
- physical states precluding operation (septic shock, multi-visceral organ failure)
Baseline Characteristics
“Data shown for all patients (n=102), mean and range displayed”
- Age 61 years (25-93)
- Male 50%
- BMI 26.8 (19.3-44.6)
- ASA grade > 1: 86.3%
- Mannheim Peritonitis Index (MPI) Score 26 (16-43)
- MPI > 26 is considered to have a high mortality rate
- Hinchey stage IV 19.8%
- First surgeon resident 46.5%
- Night operation 40.2%
Interventions
- Primary anastomosis
- via midline laparotomy
- anastamosis stapled or handsewn, end to side or end-to-end
- diverting ileostomy or colostomy were allowed
- Stoma reversal 3 months after index operation
- 10/45 patients in the primary anastomosis group did not have a proximal ostomy placed, which constituted a protocol violation.
- 5/45 patients in the primary anastomosis group did not receive an anastomosis (Hartman's procedure)
- Hartmann Pouch
- sigmoid resection with rectal closure and end colostomy
- rectal stump washed
- reversal at 6 months (laparotomy or laparoscopy)
Outcomes
Comparisons are Hartmann’s procedure vs. Primary Anastamosis.
Primary Outcomes
- Mortality
- 7.7% vs. 4.0%, P=0.68
- Definitive stoma
- 35.4% (17/48) vs. 4% (2/48), P<0.001
Secondary Outcomes
Length of stay in ICU/hospital Stoma reversal rates
- Operating time (minutes)
- 235 vs. 198, P=.26
- ICU length of stay (days)
- 8.5 vs. 9.5 (P=0.20)
- Hospital length of stay (days)
- 16 vs. 15.5, P=0.30
- Overall morbidity
- 39.2% vs. 44%, P=.42
- Serious complication (Clavien-Dindo III-IV)
- 17.3% vs. 16%, P=.85
- Above presented outcomes at primary operation
- Secondary outcomes were reevaluated at secondary outcome. Operating time did ultimately differ in the second operation, significantly favoring reduced operative times during the primary anastomosis. No other differences in terms of complication rate, morbidity, or hospital stay were noted.
Subgroup Analysis
- No significant subgroup analysis was performed. The authors report morbidity and a non-operation related mortality in those without a diverting ostomy.
Adverse Events
- 1 patient underwent total proctocolectomy for malignant obstructing colon cancer
- 2 patients assigned to primary anastamosis had a Hartmann’s due to hemodynamic instability (which precludes an anastamosis)
- 3 patients assigned to primary anastamosis had a Hartmann’s due to technical factors
Criticisms
- Difficulty recruiting patients due to emergent conditions may have biased the cohort
- Hinchey III undergoing evaluation for peritoneal lavage
- No data on excluded patients
- High rate of protocol violation with primary anastamosis without ostomy
Funding
- French Ministry of Health
Further Reading
- ↑ Abbas S Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007. 22:351-7.
- ↑ Cirocchi R et al. Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2013. 28:447-57.
- ↑ Lambrichts DPV et al. Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol 2019. 4:599-610.
- ↑ Halim H et al. Primary resection anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis. World J Emerg Surg 2019. 14:32.
- ↑ Hall J et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020. 63:728-747.