Should the Guidelines for Operative Management of Perforated Diverticulitis Be Revised?

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Emergent surgery is warranted for patients with acute diverticulitis who present with frank bowel perforation and purulent or feculent peritonitis. In this setting, the two procedures most often advocated are partial colectomy with creation of an end colostomy—the Hartmann procedure (HP)—and partial colectomy with the creation of a primary anastomosis with proximal diversion (PAPD).

In 2014, the American Society of Colon and Rectal Surgeons (ASCRS) changed its guidelines for the treatment of sigmoid diverticulitis from recommending only an HP in the emergent setting to also accepting a primary anastomosis. The choice between procedures is based on operative and clinical factors, including patient hemodynamic stability, tissue condition and surgeon preference.

These recommendations, intended for the general surgical community, were based on studies performed at large-volume referral centers with experienced colorectal surgeons. By analyzing a large administrative dataset, Robert Goldstone, MD, surgeon in the Division of General and Gastrointestinal Surgery at Massachusetts General Hospital, Liliana Bordeianou, MD, MPH, FACS, FASCRS, chief of the Colorectal Surgery Center, co-chair of the Partners Healthcare Colorectal Surgery Collaborative and associate professor of surgery at Harvard Medical School, and colleagues have determined that the guidelines do not seem appropriate for non-colorectal surgeons. Their findings are published in Diseases of the Colon & Rectum.

Study Design

Using a New York State Department of Health database, the researchers identified 2,085 surgeons who performed 10,780 urgent/emergent HP (98.3%) or PAPD (1.7%) operations for patients with diverticulitis between 2000 and 2014.

111 of the surgeons (5.3%) were board-certified colorectal surgeons. They performed 6% of the colectomies; the other 94% were performed by non-colorectal surgeons. There were no significant differences in patient demographics between the two surgeon cohorts.

The primary study outcomes were in-hospital postoperative mortality and postoperative morbidity, defined as shock; sepsis; hemorrhage; wound disruption; infection; a pulmonary, gastrointestinal or urinary complication; dehydration and/or required reoperation during the same hospital stay.

Overall, in-hospital postoperative mortality was 7.4% and postoperative morbidity was 40%.

Univariate Analysis

Mortality was 1.8 times greater following PAPD than HP (13% vs. 7%; P = .002) on univariate analysis. The difference was even greater among non-colorectal surgeons (15% vs. 7%; P < .001). Among board-certified colorectal surgeons, there was no significant difference in mortality following PAPD versus HP.

Morbidity, too, was significantly greater for PAPD than for HP (57% vs. 40%; P < .001). Similar to the results for mortality, this difference remained significant for non-colorectal surgeons (58% vs. 40%; P < .001) and not for board-certified colorectal surgeons.

Multivariable Analysis

The researchers performed multivariable logistic regression analysis adjusted for age, sex, race, Charlson Comorbidity Index, year, payer, hospital academic status, urgent/emergent status and surgeon training. Compared with HP, PAPD remained associated with significant increases in:

• Mortality (OR, 2.6; 95% CI, 1.6–4.2; P < .001)
• Morbidity (OR, 1.9; 95% CI, 1.4–2.5; P < .001)
• Reoperation (OR, 3.4; 95% CI, 1.8–6.5; P < .001)

Colorectal board certification was associated with significantly decreased mortality (OR, 0.66; 95% CI, 0.46–0.96; P = .03). Surgical training had no effect on the risk of morbidity or reoperation.

Revision of Guidelines Is Indicated

Based on these data, the safety of PAPD performed in the emergent setting for diverticulitis is questionable. Moreover, only a small fraction of the operations were performed by the colorectal surgeons, whose interventions were associated with decreased postoperative mortality regardless of the operation performed.

These facts should potentially direct a change in referral patterns. The current ASCRS practice parameter should be reevaluated, to consider incorporating guidelines about surgical subspecialty, until larger randomized controlled trials are completed that include non-colorectal surgeons.

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