Laparoscopic and converted approach benefits patients in complicated diverticulitis

Trevor Teetor, MD, Ted Bell, MS, Rod Grim, PhD, Vanita Ahuja, MD, MPH. WellSpan York Hospital

Introduction: There is an increasing trend towards laparoscopic Hartmann’s procedure versus standard laparotomy in patients with complicated diverticulitis (abscess and perforation).  No major study has reviewed performance measures and results in order to better identify trends, assist in patient selection, and lead to improvement in morbidity and mortality.  The study examines outcomes including length of stay, complications, mortality and charges of complicated diverticulitis by different operative approaches.

Methods and Procedures: A total of 16,043 cases were captured between 2009 and 2011 from HCUP-NIS data on patients identified as complicated (abscess or perforated) Hartmann procedure.  Variables under consideration included patient age, gender, race, payment method, and Charlson comorbidity index.  Hospital factors included size, location, and teaching status.  Outcomes included complications, median LOS, median charges, and mortality.  These were examined for open Hartmann’s (OH), laparoscopic Hartmann’s (LH), and procedures requiring conversion to open (CH).

Results: Identified total 16,043: OH 14,665 (91.4%): LH 832 (5.2%), CH 546 (3.4%).  LH (20%) and CH (23.4%) had lower complications than OH (27.3%, p< 0.001).  Median age for each group is presented in Table 1.  Also, LH and CH (10 and 10 days, respectively) had significantly shorter LOS than OH (11 days) (p<0.001).  While not statistically significant, CH had lower charges ($69,675) than LH ($81,624) and OH ($72,795, P=0.975).  CH had lower mortality rate (.9%) than OH (3.5%) and LH (1%, p<0.001).  None of the surgery groups were predictive of complications or mortality.  The predictors of complications included ages 60+ (OR 1.3), median income of $35-45K (OR 1.3), Charlson score of 3 (OR 1.6), median hospital bed size (OR 1.2), Midwest hospital region (OR 1.2) and elective admission (OR 1.4).   Predictors of mortality included age 60+ (OR 2.7), Charlson 3 (OR 2.0), teaching hospital (OR 1.7), West hospital region (OR 2.6) and complication (OR 2.5).  LH surgery contributed $10,155 to total charges.  

Conclusions: Laparoscopic approach for complicated diverticulitis remains low, however LH and even CH approach benefits patients over open methodology. Converted approach had slightly higher complication than laparoscopic but lowest charges and mortality.  Surgeons attempting LH should consider CH for (difficult, cases with high intraoperative time) cases as this has shown to be beneficial for patient outcomes.

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