Hartmann’s Procedure or Primary Anastomosis

for Generalized Peritonitis due to Perforated

Diverticulitis: A Prospective Multicenter Randomized
Trial (DIVERTI)
Valerie Bridoux, PhD, Jean Marc Regimbeau, PhD, Mehdi Ouaissi, PhD, Muriel Mathonnet, PhD,
Francois Mauvais, MD, Estelle Houivet, PhD, Lilian Schwarz, PhD, Diane Mege, PhD, Igor Sielezneff, PhD,
Charles Sabbagh, PhD, Jean-Jacques Tuech, MD, PhD

BACKGROUND: About 25% of patients with acute diverticulitis require emergency intervention. Currently,
most patients with diverticular peritonitis undergo a Hartmann’s procedure. Our objective
was to assess whether primary anastomosis (PA) with a diverting stoma results in lower mor-
tality rates than Hartmann’s procedure (HP) in patients with diverticular peritonitis.
STUDY DESIGN: We conducted a multicenter randomized controlled trial conducted between June 2008 and
May 2012: the DIVERTI (Primary vs Secondary Anastomosis for Hinchey Stage III-IV
Diverticulitis) trial. Follow-up duration was up to 18 months. A random sample of 102
eligible participants with purulent or fecal diverticular peritonitis from tertiary care referral
centers and associated centers in France were equally randomized to either a PA arm or to an
HP arm. Data were analyzed on an intention-to-treat basis. The primary end point was
mortality rate at 18 months. Secondary outcomes were postoperative complications, operative
time, length of hospital stay, rate of definitive stoma, and morbidity.
RESULTS: All 102 patients enrolled were comparable for age (p ¼ 0.4453), sex (p ¼ 0.2347), Hinchey
stage III vs IV (p ¼ 0.2347), and Mannheim Peritonitis Index (p ¼ 0.0606). Overall mor-
tality did not differ significantly between HP (7.7%) and PA (4%) (p ¼ 0.4233). Morbidity
for both resection and stoma reversal operations were comparable (39% in the HP arm vs
44% in the PA arm; p ¼ 0.4233). At 18 months, 96% of PA patients and 65% of HP pa-
tients had a stoma reversal (p ¼ 0.0001).
CONCLUSIONS: Although mortality was similar in both arms, the rate of stoma reversal was significantly
higher in the PA arm. This trial provides additional evidence in favor of PA with diverting
ileostomy over HP in patients with diverticular peritonitis. ClinicalTrials.gov Identifier:
NCT 00692393. (J Am Coll Surg 2017;225:798e805.
2017 Published by Elsevier Inc.
on behalf of the American College of Surgeons.)

Diverticular disease is a common gastrointestinal disor-

Disclosure Information: Nothing to disclose.
Received July 21, 2017; Revised September 5, 2017; Accepted September 6,
2017.
From the Departments of Digestive Surgery (Bridoux, Schwarz, Tuech) and
Biostatistics (Houivet), Rouen University Hospital, Rouen, Department of
Digestive Surgery, Amiens University Hospital, Amiens (Regimbeau,
Sabbagh), Department of Digestive Surgery, Marseille University Hospital
La Timone, Marseille (Ouaissi, Mege, Sielezneff), Department of Digestive
Surgery, Limoges University Hospital, Limoges (Mathonnet), and Depart-
ment of Digestive Surgery, Beauvais General Hospital, Beauvais (Mauvais),
France.
Correspondence address: Jean-Jacques Tuech, MD, PhD, Department of
Digestive Surgery, Rouen University Hospital, 1 rue Germont, 76031
Rouen Cedex, France. email: Jean-jacques.tuech@chu-rouen.fr
der, found in one-third of people older than 60 years of
age in the Western world.1 The majority of patients
admitted with acute diverticulitis can be managed with
medical treatment, but emergency operations are required
in about 25% of patients.2
Patients presenting with purulent or fecal peritonitis
most commonly undergo a radical Hartmann’s procedure
(HP),3-5 despite several guidelines stating that resection
with primary anastomosis (PA) in selected patients is a
safe alternative to nonrestorative colon resection.6-8
The recent review published by Cirocchi and col-
leagues9 suggested that PA offers significant advantages

ª 2017 Published by Elsevier Inc. on behalf of the American College of https://doi.org/10.1016/j.jamcollsurg.2017.09.004

Surgeons. 798 ISSN 1072-7515/17
Vol. 225, No. 6, December 2017 Bridoux et al
in terms of lower mortality rate compared with HP (p ¼
0.02). However, many published studies have reported
significant patient selection bias, therefore, limiting the
ability to draw conclusions. Two randomized controlled
studies were published in 2012 comparing Hinchey
stage III and IV patients who had PA with ileostomy
vs HP.10,11
The first trial published by Binda and colleagues10 was
prematurely stopped due to recruitment difficulties. Dur-
ing a 9-year period, 34 patients were randomly assigned to
the PA arm and 56 to the nonrestorative colon resection
arm. There was no significant difference in mortality
(2.9% vs 10.7%; p ¼ 0.247) or morbidity (35.3% vs
46.4%; p ¼ 0.38) rates between the 2 arms. The rate of
stoma reversal was similar in the 2 arms (p ¼ 0.659),
but the morbidity rate after stoma reversal was lower after
PA (4.5% vs 23.5%; p ¼ 0.0589) than after nonrestora-
tive colon resection.
The second trial published by Oberkofler and col-
leagues11 was also stopped, in this case because of an
interim safety analysis that reported significantly more
serious complications with stoma reversal after HP
than after PA (20% vs 0%). The authors also reported
a significantly higher rate of stoma reversal after PA
with diverting ileostomy than after HP (90% vs 57%;
p ¼ 0.005).
The objective of the current multicenter randomized
clinical trial conducted in France between June 2008
and May 2012 was to assess the mortality rate after PA
with a diverting stoma vs HP in patients with diverticular
peritonitis.
METHODS
Patients and study design
The current trial was designed as a prospective, multi-
center, randomized controlled study comparing mortality
between patients with diverticular peritonitis (Hinchey
stage III and IV) who had a PA with a protective diverting
stoma vs patients who had an HP. The DIVERTI
(Primary vs Secondary Anastomosis for Hinchey Stage
III-IV Diverticulitis) trial was registered at ClinicalTrials.
gov (NCT 00692393). The protocol was approved by the
Haute-Normandie Ethics Committee (France) and
authorized by the French competent authority. Written
informed consent was obtained from all patients before
randomization. A data safety monitoring board was estab-
lished with experts independent of the investigators. Data
were analyzed according to the intention to treat princi-
ple. The aim of this study was to confirm the hypothesis
that PA results in lower mortality than HP in peritonitis
due to perforated diverticulitis.
Generalized Peritonitis and Perforated Diverticulitis 799
Study end point
The primary end point was the rate of mortality after PA
or HP and ostomy reversal. After emergency operation,
patients were followed for up to 18 months.
Secondary end points were overall morbidity, including
the first and the second operation, assessed according to
the Clavien-Dindo classification12; operating time; length
of stay in ICU; length of stay in hospital; and stoma
reversal rates.
Eligibility criteria
Inclusion criteria were patients older than 18 years with
purulent or fecal peritonitis (Hinchey stage III and IV)
secondary to perforated diverticulitis and able to provide
informed consent.
Before enrollment, all patients had clinical assessment
and CT scan and were informed about the study. The
diagnosis was confirmed during laparotomy. Exclusion
criteria were physical states that prevented patient’s partic-
ipation (eg septic shock or multivisceral failure) and fail-
ure to provide consent.
Randomization
Randomization was executed by means of envelopes that
were prepared and sequentially numbered by the Depart-
ment of Biostatistics of Rouen University Hospital and
sent to the participating centers. The patients were
informed by the surgeon at the time of admission to the
emergency department, and randomization took place
immediately before the operation.
Participating centers
Participating centers were 4 tertiary care referral hospitals
(Departments of Digestive Surgery at Rouen University
Hospital, France; Amiens University Hospital, France;
Limoges University Hospital, France; and Marseilles Uni-
versity Hospital, La Timone, France) and 3 affiliated cen-
ters (Departments of Surgery at Beauvais General
Hospital, France; Dunkerque General Hospital, France;
and Lomme General Hospital, France).
Study interventions
Primary anastomosis was performed through a midline
laparotomy according to the standard technique, with
lateral to medial mobilization of the left colon and mobi-
lization of splenic flexure. Vascular ligations were per-
formed close to the intestine. The rectosigmoid junction
was exposed and transected with a stapler. Proximal sec-
tion was performed on a healthy colonic segment. The
anastomosis was performed on well-vascularized digestive
segments, without tension, according to the habits of the
surgeon investigator (mechanical or manual anastomosis;
800 Bridoux et al Generalized Peritonitis and Perforated Diverticulitis
end to end or side to end). After instillation of saline into
the pelvis, the anastomosis was tested by air insufflation
through the rectum. Decisions to clean the colon intrao-
peratively, to place a drain, and to perform ileostomy or
colostomy were left to the discretion of the surgeon.
The stoma reversal operation was performed at least 3
months after the first operation and after performing a
barium enema to check for the absence of fistula or steno-
sis at the level of the anastomosis.
The HP (sigmoid resection, rectal closure, end colos-
tomy) was performed according to the habits of the sur-
geon investigator. The rectal stump was washed to
reduce the risk of bacterial overgrowth in the excluded
rectum. The stoma reversal operation was performed at
least 6 months after HP. Hartmann reversal was per-
formed by laparotomy or laparoscopy according to the
habits of the investigator surgeon after performing a rectal
enema to assess the length of the rectal stump and to
verify the absence of fistula.
Sample size calculation
Analysis of available data in the literature during protocol
development13-48 suggested that the mortality rate for HP
was 21.1% and for PA was 8.6%.
To achieve 80% power relative to this between-group
difference for a 2-sided 0.05 significance level with Pear-
son’s chi-square test, the target sample size was 246 pa-
tients, 123 in each group.
Statistical analysis
Continuous variables were compared with the Student’s t-
test and the Mann-Whitney test, where appropriate. Dif-
ferences among proportions derived from categorical data
were compared using Fisher’s exact test and Pearson’s chi-
square test, where appropriate.
Results are reported as median with range or percent-
ages. For all statistical tests, a 2-sided p value <0.05
was considered significant. Statistical analyses were per-
formed using SAS (version 9.3, SAS Institute).
Role of the funding source
This study was funded by the French Ministry of Health
(Programme Hospitalier de Recherche Clinique). The
work was completely independent. The Ministry of
Health had no role in the study design, conduct, data
collection, analyses, data interpretation, or writing of
this paper. The sponsor was not involved in developing
the analysis plan or in the analysis. The corresponding
author had full access to all the data. The authors had
final responsibility for the decision to submit for
publication.
J Am Coll Surg
RESULTS
Patient flow
From June 2008 to May 2012, a total of 102 patients were
randomly assigned to HP (n ¼ 52) or PA with a diverting
stoma (n ¼ 50) (Fig. 1). In the HP arm, all patients
received the allocated procedure, except for 1 patient
who underwent total coloproctectomy for malignant left-
sided colonic obstruction identified perioperatively.
Five patients initially randomized for a PA had an HP.
In 2 patients, the hemodynamic condition had worsened
during the intervention and did not allow the realization
of an anastomosis. In the other 3 patients, the decision to
perform HP was made due to the following technical dif-
ficulties: mobilization of the splenic flexure, resection of
the associated small intestine, and fistula of the rectal
stump. Among the 45 remaining patients, a diverting
stoma was not performed in 15 cases due to protocol
violation. Twenty-three patients had a colostomy and 7
had an ileostomy.
All patients were operated by laparotomy. Surgical pa-
thology analysis confirmed preoperative diagnosis except
for 4 patients with perforated left-sided colon cancer (3
PA, 1 HP, and 1 coloproctectomy).
Baseline data
Patients’ characteristics are shown in Table 1. There was no
statistical difference between the 2 arms in terms of age,
sex, BMI, previous abdominal operation, American Society
of Anesthesiologists physical status classification, and Man-
nheim Peritonitis Index score. The severity of peritonitis
defined by Hinchey stage classification was similar in
both arms. Operations were performed overnight in 41%
of cases and by a senior surgeon in 53.5% of cases.
Primary end point: overall mortality
At the end of the study, the rate of mortality was higher in
the HP arm than in the PA arm, but the difference was not
statistically significant (7.7% [n ¼ 4] vs 4% [n ¼ 2]; p ¼
0.6783). Of the 6 patients who died during the 18 months
after the first operation, 4 deaths (3 in the HP arm and 1
in the PA arm) were related to the operation (Fig. 1).
Four patients died after the first operation. In the PA
arm, 1 patient died of inhalation pneumonia on day 3
and 1 patient died during follow-up for otolaryngologic
cancer. In the HP arm, 1 patient died of acute respiratory
distress syndrome on the day 38 and 1 patient died of
heart failure 14 months after operation.
Two other patients died after the second operation in
the HP arm: 1 patient died 3 days after restoration of con-
tinuity of mesenteric ischemia and 1 patient died 98 days
after cardiac decompensation.
Vol. 225, No. 6, December 2017 Bridoux et al Generalized Peritonitis and Perforated Diverticulitis 801

Figure 1. Patient CONSORT (Consolidated Standards of Reporting Trials) flow chart. HP, Hartmann’s procedure; PA,
primary anastomosis. *Death related to operation.

Secondary end points Other intraoperative and postoperative data, such as

At the end of the study, the overall complication rates
(Clavien-Dindo grades I to V) and severe complication
rates (Clavien-Dindo grade III to V) were similar in
both arms: 39.2% and 17.3% in the HP arm vs 44%
and 16% in the PA arm (Table 2).
operating time, intraoperative complications, ICU stay,
and hospital stay were similar in both arms.
Results of the emergency operation
Table 3 shows the intraoperative data and results of the
first procedure. With the exception of operating time,

Table 1. Baseline Demographic Characteristics

Characteristic All patients (n ¼ 102) Hartmann’s procedure (n ¼ 52) Primary anastomosis (n ¼ 50) p Value
Age, y, median (range) 61 (25e93) 61.5 (29e92) 61 (25e93) 0.4453
Male, n (%) 51 (50) 23 (44.2) 28 (56) 0.2347
BMI, kg/m2, median (range) 26.8 (19.3e44.6) 26.8 (19.3e44.6) 26.1 (20e43) 0.5405
ASA grade >1, n (%) 88 (86.3) 43 (82.7) 45 (90) 0.2836
MPI score, median (range) 26 (16e43) 27 (20e43) 26 (16e39) 0.0606
Hinchey stage IV, n (%) 20 (19.8) 12 (23.5) 8 (16) 0.2347
First surgeon resident, n (%) 47 (46.5) 23 (45.1) 24 (48) 0.77
Night operation, n (%) 41 (40.2) 22 (43.1) 19 (38) 0.5991
ASA, American Society of Anesthesiologists; MPI, Mannheim Peritonitis Index.
802 Bridoux et al Generalized Peritonitis and Perforated Diverticulitis J Am Coll Surg

Table 2. Overall Outcomes Combining the First (Emergency Operation) and Second Interventions (Stoma Reversal)
All patients Hartmann’s procedure Primary anastomosis
Outcomes (n ¼ 102) (n ¼ 52) (n ¼ 50) p Value
Operating time, min, median (range) 210 (45e650) 235 (45e650) 197.5 (74e510) 0.2561
Intraoperative complication, n (%) 11 (10.8) 6 (11.5) 5 (10) 0.8023
ICU stay, d, median (range) 9.5 (0e71) 8.5 (1e71) 9.5 (0e27) 0.2012
Hospital stay, d, median (range) 16 (3e88) 16 (4e88) 15.5 (3e61) 0.3012
Overall morbidity, n (%) 53 (41.6) 25 (39.2) 28 (44) 0.4233
Serious complication,* n (%) 17 (16.7) 9 (17.3) 8 (16) 0.8593
Mortality, n (%) 6 (5.9) 4 (7.7) 2 (4) 0.6783
Definitive stoma, n/N (%) 19/96 (19.8) 17/48 (35.4) 2/48 (4) 0.0001
*Clavien-Dindo III to V.

which favored the HP arm, patients were comparable for
intra- and postoperative data. There were no significant
differences in overall mortality or morbidity between
the 2 study arms.
In the HP arm, 4 patients presented with an intra-
abdominal abscess, 2 of them were reoperated and 2 un-
derwent CT scan-guided drainage. Another 2 patients
were reoperated for occlusion.
In the PA arm, 2 patients presented an intra-abdominal
abscess, 1 patient was reoperated and 1 had CT scan-
guided drainage. Two patients presented with an anasto-
motic leak, 1 was reoperated (HP) and 1 patient was
treated with a stent. One patient presented with a pancre-
atic fistula and 1 patient presented with an anastomotic
stricture; these 2 patients were treated endoscopically.
In the subgroup of patients without a protective stoma,
there was no mortality related to the operation (1 died
during follow-up of otolaryngologic cancer), and
morbidity was 26% (n ¼ 4): 3 patients presented with
an incisional abscess and 1 patient had a prolonged ileus,
which was treated medically.
Overall morbidity and serious complications (Clavien-
Dindo III to IV) were significantly lower in the group of
patient without protective stoma than with stoma
(27% and 0% vs 67% and 23%; p ¼ 0.01 and p ¼
0.042), but they were selected patients.
Results of the second operation
Of the 98 patients who survived the first operation, 65
had elective stoma reversal (Fig. 1). Among the 48 pa-
tients in each arm, 17 in the HP arm were not reversed
compared with 2 in the PA arm (35.4% vs 4%; p ¼
0.0877). The 2 patients not reversed in the PA arm
were deviated to HP during the first operation.
The 17 patients who did not received Hartman reversal
procedure were older (mean age 78 years vs 56 years; p <
0.001), lived more often in nursing homes (12% vs 0%;
p ¼ 0.044), had more comorbidities (American Society
of Anesthesiologists grade >I: 94% vs 75%; p ¼
0.044), and had more often required hospitalization in
rehabilitation unit after the first operation (71% vs 9%;
p < 0.001).
The operation time was significantly longer in the HP
arm (170 minutes vs 70 minutes; p < 0.001), but there
were no significant differences in morbidity between the
2 arms (Table 4).
One patient in the PA arm had a postoperative anasto-
motic leak that required reoperation and was treated

Table 3. Intra- and Postoperative Data of First Operation

Variable All patients (n ¼ 102) Hartmann’s procedure (n ¼ 52) Primary anastomosis (n ¼ 50) p Value
Operating time, min, median (range) 140 (40e360) 120 (40e360) 175.5 (74e320) 0.0016*
Perioperative complication, n (%) 7 (6.9) 3 (5.8) 4 (8) 0.7127
Small intestine injury, n (%) 2 (2) 1 (2) 1 (2) d
Spleen injury, n (%) 3 (3) 1 (2) 2 (4) d
Colon injury, n (%) 1 (1) 1 (2) d d
Septic shock, n (%) 1 (1) d 1 (2) d
Overall morbidity, n (%) 49 (48) 22 (42.3) 27 (54) 0.2373
Serious complication,y n (%) 14 (13.7) 7 (13.5) 7 (14) 0.9370
ICU stay, d, median (range) 9.5 (1e71) 9.5 (1e71) 9.5 (3e27) 0.8141
Hospital stay, d, median (range) 11 (3e88) 11 (4e88) 11.5 (3e53) 0.4415
*Significant.
y
Clavien-Dindo III to V.
Vol. 225, No. 6, December 2017 Bridoux et al
Table 4. Intra- and Postoperative Data of Second Operation
All patients
Outcomes (n ¼ 65)
First surgeon resident, n (%) 29 (44.6)
First surgeon senior, n (%) 36 (55.4)
Operating time, min, median (range) 120 (30e510)
Perioperative complication, n (%) 4 (6.2)
Small intestine injury, n 3 3
Vein injury, n 1 1
Colon injury, n 2 1
Vagina injury, n 1 1
Overall morbidity, n (%) 11 (17)
Serious complication,y n (%) 4 (6.1)
Hospital stay, d, median (range) 7 (3e33)
*Significant.
y
Clavien-Dindo III to V.
conservatively. After reversal of HP, 1 patient died of
mesenteric ischemia after atrial fibrillation, 1 patient
had intra-abdominal bleeding that required reoperation,
and 1 patient underwent CT scan-guided drainage of
intra-abdominal abscess.
DISCUSSION
The optimal surgical treatment for diverticular peritonitis
remains controversial. In 2000, a randomized controlled
trial demonstrated the advantage of primary resection
over secondary resection due to significantly less postoper-
ative peritonitis, fewer reoperations, and shorter hospital
stay.30 In 2012, two randomized controlled trials provided
arguments in favor of PA. Ileostomy reversal was more
frequent and associated with fewer severe complications
than colostomy reversal after HP.10,11
This study is the third randomized clinical trial
comparing PA with a diverting stoma and HP for the
treatment of perforated diverticulitis with peritonitis.
Contrary to the review published by Cirocchi and col-
leagues9 in 2011, we were not able to demonstrate that
resection-anastomosis reduces mortality, which was our
primary end point. However, the rate of patients with a
definitive stoma was significantly lower in the PA arm
than in the HP arm (4% for PA vs 35% for HP).
The 2 patients without stoma reversal in the PA arm
(n ¼ 2) had been deviated from PA to HP during the
emergency operation; however, because this analysis was
performed on an intention-to-treat basis, these 2 patients
were analyzed in their allocated arm. Analyzing the overall
outcomes, we found comparable morbidity and mortality
rates in both arms. These results are consistent with those
of the 2 trials published previously.10,11 In our study, a
diverting stoma was not performed in 15 patients. All
Generalized Peritonitis and Perforated Diverticulitis 803
Hartmann’s procedure Primary anastomosis
(n ¼ 33) (n ¼ 32) p Value
13 (39.4) 16 (50) 0.3898
20 (60.6) 16 (50)
170 (80e510) 70 (30e300) 0.0001*
3 (9.1) 1 (3.1) 0.6132
d
d
1 (3.1)
d
7 (21.2) 4 (12.5) 0.3490
3 (9) 1 (3) 0.3170
7 (3e22) 5 (3e33) 0.0795
patients but one had Hinchey stage III peritonitis. This
was a deviation from the protocol, but results show that
the morbidity was low in these selected patients. Other
studies have reported similar results for Hinchey stage II
or III peritonitis, but these were retrospective studies.13,33
The originally planned protocol did not include diverting
ileostomy in the PA group, but this study comparing
1- and 2-step procedures was refused by the Ethics Com-
mittee. Potential future studies should compare surgical
approaches with and without a diverting stoma.
In our study, only 54% of patients were operated by se-
nior surgeons. This is an important result because it reflects
the reality of current practice. In France, patients with acute
colonic perforation are managed by all surgical departments
and not only those specializing in colorectal surgery.
The main limitation of our study is that the required
number of patients could not be reached at the end of
the study period. Binda and colleagues,10 were confronted
with the same logistical difficulties with recruitment and
concluded that “a randomized controlled trial comparing
primary anastomosis with nonrestorative colon resection
for perforated diverticulitis with peritonitis is practically
unfeasible.” There were insurmountable difficulties
inherent in researching emergency operation for a life-
threatening condition, as well as the multicenter design.
Another reason for recruitment difficulties resides in the
fact that alternative treatments to colon resection have
been proposed in Hinchey stage III peritonitis. In 2008,
Myers and colleagues49 reported a large prospective case
series of laparoscopy with abdominal lavage, with very
good results. The practice has gradually spread to France50
and some surgeons declined trial participation or were no
longer willing to enroll patients with Hinchey stage III
peritonitis, making the recruitment process difficult.
Today, the results of 3 controlled trials comparing
804 Bridoux et al Generalized Peritonitis and Perforated Diverticulitis
laparoscopic lavage with sigmoid resection (Hartmann
and/or protected anastomosis resection) have been pub-
lished and the place of this treatment is in sharp decline.
The DILALA (DiverticulitisdLaparoscopic Lavage vs
Resection [Hartmann Procedure] for Acute Diverticulitis
with Peritonitis) trial, comparing laparoscopic drainage
lavage with Hartmann intervention in 75 patients with
Hinchey stage III peritonitis, was inconclusive. Laparo-
scopic drainage did not significantly improve operative
mortality, morbidity, or reoperation rates for immediate
complications.51 The SCANDIV Trial (Scandinavian
Diverticulitis Trial) included 162 patients with Hinchey
stage II to IV peritonitis: 89 had a laparoscopic lavage
and 83 had a sigmoid resection (62 HP and 21 PA).52
There were significantly more reoperations after laparos-
copy than after resection (20% vs 6%; p ¼ 0.01). The
LOLA (Laparoscopic Peritoneal Lavage or Resection for
Generalised Peritonitis for Perforated Diverticulitis) trial
was stopped during an interim analysis because of the
morbidity observed in the laparoscopic lavage group.
Overall morbidity (39% vs 19%) and the immediate
complication rates (35% vs 7%) were significantly higher
after lavage than after resection (p ¼ 0.04).53
Another limitation of our study was that the number of
patients excluded was not recorded at the request of the
Ethics Committee. Even if fecal peritonitis is less common
than purulent peritonitis, the low proportion of Hinchey
stage IV peritonitis raises the question of a selection bias.
It would have been interesting to know the number of pa-
tients considered by surgeons as “too ill” to be able to benefit
from an anastomosis. However, when the surgeon estimated
that a resection could be performed, it was possible in 90%
of cases (45 of 50) and no patient had a definitive stoma in
this sub-group (per-protocol analysis).
CONCLUSIONS
In our study, 90% of patients with Hinchey stage III and
IV diverticular peritonitis were able to have PA. Although
there was no significant difference in mortality between
the 2 arms in terms of primary outcomes, the rate of
stoma reversal was significantly higher in the PA arm.
This multicenter randomized clinical trial confirms the
safety of PA in patients with severe diverticular peritonitis.
In addition, it provides additional evidence in favor of PA
with a diverting stoma over HP. Questions remain about
which patients might not necessarily require a diverting
stoma with PA.
Author Contributions
Study conception and design: Mathonnet, Mauvais,
Tuech
J Am Coll Surg
Acquisition of data: Regimbeau, Ouaissi, Mathonnet,
Mauvais, Schwarz, Mege, Sielezneff, Sabbagh, Tuech
Analysis and interpretation of data: Regimbeau, Ouaissi,
Houivet, Schwarz, Tuech
Drafting of manuscript: Bridoux, Sabbagh, Tuech
Critical revision: Regimbeau, Ouaissi, Mathonnet,
Mauvais, Mege, Sielezneff, Sabbagh
Acknowledgment: The authors are grateful to Nikki
Sabourin-Gibbs, Rouen University Hospital, for editing
the manuscript. The authors thank Armelle Guidotti, Rouen
University Hospital, for her help with data management.
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