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Hinchey Stage III and IV Diverticulitis: Primary Anastomosis versus Hartmann's Procedure2019

Type: New Evidence Based Review (EBR)
Category: Emergency General Surgery
Committee Liaison: Asanthi M. Ratnasekera, DO, FACS

Team leader(s)

Perforated diverticulitis with peritonitis is a life-threating condition. The optimal operation for perforated diverticulitis with peritonitis, Hinchey Stage III and IV, continues to be controversial. Surgical management of Hinchey Stages III and IV diverticulitis warrants either primary resection and anastomosis with or without fecal diversion (PRA) or a Hartmann’s procedure. To date, practice management guidelines using the GRADE methodology do not exist. Two recent systematic reviews suggest that PRA may be associated with an overall lower mortality, lower organ/space surgical site infections and lower ostomy nonreversal rates (1,2). An EAST PMG regarding this topic would help guide surgical decision making for this prevalent disease. Previous efforts: Diverticulitis was identified as one of the first four diseases targeted in a general surgery guidelines gap analysis performed in 2018. A few recent randomized controlled trials have been performed to identify the ideal operative intervention for Hinchey Stage III and IV diverticulitis – but to date, no PMG has been performed evaluating the optimal surgical intervention for Stage III and IV diverticulitis. In 2014, a Clinical Practice Guideline Committee from the American Society of Colon and Rectal Surgeons created Practice Parameters for the treatment of sigmoid diverticulitis. Though they recommended urgent sigmoid colectomy for diffuse peritonitis (1B recommendation), the decision to restore bowel continuity was left as an individualized decision based on the patient’s clinical status (1C). Our guidelines would help guide this exact clinical decision regarding primary anastomosis in the setting of peritonitis secondary to diverticulitis. Since this review in 2014, a few high quality randomized controlled trials have been published regarding this clinical decision. We would be able to incorporate these for a new practice management guideline. Methods: A systematic review and meta-analysis of the current literature regarding the optimal surgical procedure for Hinchey Stage III and IV diverticulitis will be performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. This review will be performed by the Emergency General Surgery working group from the Guidelines of the Eastern Association for the Surgery of Trauma (EAST). Recommendations needed: Recommendations are needed for the optimal operation, primary resection and anastomosis with or without fecal diversion or a Hartmann’s procedure, in a patient with Hinchey Stage III and IV perforated diverticulitis. 1. H Halim, A Askari, R Nunn, J Hollingshead. Primary resection anastomosis versus Hartmann’s procedure in Hinchey III and IV diverticulitis. World J Emerg Surg. 2019 Jul 11;14:32. 2. M Gachabayov, CE Oberkofler, JJ Tuech, D Hahnloser, R Bergamaschi. Resection with primary anastomosis versus nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis. 2018 Sep;20(9):753-770. 3. CE Oberkofler et al. A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann’s Procedure for Perforated Left Colonic Diverticulitis with Purulent or Fecal Peritonitis. Ann Surg. 2012 Nov;256(5):819-26. 4. D Feingold, SR Steele, S Lee, A Kaiser, R Boushey, D Buie, JF Rafferty. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014;284-294.

Work Group
Shailvi Gupta, MD, MPH 
Jessica Babcock, MD
Nikolay Bugaev, MD
William Chiu, MD
John Como, MD, MPH
Haytham Kaafarani, MD, MPH
Jin Ra, MD
Jaswin Sawhney, MD
Kaushal Shah, MD
Devesh Tiwary, MD
Danielle Detelich, MD

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