QS224 - Primary Anastomosis with Diverting Loop Ileostomy Still Underutilized in Acute Diverticulitis

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Purpose/Background: The management of acute, complicated diverticulitis is an area of ongoing evaluation. For patients who require operation in the acute setting, the Hartmann procedure has been questioned as the de facto operation. Many who undergo Hartmann procedure never receive stoma reversal and the stoma reversal itself is fraught with morbidity. In the 2020 Clinical Practice Guidelines released by the American Society of Colon and Rectal Surgeons, the decision to perform a Hartmann procedure or a primary anastomosis with or without diversion should incorporate patient characteristics, intraoperative factors, and surgeon preference. We hypothesized that patient factors are driving the decision to perform Hartmann procedure or primary anastomosis with diverting ileostomy.

Methods/Interventions: This is a retrospective cohort study from the National Surgical Quality Improvement (NSQIP) Participant Use File and Targeted Colectomy databases. Patients undergoing Hartmann procedure or primary anastomosis with diverting loop ileostomy for diverticulitis in an emergent fashion from 2015 to 2022 were included. Patients undergoing primary anastomosis and diverting ileostomy were propensity score matched in a 1:3 ratio to patients undergoing a Hartmann procedure using nearest neighbor matching. Matched variables included age, gender, race, ASA class, BMI, smoking status, diabetes, low albumin, pulmonary, cardiac, and renal comorbidities. P values of < 0.05 were considered statistically significant.

Results/Outcomes: There was an annual increase in the rate of primary anastomosis with diverting loop ileostomy (PADLI) compared to Hartmann procedure (HP) (p < 0.001) (Figure 1). We identified 6,825 (89%) patients who underwent HP and 841 (11%) who underwent PADLI. Patients who underwent PADLI were younger (mean age 63 versus 65 years, p< 0.001), more likely to be a lower ASA class (p < 0.001), and more likely to be independent functional status (97% versus 95%, p=0.008). There was no difference between the two cohorts with respect to smoking status or diabetes. PADLI had a 4% anastomotic leak rate. After matching PADLI was not associated with more 30-day serious complications (29% vs 28%, p=0.78). PADLI was associated with decreased discharge to rehab (13.7% vs 10.4%, p=0.02). Compared to HP, PADLI was associated with increased readmission (13% vs 9%, p < 0.001).

Conclusion/Discussion: The proportion of patients receiving a PADLI compared to a HP in acute diverticulitis has been increasing annually, with no significant difference in serious complication rate between PADLI and HP. Propensity matching indicates that although patients who are receiving PADLI are generally younger and fitter than those who undergo HP, the operation itself is not associated with a higher rate of serious complications. Some of the limitations of this study and the NSQIP database are an inability to study the combined morbidity of the index procedure and possible stoma reversal, but previous studies indicate increased morbidity associated with Hartmann reversal over loop ileostomy reversal. Recognizing that operating in acute diverticulitis is morbid, more patients may benefit from PADLI than HP.