By Will Boggs MD
NEW YORK (Reuters Health) - 24/4/2019
Primary anastomosis with diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for emergency management of patients with acute diverticulitis, researchers report.
"Most surgeons believe that the safest procedure to perform in the emergent setting for acute diverticulitis is a Hartmann's procedure, where we remove the diseased piece of colon, and bring the residual colon to the skin level as an ostomy," said Dr. Haytham M. A. Kaafarani from Massachusetts General Hospital and Harvard Medical School, in Boston.
"Our study suggests that, accounting for all risk factors, it is likely safe to perform the anastomosis (i.e., reconnecting the colon) and diverting the small intestine, and, perhaps, we should be performing the reconnection more often across the country," he told Reuters Health by email.
Several earlier reports suggested that PADLI is a safe alternative to HP for selected patients with complicated acute diverticulitis requiring emergent or urgent surgery, but the optimal surgical approach to these patients remains controversial.
Dr. Kaafarani and colleagues used data from the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) Colectomy Procedure Targeted Database to compare the 30-day mortality and morbidity outcomes of 2,521 HP and 208 PADLI patients.
HP patients had more comorbidities and were sicker than PADLI patients before surgery, the researchers report in the Journal of the American College of Surgeons, online March 19.
In unadjusted analyses, HP patients had higher 30-day mortality (7.6% vs. 2.9%) and higher 30-day morbidity (55.4% vs. 48.6%).
After adjustment for all relevant preoperative, intraoperative, and procedure-specific variables, PADLI was not associated with any independent increase in 30-day mortality or overall 30-day morbidity, compared with HP, however.
"Whether HP or PADLI is more cost-effective on the long-term, when one considers the rates and risks of either colostomy or ileostomy takedown, remains to be determined," the researchers note.
"The reconnection procedure requires a little bit more time during surgery, and perhaps familiarity with the circular staples to perform an end-to-end anastomosis, but most surgeons can perform both procedures safely and soundly," Dr. Kaafarani said. "The main message is to go out of our comfort zone, and perhaps perform the reconnection in the initial surgery, if the patient remains reasonably stable at the end of the diseased segment of colon resection."
"Perhaps a large well-powered randomized clinical trial would show even an overall superiority of PADLI," he speculated.
J Am Coll Surg 2019.