The surgical management of perforated diverticulitis Hinchey III: a systematic review and meta-analysis

The purpose of the present study was to perform a systematic review and meta-analysis of the available literature on the surgical management of Hinchey III diverticulitis comparing laparoscopic lavage with surgical resection.

A PubMed and EMBASE search using well-defined mesh terms was used. All identified papers were screened for possible inclusion in the study by initial review of abstracts. Only randomized trials were included in the meta-analysis.

The search resulted in 23 studies available for closer investigation. We managed to identify 3 separate randomized trials comparing the outcome after laparoscopic lavage and sigmoid resection for Hinchey III diverticulitis. Early and late results of these trials have been reported in 7 scientific papers constituting the basis of the present systematic review and meta-analysis. For the different endpoints, pooled data from between 292 and 380 patients randomized to either sigmoid resection or laparoscopic lavage was available for analysis. Ninety-day mortality was similar between the groups (OR = 0.69 (0.32-1.49)), but the risk of severe complications and of recurrent diverticulitis was lower among patients randomized to sigmoid resection (OR = 0.61 (0.38-0.98) and OR = 0.15 (0.05-0.44), respectively). The risk of having a stoma after 1 year was higher among patients randomized to resection (OR = 2.97 (1.30-6.81)). No significant differences were identified regarding the need for reoperation. Subsequent analysis of data from two of the randomized trials showed that smoking and use of immunosuppressant medications were associated with a poorer outcome after laparoscopic lavage.

Laparoscopic lavage has certain advantages when compared to resection for Hinchey III diverticulitis, but should be used with caution in smokers and patients taking immunosuppressants. After lavage, recurrent diverticulitis (often uncomplicated) is likely to occur. Resection with primary anastomosis is a good option in stable and fit patients when surgical expertise is available, but for a number of patients, resection with formation of a stoma seems to be the safest option.