Laparoscopic resection and primary anastomosis for perforated diverticulitis: with or without loop ileostomy?

BACKGROUND: Evidence is growing about the benefits of laparoscopic resection with primary anastomosis (RPA) in perforated diverticulitis. However, the role of a diverting ileostomy in this setting is unclear. The aim of this study was to analyze the outcomes of laparoscopic RPA with or without a proximal diversion in Hinchey III diverticulitis. METHODS: This is a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for perforated Hinchey III diverticulitis during the period 2000-2019. The sample was divided into two groups: RPA without diversion (G1) and RPA with protective ileostomy (G2). Primary outcomes of interest were 30-day overall morbidity, mortality, length of hospital stay (LOS), and urgent reoperation rates. Secondary outcomes of interest included operative time, readmission, and anastomotic leak rates. RESULTS: Laparoscopic RPA was performed in 94 patients: 76 without diversion (G1) and 18 with proximal loop ileostomy (G2). Mortality (G1: 1.3% vs. G2: 0%, p = 0.6), urgent reoperation (G1: 7.9% vs. G2: 5.6%, p = 0.73), and anastomotic leak rates (G1: 5.3% vs. G2: 0%, p = 0.32) were comparable between groups. Higher overall morbidity (G1: 27.6% vs. G2: 55.6%, p = 0.02) and readmission rates (G1: 1.3% vs. G2: 11.1%, p = 0.03), and longer LOS (G1: 6.3 vs. G2: 9.2 days, p = 0.02) and operative time (G1: 182.4 vs. G2: 230.2 min, p = 0.003) were found in patients with proximal diversion. CONCLUSION: Laparoscopic RPA had favorable outcomes in selected patients with Hinchey III diverticulitis. The addition of a proximal ileostomy resulted in increased morbidity, readmissions, and length of stay. Further investigation is needed to establish which patients might benefit from proximal diversion.