Actual use of surgical options for left-sided complicated colonic diverticulitis: comparing Hartmann’s procedure vs colonic resection and primary anastomosis

Abstract

Background. Choosing the optimal procedure for acute Hinchey III-IV perforated diverticulitis with purulent or fecal peritonitis remains uncertain because of potential selection bias. Objective of the study. The determine the efficiency of different surgical option (Hartmann’s procedure (HP) vs colonic resection and primary anastomosis (PA) in terms of length of the hospital stays, economic worthiness, clinical outcomes, likelihood of stoma reversal, morbidity, and mortality rate. Material and methods. A bibliographic search for specialized free available English literature was performed in PubMed database according to the MeSH terms: “acute diverticulitis”, “Hartmann’s procedure”, “colonic resection and primary anastomosis”, “Hinchey classification”, article type – clinical trials, publication period – 2014-2024. Results. A total of 4 trials demonstrating the competence of HP and PA met the inclusion criteria and were reviewed. The prospective multicenter randomized clinical trial DIVERTI demonstrated the advantage of PA in terms of lower rate of patients with definitive stoma (4% vs 35% respectively). The LADIES trial and the DIVA arm found that the patients in PA group had significantly better stoma-free survival (92% vs 81%), less in-hospital days and lower risk for parastomal hernia occurrence (1,8% vs 16,1%). Also, it was shown PA was more cost-effective (4382€ vs 8372€). The clinical trial NCT04034407 revealed that applying the principles of damage control surgery may enhance reconstruction of bowel continuity. Goodbye Hartmann trial supported the use of PA as the gold standard for surgery in patients with left-sided colonic emergencies. Conclusion. PA is associated with better clinical outcomes for the management of left-sided complicated colonic diverticulitis due to lower incidence of complications, better quality of life, higher stoma-free rates, and greater cost-effectiveness.