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

Abstract

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...

Utility of a Large, Retrospective Database in Guiding Deliberate Use of Primary Anastomosis With Proximal Diversion

“…A meta-analysis of the aforementioned RCTs 2 suggested this conclusion. However, while Sanaiha and colleagues 7 found similar index outcomes between PAPD and HP, they did not find advantages of PAPD compared with HP during index admission.…”

“…Prior analysis of the New York State All Payer Database by Goldstone et al 6 found that colorectal board certification was associated with increased use of PAPD and decreased postoperative mortality. While the NRD lacks surgeon-specific data, sensitivity analysis in the study by Sanaiha et al 7 found decreased mortality and complication rates when PAPD was performed at hospitals with increased volume of emergency general surgical procedures (>50 procedures per year). Finally, while several index outcomes were similar with PAPD and HP in adjusted analyses, there is a significant selection bias associated with which patients are offered PAPD outside of an RCT setting.…”

“…Retrospective reviews of statewide or national clinical and administrative databases have attempted to counter these selection biases by using larger samples that include patients with hemodynamic instability, but these studies have not always produced consistent results. 3,4,6 Given the relative paucity of large, nationally sourced studies, Sanaiha and colleagues 7 performed a retrospective cohort study using the 2014 to 2017 Nationwide Readmissions Database (NRD) to investigate the association of HP vs PAPD with postoperative outcomes. Their study is among the largest retrospective analyses of urgent surgical management of acute perforated diverticulitis, and the findings are consistent with several established trends.…”

Anastomotic Considerations in Diverticulitis

“…7 Surgeon preference is the main factor in choosing an ostomy for perforated diverticulitis. 7 Diversion not only allows the healing of a higher risk anastomosis but also increases the likelihood of restoring bowel continuity. Stoma reversal rates are observed to be much lower in Hartmann's patients (30-57%) compared with a diverting ileostomy (90-95%).…”

“…In the acute setting, the performance of a primary anastomosis with diversion is becoming more popular. 7 Surgeon preference is the main factor in choosing an ostomy for perforated diverticulitis. 7 Diversion not only allows the healing of a higher risk anastomosis but also increases the likelihood of restoring bowel continuity.…”