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A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann's Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis

Oberkofler, Christian Eugen MD*; Rickenbacher, Andreas MD*; Raptis, Dimitri Aristotle MD, MSc*; Lehmann, Kuno MD*; Villiger, Peter MD; Buchli, Christian MD; Grieder, Felix MD; Gelpke, Hans MD; Decurtins, Marco MD; Tempia-Caliera, Adrien A. MD§; Demartines, Nicolas MD§; Hahnloser, Dieter MD§; Clavien, Pierre-Alain MD, PhD*; Breitenstein, Stefan MD*

doi: 10.1097/SLA.0b013e31827324ba
Original Articles From the ESA Proceedings

Objectives: To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis.

Background: The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the 2 procedures.

Methods: Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary end point was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary end points as well as a decreasing accrual rate (NCT01233713).

Results: Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group.

Conclusions: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Supplemental Digital Content is Available in the Text.This is the first randomized clinical trial to show that primary anastomosis with diverting ileostomy is superior to the Hartmann procedure in acute left-colonic perforation with generalized peritonitis. Advantages relate to the reversal of the diverting ileostomy, which is more likely to occur and safer than the reanastomosis of the colon after end colostomy.

*Department of Surgery University Hospital Zurich, Zurich, Switzerland

§Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland

Department of Surgery, Cantonal Hospital, Chur, Switzerland

Department of Surgery, Cantonal Hospital, Winterthur, Switzerland

Reprints: Stefan Breitenstein, MD, Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland. E-mail:

CEO, AR, and DAR contributed equally as first authors.

Disclosure: The authors declare no conflicts of interest.

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© 2012 Lippincott Williams & Wilkins, Inc.