EP102 - Emergent Colectomy for Diverticulitis: Impact of Operative Approach and Severe Obesity

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Purpose/Background: Despite advances in the understanding and management of diverticular disease, a proportion of patients with left-sided diverticulitis still require an emergency operation. The choice of operative procedure in this situation usually includes resection of the diseased colon with either an end colostomy or restoration of intestinal continuity with or without fecal diversion. While these procedures can be performed by a laparotomy or a minimally invasive surgery (MIS) technique, the decision regarding the type of surgery and approach is impacted by several patient- and disease-related factors at the time of surgery.

We aimed to characterize the impact of different body mass index (BMI) groups on operative procedure and approach and assess perioperative clinical outcomes after open and minimally invasive surgery in a cohort of patients undergoing emergency surgery for left-sided diverticular disease.

We hypothesized that patients with severe obesity (BMI>40) would have higher rates of open surgery and patients with severe obesity undergoing open surgery would have worse perioperative outcomes.

Methods/Interventions: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing emergent colectomy for left-sided diverticulitis between 2015 and 2021. Operation performed was determined by CPT code and after separating open versus laparoscopic (includes all MIS) approach, patients were grouped into three main categories of operative procedures: resection with end colostomy, resection with anastomosis and diversion, and resection with anastomosis alone. Operative procedures and approaches were compared between patients with BMI < 30, BMI 30-40, and BMI>40. Within the BMI>40 group, 30-day perioperative outcomes were compared between open and MIS approaches.

Results/Outcomes: We identified 11,734 patients with BMI < 30, 6,552 with BMI 30-40, and 1,676 with BMI>40 who underwent emergent colectomy for diverticulitis. Rates of each operative procedure and approach were similar between all three groups (Table 1). In each group, patients who underwent minimally invasive surgery were less likely to receive an ostomy. Overall, only 34% of patients whose surgeries were performed minimally invasively received an ostomy versus 74% in the open surgery group.

MIS approach was associated with lower infectious complications, including superficial incisional infection (5% vs 8%, P< 0.05), deep incisional infection (1% vs 3%, P< 0.05), organ space infection (10% vs 15%, P< 0.05), sepsis (18% vs 24%, P< 0.05), and septic shock (4% vs 16%, P< 0.001). Rates of pulmonary embolism, stroke, and myocardial infarction were less than 2% each and not significantly different between open and MIS approaches. The 30-day mortality rate was 6% in the open group versus 1% in the MIS group (P < 0.001).

Conclusion/Discussion: Among patients undergoing emergent surgery for left-sided diverticulitis, a majority required an ostomy and only 20% of patients had an MIS approach. However, patients with severe obesity had rates for reestablishment of intestinal continuity and MIS approach similar to patients with normal BMI or low- to moderate-risk obesity. While clinical presentation may impart a significant probability of selection bias, a minimally invasive approach in patients with severe obesity was associated with better postoperative outcomes, including decreased infectious complications and 30-day mortality.