Introduction: Perforated diverticulitis of the sigmoid colon is a common cause for emergency laparotomy. Several non-randomized studies reported in recent years that a sigmoid colectomy with primary anastomosis in Hinchey I-III patients yields similar results when compared to the Hartmann procedure, while avoiding the frequently difficult operation for take-down and reanastomosis of the colostomy. The aim of this study was to review the results of this practise in our hospital and to identify patients at risk for morbidity and lethal outcome.
Methods: All patients who were admitted to our hospital with the diagnosis diverticulitis of the sigmoid colon from 1996 to 2006 were identified by the institutional data base and the patient charts reviewed. While 787 patients were admitted, 73 were operated on an emergency basis i.e. within 24 h after hospitalization (f: m ratio 1.3:1; median age 66 years, range 42-91). The primary end points were lethality, anastomotic leakage in patients with primary anastomosis and leakage of the rectal stump following Hartmanns procedure. Statistical analysis was performed by Chi-Square Test.
Results: 36 (49 %) of 73 patients who were operated on an emergency basis had a primary anastomosis without any stoma. 11 (15 %) patients received a primary anastomosis and a loop ileostomy. A Hartmann procedure was performed in 26 (36 %) patients. Complications were observed in 27 (37 %) of all patients. Anastomotic leakage occurred in 9 of 36 patients (25 %) following primary anastomosis without protective loop ileostomy and in 1 of 11 patients (10 %) who had an additional loop ileostomy. Seven patients died. Six of them had undergone a Hartmann operation and two primary anastomosis; one with and one without loop ileostomy (total mortality 10 %). The incidence of anastomotic leakage was independent of the Hinchey classification (Hinchey I. 3 pts, Hinchey II: 4 pts., Hinchey III 2 pts; n.s.), but associated with the comorbidity of the patients (ASA II: 1 pts; Asa III: 5 pts; ASA IV: III pts.; p<0.05).
Conclusions: Lethality and morbidity following operations for perforated sigmoid diverticulitis are high. Anastomotic leakage was primarily associated with severe comorbidity and was not dependent on the extent of the abdominal infection according to the Hinchey classification. The indication for a primary anastomosis following emergency surgery for sigmoid colectomy in perforated diverticulitis should not be based on the local intraabdominal findings but rather on the extent of the patients comorbidity.