Emergency Hartmann’s Procedure and its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis

Dear Editor, On behalf of all of the coauthors, I would like to thank Dr Morini and his colleagues for highlighting our published study. We appreciate the interest they have shown in our article and thank you for giving us the opportunity to reply. In our article, we concluded that laparoscopic Hartmann’s procedure for Hinchey III and IV acute diverticulitis showed significantly lower morbidity associated with higher rates of laparoscopic reversal procedure. Our results support the idea that the laparoscopic approach affords the same effective control of sepsis and enables more prompt postoperative recovery than the open approach. In his letter, Dr Morini summarized the most important findings of our study: postoperative data, surgical indications, morbidity, and particularly mortality. Dr Morini pointed out that a 17% overall mortality seems “quite high” in hemodynamically stable patients. This observation is legitimate. From a recent trial, we know that mortality after Hartmann’s procedure for perforated diverticulitis ranges from 0% to 8%. Our result is higher probably because we analyzed an unselected series of patient including oldest old patients (>85 years). Moreover, 56% of them presented with a Hinchey IV, and 44.4% were American Society of Anesthesiologists (ASA) IV. We strongly believe that age and comorbidity influenced the mortality rate in our study. It is also necessary to clarify that the mortality rate in patients affected by purulent or feculent peritonitis is only partially conditioned by the hemodynamic status at first presentation. All these patients suffered with sepsis typical of this condition, which could have led to a postoperative multiorgan failure in high-risk patient. This occurs despite the surgical approach used. For this reason, as already stressed in our article, the benefits brought by the laparoscopic approach are just minimal in the first postoperative time, but gain importance in the long-term follow-up, increasing the chance of having a successful laparoscopic reversal and reducing all the typical complications of a laparotomy. With regard to a low rate of reversal procedure, we respectfully disagree. On 50 patients with stoma, only 4 (8%) were not reversed and only 4 (8.7%) underwent a conversion to an open approach. A recent article showed higher rates of nonsuccess and a higher conversion rate (among 50%). In our series, the reversal procedure was possible in 92%, and from the literature we know that rates of restoration of bowel continuity is usually lower, 40% to 70%. Regarding Hinchey III management, we have read carefully your data regarding nonoperative treatment (success more than 90%). About your article, interestingly, we noticed that your demographic data on Hinchey III patients were dramatically different from our series, reporting 45.7% of ASA I, lower mean age (54.7 years), with sepsis present in only 10% of patients. Probably in your series conservative management was the best option of treatment. Regarding other available procedures, we perfectly know that lavage/drainage could be an option but nowadays this procedure is still controversial, as stated by the latest trials. In our recent study, indeed, we found that the morbidity rate was 33% and the reoperation rate was 13.7%. The decision to not perform resection with primary anastomosis was induced, once again, considering high ASA score and severe comorbidity of the patient enrolled. 874272 SRIXXX10.1177/1553350619874272Surgical InnovationCassini et al research-article2019