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Surgeon not patient disease determines the operation for acute complicated diverticulitis
*Mohammad S Jafferji, Neil H Hyman University of Vermont, Burlington, VT
Objective: The “best’ operation in the setting of acute complicated diverticulitis has been debated for decades. Multiple studies, including a recent prospective randomized trial, have demonstrated improved outcomes with primary anastomosis. The objective is to determine whether surgeon training and background or patient specific factors drive the choice of operative procedures. Design: Retrospective review of a prospective database Setting: Academic Medical Center Patients: Consecutive adult patients with sigmoid diverticulitis requiring operative treatment during an index admission with acute complicated diverticulitis from 1997-2012. Interventions: Hartmann procedure (HP) or primary anastomosis(PA), with or without loop ileostomy Main outcome measures: Choice of operation, postop complications, stoma reversal Results: 151 patients underwent urgent resection and 136 met study criteria. 88 cases (64.7%) were performed by general surgeons and 48 by colorectal surgeons (35.3%)-see table. General surgeons performed more HP (64% vs 29%, p=.01) despite similar demographics, ASA classification and Hinchey stage. Postop complications were lower in the colorectal group (43.2% vs 16.7, p=.02). Conclusions: Surgeon training rather than degree of sepsis, patient comorbidities or demographics is the primary driver of choice of operative procedure. Our data suggests that a more aggressive approach to primary resection with anastomosis may lower the complication rate after surgical treatment of severe acute diverticulitis. | | | | Table 1. Study Population Characteristics | | | | Characteristics | General and Other Surgeons | Colorectal Surgeons | P-value | | | | | Median Age_yrs | 61 | 56 | 0.32 | Female (%) | 36.4 | 50 | 0.07 | Median Body Mass Index | 27.8 | 27.6 | 0.62 | Hinchey Class (Median) | 3.0 | 3.0 | 0.96 | I, n | 2 | 4 | | II, n | 22 | 12 | | III, n | 36 | 24 | | IV, n | 28 | 8 | | Operation, n | 88 | 48 | | Hartmann Procedure, n (%) | 56 (64.0) | 18 (38.0) | 0.012 | Primary Anastomosis, n (%) | 6 (7.0) | 14 (29.0) | 0.029 | Primary Anastomosis w/ diverting ileostomy, n(%) | 20 (23) | 12 (25.0) | 0.80 | Abdominal Washout, n (%) | 6 (7.0) | 4 (8.0) | | | | | | Median Length of Stay, days | 8.5 | 7 | 0.86 | Median ASA Class | 3 | 3 | 0.93 | Stoma Reversal, (%) | 61.4 | 68.2 | 0.24 | ICU Admission, (%) | 20.5 | 0 | 0.029 | Re-intervention, (%) | 13.7 | 8.3 | 0.076 | Median Length of Operations (mins) | 181 | 169 | 0.63 | Stoma Reversal, (%) | 61.4 | 68.2 | 0.24 | Stoma Reversal, days | 124 | 92 | | Complications (SATS) | | | | Intra-operative, n (%) | 2 (2.3) | 0 (0) | 0.43 | Post-operative, n (%) | 38 (43.2) | 8 (16.7) | 0.021 | | | | |
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