- In this study, surgeons at Massachusetts General Hospital examined 27 years of data from the National Inpatient Sample and identified 993,220 patients with complicated diverticulitis (abscess and/or perforation)
- Patients with abscess had a 16.4% complication rate and 1.5% inpatient mortality; respective rates for patients with perforation were 22.1% and 5.4%; all rates were significantly higher than in patients with uncomplicated disease
- Some of the factors significantly associated with increased risk of inpatient mortality were age ≥65 (OR, 6.51), perforation (OR, 2.38), surgery (OR, 4.91) and a post-procedure complication (OR, 3.74)
- In the subgroup of patients with perforated diverticulitis who had an operation, each day after admission a procedure was delayed was associated with 31% increased odds of mortality (P=0.03)
- Patients with perforated diverticulitis who have any potential for needing surgery during an admission should have it performed expeditiously
Outcomes are worse when diverticulitis is complicated by an abscess and/or perforation, according to multiple studies. However, unless patients need urgent surgery due to frank peritonitis, there is no consensus on the optimal timing of surgery for hospitalized patients. Some surgeons operate immediately whereas others order a course of intravenous antibiotic therapy in hopes of avoiding resection.
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Naomi M. Sell, MD, MHS, general surgery resident, Rocco Ricciardi, MD, MPH, chief of the Section of Colon and Rectal Surgery at Massachusetts General Hospital, and colleagues recently examined 27 years of data on inpatients with complicated diverticulitis. Their most striking finding, reported in the Journal of Gastrointestinal Surgery, was that delay to intervention was associated with higher inpatient mortality.
From the National Inpatient Sample, a database maintained by the U.S. Agency for Healthcare Research and Quality, the researchers identified 993,220 adults who were discharged between January 1988 and September 2015 with a principal diagnosis of diverticulitis.
ICD-9 codes for abscess and perforation were used to indicate complicated disease. Researchers found that 10.7% of the cohort had an abscess and 1.0% had a perforation associated with diverticular disease.
At least one procedure-related complication was experienced by:
- 16.4% of patients with an abscess vs. 8.6% of patients with uncomplicated disease (P<0.001)
- 22.1% of patients with a perforation vs. 9.3% of patients with uncomplicated disease (P<0.001)
In both subgroups, sepsis, hemorrhage, wound disruption, postoperative infection, deep venous thrombosis, pulmonary embolus and ileus were all significantly increased (all P<0.001).
The inpatient mortality rate was:
- 1.5% in patients with an abscess vs. 0.9% in patients with uncomplicated disease (P<0.001)
- 5.4% in patients with a perforation vs. 1.0% in patients with uncomplicated disease (P<0.001)
Factors associated with significantly increased risk of inpatient mortality were:
- Female sex (OR, 1.07)
- Age ≥65 (OR, 6.51)
- Urgent/emergent admission (OR, 3.51)
- Perforation (OR, 2.38)
- Percutaneous drainage (OR, 1.41)
- Peritoneal lavage (OR, 1.95)
- Surgery (OR, 4.91)
- Post-procedure complication (OR, 3.74)
- Charlson Comorbidity Index (CCI)—risk rose progressively with each increase in score above 0, with CCI ≥5 conveying the greatest odds (OR, 6.38)
An abscess was associated with significantly decreased mortality risk (OR, 0.88).
The researchers separately analyzed patients with perforated diverticulitis who underwent an operation. Female sex, age ≥ 65, urgent/emergent admission and increasing CCI score were again associated with increased risk of inpatient mortality.
Compared with sigmoid colectomy, mortality risk was higher with total colectomy (OR, 5.07) or transverse colectomy (OR, 4.21). Additionally, colostomy creation (OR, 1.41), peritoneal lavage (OR, 2.24) and a post-procedural complication (OR, 2.74) were associated with increased risk. Percutaneous drainage was linked to decreased risk (OR, 0.61).
Notably, patients had 31% increased odds of mortality for each day after admission a procedure was delayed (P=0.03).
Advice for Surgeons
No paradigm shift is necessary for the management of patients with complicated diverticulitis. Many patients do well when managed non-operatively, and emergent surgery increases the risk of mortality compared to elective surgery, as thoroughly demonstrated in prior studies.
However, this study does suggest there may be an optimal time during an admission in which a procedure should be done. Based on these results, patients with any potential for needing surgery during an admission should have it performed expeditiously. The surgeon should watch closely for any changes in patient status or lack of progress.
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