Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures

Abstract

Objective: To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis.

Summary background data: The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure.

Methods: Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed.

Results: A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively.

Conclusion: Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

FIGURE 1. Multiple-operation decision tree.

FIGURE 2. One-way sensitivity analysis for probability of complications and mortality after PADS for the multiple-operation model. PRA, primary resection and anastomosis; PADS, primary anastomosis with defunctioning stoma; HP, Hartmann's procedure; QALY, quality-adjusted life-years. Vertical dotted line represents the “threshold value” for complications of HP after which a change in operative strategy is indicated.

FIGURE 3. Three-way sensitivity analysis for probability of postoperative complications. PRA, primary resection and anastomosis; PADS, primary anastomosis with defunctioning stoma; HP, Hartmann's procedure. Vertical dotted line represents the baseline estimate of probability of complications after PRA. Horizontal dotted line represents the baseline estimate of probability of complications after PADS. The point of intersection between the 2 lines represents the optimal strategy at the given probability of HP-related complications.