K. T. Weber1, P. Chung2, M. Sfakianos1, V. Patel1, A. Alfonso1, J. Nicastro1, G. Coppa1, G. Sugiyama1 1Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 2Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA
Introduction: For perforated diverticulitis, an open resection with ostomy creation has endured as the standard treatment, despite trends toward laparoscopic lavage in diverticulitis and increasing utilization of minimally invasive techniques in colorectal surgery. With rising rates of both morbid obesity and diverticular disease in the US, we sought to evaluate if findings in the literature suggesting similar outcomes between obese and non-obese patients are substantiated among patients who have open, emergent procedures for diverticulitis.
Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010-2015, we identified cases of emergent admission for diverticulitis (ICD 9 code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification in which a resection with ostomy (CPT 44141, 44143, 44144) was performed. We excluded cases with age <18 years, ventilator dependence, evidence of disseminated cancer and missing sex, race, BMI, functional status, ASA class, length of stay (LOS), and operative time data. We defined morbid obesity as BMI>35 m2/kg. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-day postoperative complications and mortality. Univariate and propensity score analyses were performed.
Results: A total of 2,019 patients met inclusion/exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 vs 62.6 years, p<0.001), have higher rate of insulin-dependent diabetes (8.0% vs 4.2%, p<0.0001), and have ASA class 4 (23.5% vs 19.6%, p<0.0001). Morbidly obese patients also had higher rates of postoperative septic shock (17.7% vs 12.1%, p=0.0040), return to operating room (11.1% vs 6.4%, p=0.0015), and surgical site infection (SSI), both superficial SSI (8.9% vs 5.8%, p=0.026) and deep SSI (4.4% vs 1.9%, p=0.0073). We identified 397 morbidly obese patients that were well-matched by propensity score to 397 non-morbidly obese patients. Conditional logistic regression showed increased risk of postoperative septic shock (OR 1.60, 95% CI [1.09, 2.34], p=0.015), however there was no difference in LOS (mean 12.8 vs 12.3 days, p=0.46) and no increased risk of 30-day mortality (p=0.947).
Conclusion: This analysis of a large national clinical database demonstrates that patients presenting with perforated diverticulitis undergoing a Hartmann’s procedure, after adjusting for the effects of morbid obesity, do not have increased mortality or LOS. Among morbidly obese patients, only increased risk of 30-day postoperative septic shock was found to be significant. Further prospective studies identifying risk factors associated with these adverse outcomes are warranted to guide clinicians when faced with these difficult cases.