Safety of primary anastomosis for severe diverticular peritonitis confirmed

Last Updated: 2017-10-02

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Patients with generalized peritonitis related to perforated diverticulitis more often experience stoma reversal after primary anastomosis (PA) with diverting ileostomy than after Hartmann's procedure, new research from France suggests.

"In our study, 90% of patients with Hinchey stage III and IV diverticular peritonitis were able to have PA. Although there was no significant difference in mortality between the two arms in terms of primary outcome, the rate of stoma reversal was significantly higher in the PA arm," lead author Dr. Valerie Bridoux, of Rouen University Hospital in Rouen, and colleagues reported online September 21 in the Journal of the American College of Surgeons.

"This multicenter randomized clinical trial confirms the safety of PA in patients with severe diverticular peritonitis. Furthermore, it provides additional evidence in favor of primary anastomosis with a diverting stoma over Hartmann's procedure," they write.

In the DIVERTI trial, conducted from 2008 to 2012 at seven academic medical centers in France, Dr. Bridoux and colleagues randomized 102 adults (median age, 61; 50% male) with purulent or fecal diverticular peritonitis to undergo either PA with a diverting stoma or Hartmann's procedure.

Mortality incidence at 18 months - the primary outcome - was statistically similar in the PA (4%) and Hartmann's groups (7.7%), as was the overall rate of morbidity (44% for PA, 39% for Hartmann's). However, significantly more patients in PA group than the Hartmann's group (96% vs. 65%) experienced stoma reversal.

These results are consistent with those from previous studies comparing PA with the Hartmann's procedure, the authors note.

They also highlight that only 54% of study participants were operated on by colorectal surgeons, reflecting current surgical practice in France, where patients with acute colonic perforation are treated by surgeons in various specialties, not just those with an expertise in colorectal surgery.

The authors acknowledge that the study was limited by not enrolling enough patients by the end of the study period, difficulties in researching emergency surgery for a life-threatening condition, and possible selection bias.

Dr. Hermann Kessler of Cleveland Clinic, who was not involved in the study, told Reuters Health by email, "It is a known fact that often stomas after Hartmann's procedures are not reversed. However, the high rate of non-reversal after Hartmann's procedure in comparison with the group having primary anastomosis and diverting loop ileostomy is surprising."

"It was important to do this study, as many surgeons still prefer a Hartmann's resection in Hinchey III/IV diverticulitis, and it showed that primary anastomosis can be done with no increased risk," he said. "More surgeons might be more confident to perform a primary anastomosis, and more patients will have a chance to end up without a permanent stoma."

Dr. Kessler added, "Further studies may include a patient group where even a diverting loop ileostomy after primary anastomosis may be omitted."

The study's corresponding author did not respond to requests for comment.

SOURCE: http://bit.ly/2hwOTko

J Am Coll Surg 2017.