Non-Elective Surgery for Acute Complicated Diverticulitis. Primary Resection-Anastomosis or Hartmann’s Procedure? A Systematic Review and Meta-Analysis

Colonic diverticulosis is a common condition in the Western world and its incidence increases substantially with age. It was estimated that in patients older than age 60 years, 50% have diverticulosis [1,2]. Surgeons’ interest for this disease is related to the treatment of the complications of diverticulitis (perforation, occlusion, bleeding). About 25% of patients hospitalized for diverticulitis will require a non-elective surgical intervention, in most cases for perforation [3,4]. The surgical management of emergencies for diverticulitis progressed over the past years. The three stage procedure (stoma without resection of the diseased segment as first stage) only maintains a historical value. The two stage procedure, better known as Hartmann’s procedure (HP), includes the resection of the perforated or stenotic segment with terminal colostomy (first stage) and the subsequent restoration of the bowel continuity (second stage). Most recently a one stage surgical approach was proposed including resection of involved colon and primary anastomosis realized in the same setting, with or without protective ileostomy (PRA). Many studies demonstrated no differences between HP and PRA in terms of morbidity and mortality [5,6]. Nevertheless, most surgeons still prefer HP in the emergency setting to treat perforation or obstruction from acute colonic diverticulitis [3,7,8]. Most retrospective studies and the only two prospective trials [6,9] are focused only on patients operated for perforated diverticulitis and peritonitis (Hinchey stage III and IV). Our systematic review aimed to evaluate the literature comparing PRA (with or without protective ileostomy) with HP in all non-elective surgical patients with complicated acute diverticulitis (perforation or obstruction) to assess the effectiveness and safety of the one-stage technique.