Utility of a Large, Retrospective Database in Guiding Deliberate Use of Primary Anastomosis With Proximal Diversion

This cross-sectional study compares adverse outcomes and health care use associated with primary anastomosis with proximal diversion vs Hartmann procedure for patients with acute diverticulitis.
Key Points Question Among patients with acute diverticulitis treated with an urgent surgical procedure (ie, Hartmann procedure [HP] or primary anastomosis with proximal diversion [PAPD]), is the procedure used associated with index readmission outcomes and resource use? Findings In this cross-sectional study of an estimated 1 072 395 hospitalized patients with acute diverticulitis, 34 126 patients required diversion within 48 hours of admission, and PAPD was associated with comparable index outcomes vs HP but an increased rate of readmission and risk of ostomy reversal. Total index and readmission hospitalization costs were similar between procedures. Meaning These findings suggest that PAPD is associated with increased risk of ostomy reversal compared with HP and that patient characteristics that bias operative strategy selection are the primary factors associated with index patient outcomes.
Importance Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. Objective To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. Design, Setting, and Participants This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Exposures Undergoing HP vs PAPD. Main Outcomes and Measures Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. Results During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P