Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis

Resio, Benjamin J.; Jean, Raymond; Chiu, Alexander S.; Pei, Kevin Y.

doi:10.1001/jamasurg.2018.4359

Cited by 43 publications

(28 citation statements)

References 22 publications

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“…While 2 studies 3 , 27 comparing HP with PAPD characterized rates of ostomy reversal, few studies have directly compared rates of unplanned readmissions, to our knowledge. Despite a decreased rate of comorbidities and younger age among patients undergoing PAPD, we found that these patients had significantly more frequent readmissions on raw and adjusted analyses.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort

et al. 2021

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IMPORTANCE Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. OBJECTIVE To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. EXPOSURES Undergoing HP vs PAPD. MAIN OUTCOMES AND MEASURES Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. RESULTS During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11 514 patients [35.6%]; P < .001).In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30 851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). CONCLUSIONS AND RELEVANCEThis study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with (continued) Key Points Question Among patients with acute diverticulitis treated with an urgent surgical procedure (ie, Hartmann procedure [HP] or primary anastomosis with proximal diversion [PAPD]), is the procedure used associated with index readmission outcomes and resource use? Findin...

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Section: Discussionmentioning

confidence: 99%

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort

et al. 2021

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“…In a meta-analysis of the four trials comparing primary anastomosis with Hartmann’s procedures, patients who had a primary anastomosis were more likely to not have a stoma at 12 months after surgery (risk ratio 1.34, 1.16 to 1.54) compared with those who had a Hartmann’s procedure 104105. Less than a third of patients undergo colostomy reversal within one year of a Hartmann’s procedure, and having a colostomy is a substantial detriment to quality of life 106. Take down surgery to reverse the stoma after primary anastomosis with ileostomy had a reduced risk (risk ratio 0.23, 0.07 to 0.70) of a major postoperative complication compared with take down surgery for a Hartmann’s procedure.…”

Section: Treatmentmentioning

confidence: 99%

Management of colonic diverticulitis

Peery

2021

BMJ

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Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient’s health and immune status, and the patient’s preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.

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“…HP was first developed with the intent of treating rectosigmoid carcinoma by Henry Hartmann and involves rectosigmoid colon resection with the creation of a colostomy. It has a variety of indications, including complicated diverticulitis and less commonly volvulus, ischemia, and perforation [ 9 ]. Studies report a significant reduction in quality of life and gradual social isolation in HP patients [ 3 , 7 ].…”

Section: Reviewmentioning

confidence: 99%

Reversal of Hartmann's Procedure: Evaluating Outcomes of Single-Port Laparoscopic Approach Versus Conventional Approach

Arnold

May

Nanthakumaran

et al. 2020

Cureus

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Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis

Cited by 43 publications

References 22 publications

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort

Management of colonic diverticulitis

Reversal of Hartmann's Procedure: Evaluating Outcomes of Single-Port Laparoscopic Approach Versus Conventional Approach

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