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Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data.
J Trauma Acute Care Surg. 2012 Apr; 72(4):807-14; quiz 1124.JT

Abstract

BACKGROUND

The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD).

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome.

RESULTS

There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed.

CONCLUSION

The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.

Authors+Show Affiliations

Department of Surgery, University of Utah, Salt Lake City, Utah 84132, USA.No affiliation info available

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

22491590

Citation

Gawlick, Ute, and Ram Nirula. "Resection and Primary Anastomosis With Proximal Diversion Instead of Hartmann's: Evolving the Management of Diverticulitis Using NSQIP Data." The Journal of Trauma and Acute Care Surgery, vol. 72, no. 4, 2012, pp. 807-14; quiz 1124.
Gawlick U, Nirula R. Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data. J Trauma Acute Care Surg. 2012;72(4):807-14; quiz 1124.
Gawlick, U., & Nirula, R. (2012). Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data. The Journal of Trauma and Acute Care Surgery, 72(4), 807-14; quiz 1124. https://doi.org/10.1097/TA.0b013e31824ef90b
Gawlick U, Nirula R. Resection and Primary Anastomosis With Proximal Diversion Instead of Hartmann's: Evolving the Management of Diverticulitis Using NSQIP Data. J Trauma Acute Care Surg. 2012;72(4):807-14; quiz 1124. PubMed PMID: 22491590.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data. AU - Gawlick,Ute, AU - Nirula,Ram, PY - 2012/4/12/entrez PY - 2012/4/12/pubmed PY - 2012/6/28/medline SP - 807-14; quiz 1124 JF - The journal of trauma and acute care surgery JO - J Trauma Acute Care Surg VL - 72 IS - 4 N2 - BACKGROUND: The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD). METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome. RESULTS: There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed. CONCLUSION: The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis. SN - 2163-0763 UR - https://www.unboundmedicine.com/medline/citation/22491590/Resection_and_primary_anastomosis_with_proximal_diversion_instead_of_Hartmann's:_evolving_the_management_of_diverticulitis_using_NSQIP_data_ L2 - http://dx.doi.org/10.1097/TA.0b013e31824ef90b DB - PRIME DP - Unbound Medicine ER -