Can we reduce the residual use of Hartmann's procedure in generalized peritonitis due to perforated colonic diverticulitis ?

AIM OF THE STUDY Primary anastomosis (PA) is now recommended for most cases of diverticular peritonitis. However, recent studies have shown that Hartmann's Procedure (HP) is still included in the majority of practice patterns. The aim of this study was to analyze situations wherein HP was carried out and to define its remaining place among current treatment options for generalized peritonitis.

METHODS We performed a retrospective cohort study of patients who underwent sigmoidectomy for diverticular peritonitis at Rouen University Hospital between 2004 and 2020. Logistic regression was computed to evaluate the predictive factors of treatment attribution.

RESULTS 257 patients were included in this study, of whom 154 patients (59.9%) were managed with HP and 103 (40,1%) were managed with PA. The rate of PA progressively increased and represented the majority from 2018. PA was performed by a fellow surgeon in 28% of cases and during the night shift in 60% of cases. A procedure performed by a colorectal specialist surgeon or by a senior surgeon was significantly associated with PA, with ORs of 3.43 (p = 0.017) and 2.06 (p = 0.041), respectively. Night surgery, a medical history of immunosuppression, an ASA score = 3, and age above 75 years were significantly associated with HP, with ORs of 0.33 (p = 0.002), 0.31 (p = 0.023), 0.25 (p = 0.005), and 0.31 (p = 0.011), respectively.

CONCLUSION Over time, the use of primary anastomosis progressively increased and became the predominant strategy in our institution. These findings suggest that, in appropriately selected patients and when performed by experienced surgeons, primary anastomosis is a safe and increasingly applicable strategy in generalized diverticular peritonitis.