Nathalie Wong-Chong, MD, Maria Abou Khalil, MD, Nancy Morin, MD, Carol-Ann Vasilevsky, MD, Julio Faria, MD, Gabriela Ghitulescu, MD, Marylise Boutros, MD. Sir Mortimer B. Davis Jewish General Hospital
INTRODUCTION: Diverticulitis with purulent or feculent peritonitis has been historically managed with a Hartmann’s procedure (HP). However, increasing evidence shows that resection and primary anastomosis (PA) with or without proximal diversion may be performed safely even in the face of marked contamination. Performing a HP vs. PA remains an important intra-operative clinical decision. However, once the decision to proceed with PA is made, the benefit of adding a diverting loop ileostomy (DLI) is unclear. The aim of this study was to compare 30-day morbidity and mortality following PA vs. PA+DLI for patients with perforated diverticulitis in the emergency setting.
METHODS AND PROCEDURES: After institutional review board approval, adult patients who had a left-sided colectomy with PA or PA+DLI for perforated diverticulitis in the emergency setting from 2005-2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients with clean or clean-contaminated wound classification, septic shock, ASA 5, right-sided colectomy, diversion alone, colonic lavage, or HP were excluded. Outcomes of interest were all surgical site infections (SSI), organ-space SSI, post-operative sepsis, re-operation, length of stay (LOS), and death. Univariate analyses and multivariate regression models were performed.
RESULTS: Of the 1,088 patients who met the inclusion criteria, 132 underwent PA+DLI and 956 underwent PA alone. Both groups were clinically similar regarding age, gender, BMI, pre-operative SIRS/sepsis and steroids use. PA+DLI had more dirty wounds (88.6% vs. 77.4%, p <0.01), longer mean operative time [171 (±70) min vs. 141 (±68) min, p <0.01)] and more open surgery (90.9% vs. 80%, p <0.01) compared to PA. Post-operatively, there was no difference in organ-space SSI (5.3% vs. 6.2%), all SSI (19.7% vs. 13.8%), reoperation (6.4% vs. 6.1%), or death (19.7% vs. 15.4%) in PA+DLI compared to PA. PA+DLI had more post-operative infectious complications (37.9% vs. 25.6%, p <0.01) and sepsis (19.7% vs. 11.3%, p <0.01). After controlling for known confounders, regression analyses found that DLI did not protect against all SSI (OR 1.45, 95%CI 0.87-2.40), organ-space SSI (OR 0.72, 95%CI 0.30-1.76), post-operative sepsis or septic shock (OR 1.55, 95%CI 0.96-2.49), reoperation (OR 1.06, 95%CI 0.48-2.33), or LOS (b 0.4 days, p 0.14).
CONCLUSIONS: The addition of a diverting loop ileostomy after left-sided colectomy with primary anastomosis for perforated diverticulitis in the emergency setting did not result in decreased post-operative morbidity or mortality. Therefore, its role in the management of perforated diverticulitis in the emergency setting should be questioned.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87930
Program Number: S110
Presentation Session: Residents/Fellows Session
Presentation Type: ResFel