Massachusetts Chapter of the American College of Surgeons

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Hartmann's versus Primary Anastomosis with Diverting Ileostomy for Acute Diverticulitis: A Nationwide Analysis of 3,100 Emergency Surgery Patients
Jae Moo Lee1, Jun Bai P. Chang1, Napaporn Kongkaewpaisan1, Ahmed I. Eid1, Nikolaos Kokoroskos1, Martin G. Rosenthal1, April E. Mendoza1, Noelle N. Saillant1, David R. King1, Peter J. Fagenholz1, George Velmahos1, Haytham M.A. Kaafarani1
1Massachusetts General Hospital, Boston, MA, USA

Background: We sought to examine the 30-day outcome of patients undergoing emergent Hartmann's Procedure (HP) vs. primary anastomosis with a diverting proximal ileostomy (PADLI) for Acute Diverticulitis at a national level.

Methods: Using the ACS-NSQIP Colectomy Procedure Targeted Database from 2012-2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity and individual postoperative complications (e.g. surgical site infection, bleeding, sepsis), controlling for all preoperative variables, as well as intraoperative and procedure-specific variables.

Results: Out of a total of 130,963 patients, 3,100 patients were included. The median age was 64 years, and 47.8% were male; 92.3% underwent HP and 7.7% underwent PADLI. HP patients were overall more comorbid [e.g. COPD (10.3% vs. 5.4%, p=0.015) and sicker [e.g. ventilator dependent >48 hours (2.5% vs. 0.4%, p=0.039), preoperative systemic sepsis (69.1% vs. 60.8%, p=0.008)] than PADLI patients. The 30-day mortality rates for HP vs. PADLI were 7.6% and 3.3%, respectively (p=0.015). The overall 30-day morbidity rates were 55.0% and 50.0%, respectively (p=0.135). In multivariable analyses, compared to HP, PADLI did not result in increased rates of mortality (OR=0.57, 95% CI 0.21-1.55, p=0.271) or morbidity (OR=1.09, 95% CI 0.76-1.55, p=0.639). The risks of all major postoperative complications and the hospital length of stay were also similar across both procedures.

Conclusion: At present, surgeons are performing HP more widely than PADLI. However, when controlling for the patient population differences, PADLI appears to be a safe alternative to HP for certain patient population.


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