Comparison Between Primary Resection Anastomosis and Hartmann Procedure for the Treatment of Hinchey III and IV Acute Diverticulitis in the Emergency Setting

Aim: The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. We aimed to evaluate the safety and efficacy of primary anastomosis reducing end-stoma rate and to identify the appropriate surgical timing in the emergency setting for Hinchey III and IV acute diverticulitis. Method: Pertinent data of all patients who underwent Hartmann or primary resection anastomosis (PRA) for Hinchey III and IV diverticulitis, performed between January 2014 and April 2019, were entered in a prospectively maintained database. A retrospective analysis was conducted. Results: During the study period 365 patients underwent emergency surgery for colorectal diseases, 84 for acute left-sided colonic diverticulitis. Patients with Hinchey Stage IIb, stenosis and diverticular hemorrhage were excluded. After selection, a total of 36 Hinchey III and Hinchey IV patients, comparing 19 primary resections anastomosis and 17 Hartmann procedures, were finally enrolled in this study. Patient characteristics were equivalent between groups. The primary anastomosis group showed a reduction in reoperation rate for postoperative complications (5.3%, 1/19 vs 23.55%, 4/17; p=0.335) compared with the Hartmann group. Mortality was 10.5% (2/19) vs 29.4% (5/17) for the primary anastomosis versus Hartmann resection groups (p=0.256). Among patients, there was a statistically significant increase in reversal rate for the primary anastomosis group (42.1% vs 0%; p=0.002). Conclusion: PRA and protective ileostomy approaches for Hinchey III and IV acute diverticulitis may be safe and feasible, resulting in satisfactory perioperative outcomes, postoperative complications and reversal rate. The study is ongoing to confirm these results with increased sample size and confidence.