The review concluded that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann’s procedure in terms of peri-operative complications. However, in view of the methodological weaknesses of the review, the author’s conclusions may not be reliable.

To determine the safety and feasibility of primary resection and anastomosis, with or without a diverting stoma, in comparison with Hartmann’s procedure in patients with acute complicated sigmoid diverticulitis.

MEDLINE (1966 to December 2003), EMBASE and the Cochrane Library were searched; the search terms were reported. Unpublished articles, abstracts and presentations at meetings were excluded. No language restrictions were applied.

Study designs of evaluations included in the review

Retrospective and prospective studies were eligible for inclusion. Studies with limited sample sizes were excluded.

Specific interventions included in the review

Studies assessing resection and primary anastomosis, with or without a stoma, in comparison with Hartmann’s procedure were eligible for inclusion.

Participants included in the review

Studies of adults (aged over 18 years) with acute complicated diverticulitis requiring emergency operative intervention were eligible for inclusion. Studies where participants had other colonic complications were excluded.

Outcomes assessed in the review

Studies that assessed mortality, overall morbidity (including wound complications), hospital stay, anastomotic leakage, abdominal abscess, duration of procedure, abdominal collection and stoma complication were eligible for inclusion.

How were decisions on the relevance of primary studies made?

The author did not state how the papers were selected for the review, or how many reviewers performed the selection.

The author did not state that validity was assessed.

The author did not state how the data were extracted for the review, or how many reviewers performed the extraction. The outcomes were reported as total numbers and percentages, or as means alongside standard deviations (SDs)

How were the studies combined?

The studies were combined in a narrative. Each study was described in the text and additional descriptive information was tabulated. Pooled results for outcomes reported as total numbers and percentages were calculated by summing the total number of events from each study.

How were differences between studies investigated?

Differences between the studies were presented in the tables and discussed in the text.

Eighteen studies (n=884) were included in the main review: 16 retrospective studies (n=769) and 2 prospective reports (n=115). Three further studies (n=220) reported anastomosis with a diverting stoma.

Mortality at 30 days’ follow-up was 9% (32 out of 358) for patients in the primary anastomosis group compared with 19% (102 out of 525) for patients in the Hartmann’s procedure group. However, the difference only reached statistical significance in two of the 18 studies (p<0.05).

Overall morbidity was 29% (104 out of 358) in the primary anastomosis group compared with 33.4% (176 out of 526) in the Hartmann’s procedure group. The difference only reached statistical significance in four of the 18 studies (p<0.05).

Post-operative wound infection rates (7 studies) were 14% in the primary anastomosis group compared with 22.6% in the Hartmann’s procedure group. The difference only reached statistical significance in one study (p=0.03).

Length of hospital stay (6 studies) ranged from a mean of 7.4 (SD=8.4) to 18.7 (SD=7.9) in the primary anastomosis group and from a mean of 12.7 (SD=4.8) to 38.2 (SD=28.5) in the Hartmann’s procedure group.

Anastomotic leakage rates were 5.5% in the primary anastomosis group compared with 8% in the Hartmann’s procedure group (18 studies).

Abdominal abscess rates were 4% in the primary anastomosis group compared with 8% in the Hartmann’s procedure group (8 studies).

Two studies reported operative time and found no significant difference between the primary anastomosis group and the Hartmann’s procedure group.

Primary anastomosis with a diverting stoma was compared with Hartmann’s procedure in 3 studies. One study found no differences in mortality, anastomotic leak, intra-abdominal abscess, wound infections or operation time found. A second study concluded that complication and mortality rates were lower with primary anastomosis with a diverting stoma than with Hartmann’s procedure (no data reported). The results were unclear for the third study.

The findings suggested that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compare favourably with Hartmann’s procedure in terms of peri-operative complications. Thus, the need for revision of the Hartmann’s procedure could be avoided.

Inclusion criteria were defined in terms of the intervention, participants, outcomes and study design. Several databases were searched but handsearches were not conducted and unpublished trials were excluded, therefore the possibility of publication bias is highly likely. The methods used to select studies and extract the data were not described. However, as this is a single author study, it seems likely that these were not duplicated, thereby introducing the potential for error and bias. Study validity was not assessed, so the results from these studies and any synthesis may not be reliable. In addition, the majority of the included studies had small sample sizes and were retrospective in nature which, as the author acknowledged, means that they are subject to various potential biases. Given that no details of the participants were provided, it is not possible to assess the generalisability of the results. In addition, the results presented some outcomes without identifying the units of measurement used, and the reporting of mortality implied that a statistical test had been used on the pooled data, but the test used and the methodology applied were not described. In view of the methodological weaknesses of the review, the author’s conclusions may not be reliable.

Practice: The author did not state any implications for practice.

Research: The author stated that randomised controlled trials are required to determine whether primary anastomosis is superior to Hartmann’s procedure.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.