B. Resio1, K. Y. Pei1, J. Liang1, Y. Zhang1 1Yale University School Of Medicine,New Haven, CT, USA
Introduction: Complicated diverticulitis is a common indication for colon surgery in Western society. Traditionally, colectomy with end colostomy or Hartmann’s procedure (HP) has been the surgical procedure of choice. However there is accumulating evidence that primary anastomoses with proximal small bowel diversion (PAPD) is safe, even in complex cases. This study seeks to clarify current adoption of PAPD for diverticulitis and compare outcomes between PAPD and HP.
Methods: We performed a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participating hospitals. All patients who underwent open HP (CPT 44143) or PAPD (CPT 44140 and 44310) for primary diagnosis of diverticulitis (ICD9 562.11, 562.13) between 2005 and 2015 were identified. Primary outcome measures included overall complications, length of stay, and mortality. Outcomes were compared with logistic regression and presented as odds ratios, which were risk adjusted for patient and operative characteristics.
Results: The proportion of PAPD decreased from 64.94% in 2005 to 43.79% in 2015. Most emergency cases underwent HP and the percentage of HP for emergency cases increased overtime from 67.44% in 2005 to 82.77% in 2015. When adjusted for patient characteristics, PAPD was associated with decreased risk of overall complications (OR=0.71, 95%CI: 0.65-0.78), in non-emergency cases (OR=0.65, 95%CI: 0.58-0.72) but not in emergency cases (OR=0.87, 95%CI: 0.75-1.01). PAPD resulted in decreased length of hospital stay (OR=0.41, 95%CI: 0.37-0.46 for 7-10 days of hospital stay; OR=0.23, 95%CI: 0.20-0.25 for longer than 10 days of stay). Decreased mortality (OR=0.76, 95%CI: 0.58-0.99) was seen in non-emergency cases (OR=0.50, 95%CI: 0.32-0.77) but not in emergency cases (OR=0.90, 95%CI: 0.65-1.25). PAPD resulted in higher risk of returning to the operating room in emergency cases (OR=1.28, 95%CI: 1.00-1.64)
Conclusion: The adoption of PAPD among NSQIP hospitals was initially rapid but appears to be decreasing. PAPD resulted in decreased complications, length of stay, and 30-day mortality when compared to HP only for non-emergent cases. Outcomes were comparable to HP during emergencies, however, there was increased need to return to the operating room. Caution must be exercised in selecting PAPD during emergent procedures.
