title: 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.
  
  
  BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital London, UK.
authors.forename: Vasilis A
authors.initials: VA
authors.lastname: Constantinides
authors.forename: Alexander
authors.initials: A
authors.lastname: Heriot
authors.forename: Feza
authors.initials: F
authors.lastname: Remzi
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Asha
authors.initials: A
authors.lastname: Senapati
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
authors.forename: Paris P
authors.initials: PP
authors.lastname: Tekkis
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D003082:Colectomy; D003125:Colostomy; D003661:Decision Support Techniques; D004239:Diverticulitis, Colonic / Q000150:complications / Q000601:surgery*; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications / Q000601:surgery*; D010538:Peritonitis / Q000209:etiology / Q000601:surgery*; D019057:Quality-Adjusted Life Years; D054047:Surgical Stomas; D016896:Treatment Outcome