DOI: 10.1097/js9.0000000000005674 ISSN: 1743-9159

Primary anastomosis with diverting loop ileostomy versus Hartmann’s procedure in Hinchey III–IV diverticulitis: an international multicentric prospective cohort study

Francesco Pizza, Luigi Marano, Francesco Saverio Lucido, Dario D’Antonio, Silvia Ileana Sara Fattorusso, Luigi Brusciano, Salvatore Tolone, Antonio Brillantino, Ruslan Duka, Robert Molchanov, Valery Kryshen, Gianpaolo Marte, Andrea Tufo, Pietro Maida, Ignazio Sordelli, Ludovico Docimo, Claudio Gambardella
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Background:

The optimal surgical approach for perforated sigmoid diverticulitis (PSD) remains debated. Hartmann’s procedure (HP) is the standard, but often leads to a permanent stoma, while primary resection with anastomosis and diverting loop ileostomy (PADLI) may offer better functional recovery. This prospective multicenter study compared PADLI and HP in terms of stoma reversal, complications, and long-term quality of life (QoL) in hemodynamically stable patients with Hinchey III–IV diverticulitis.

Materials and Methods:

From January 2017 to December 2022, 664 consecutive patients with Hinchey III–IV PSD were enrolled across six high-volume tertiary referral centers in an international multicentric collaboration. The primary endpoint was stoma reversal rate at 24 months. Secondary endpoints included early (≤90 days) and late (>90 days) complications, stoma closure outcomes, long-term morbidity, and QoL assessed with the Short Form-36 Health Survey (SF-36) and EQ-5D-5L questionnaires at 3, 6, 12, and 24 months. Kaplan–Meier survival analysis and multivariable Cox proportional-hazards regression were performed to identify independent predictors of stoma-free survival.

Results:

A total of 265 patients underwent PADLI and 399 HP; 536 patients (80.7%) constituted the per-protocol population analyzed for the primary outcome (210 PADLI, 326 HP); the 19 patients re-operated within 30 days were analyzed separately in a sensitivity analysis. PADLI achieved significantly higher stoma reversal rates at 24 months (91.6% vs 57.8%; P < 0.00001), with shorter median time to closure (64 vs 178 days; P < 0.001). In-hospital mortality was comparable between groups (1.2% vs 1.8%; P = 0.747). Major complications (Clavien–Dindo ≥ IIIb) were comparable (6.1% vs 8.5%), while early readmissions were more frequent in PADLI (17.9% vs 12.3%; P < 0.05) and late readmissions in HP (12.8% vs 7.2%; P < 0.05). PADLI patients demonstrated superior QoL after 6 months, with SF-36 scores at 24 months of 80.1 ± 6.5 vs 72.3 ± 6.8 ( P < 0.001) and EQ-5D-5L of 0.90 ± 0.05 vs 0.75 ± 0.06 ( P < 0.001). Parastomal hernia rates at 24 months were lower in PADLI (43.7% vs 72.9%; P < 0.00001). PADLI independently predicted stoma-free survival at 24 months (HR, 2.63; 95% CI: 1.84–3.77; P < 0.001), while ASA III–V, age ≥70 years, and higher APACHE II scores were negative predictors.

Conclusion:

In stable patients with Hinchey III–IV PSD, PADLI is associated with higher rates of and faster stoma reversal, superior long-term QoL, and fewer late stoma-related complications compared with HP, at the expense of increased early readmissions. These findings, derived from a large international, multicenter cohort, support PADLI as a preferred strategy in selected patients, provided there is structured perioperative care and follow-up.

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