EP911 - Minimally Invasive Surgery and Primary Anastomosis in Emergency Diverticulitis Surgery: Does the Number of Days from Admission to Surgery Matter?

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Purpose/Background: Historically, an open Hartmann’s Procedure was the operation of choice in emergency surgery for diverticulitis. In recent years, studies have demonstrated the safety of both minimally invasive surgery (MIS) and primary anastomosis (PA) in the emergency setting; however, few studies have evaluated their real-world implementation. The number of days from hospital admission to surgery is a potentially modifiable factor that may be associated with the use of MIS and PA. The purpose of this study was to evaluate the association between the number of days from hospital admission to surgery and the use of MIS and PA in emergency diverticulitis surgery.

Methods/Interventions: This was a multicenter observational study using prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from the years 2012-2022. Adult (>18 years old) patients who underwent a left-sided colectomy for acute diverticulitis in the emergency setting were included. Patients with an American Society of Anesthesiologists (ASA) score of V/VI, immunosuppressed status, disseminated cancer, or preoperative mechanical ventilation were excluded. The primary exposure was the number of days from hospital admission to surgery, categorized a priori into three clinically relevant groups: early (0-1 days), subacute (2-4 days), and late (>5 days). The co-primary outcomes were an MIS approach and performance of a PA (with or without a diverting ileostomy), defined using relevant CPT codes. Multiple logistic regression was performed to adjust for relevant covariates and identify additional factors associated with each outcome.

Results/Outcomes: In total, 13,827 patients underwent emergency surgery for acute diverticulitis and were included for analysis. Among them, 9,852 (71.3%) underwent early surgery, 2,568 (18.6%) underwent subacute surgery, and 1,407 (10.2%) underwent late surgery. Patients in all three groups were similar in median age (62.0 vs. 60.0 vs. 63.0, p=0.17) but were different in proportion of female sex (49.6% vs. 48.5% vs. 54.3%, p=0.002) and ASA score of III/IV (66.3% vs. 66.8% vs. 73.8%, p< 0.001). Patients who underwent early surgery had higher median preoperative white blood cell count (13.6 vs. 11.8 vs. 12.0, p=0.006) and higher proportions of dirty (class IV) operative wounds (65.9% vs. 60.0% vs. 58.6%, p< 0.001), but had similar proportions of preoperative septic shock (6.6% vs. 6.1% vs. 5.1%, p=0.12). Overall, the minority of patients underwent an MIS resection (12.2%) or PA (27.4%), but the use of both increased steadily throughout the study period (MIS in 2012: 9.4% vs. MIS in 2022: 15.1%, p< 0.001; PA in 2012: 23.0% vs. PA in 2022: 33.7%, p< 0.001). The use of MIS (11.0% vs. 14.1% vs. 17.1%, p< 0.001) and PA (26.1% vs. 29.5% vs. 32.4%, p< 0.001) were both higher with later surgery. After adjusting for relevant patient and disease characteristics, later surgery remained associated with higher odds of MIS (subacute surgery: aOR 1.25, 95% 1.10-1.43; late surgery: aOR 1.59, 95% 1.35-1.85) and PA (subacute surgery: aOR 1.10, 95% 1.01-1.20; late surgery: aOR 1.26, 95% 1.11-1.43) as compared to early surgery. These findings remained on sensitivity analysis, excluding patients with preoperative septic shock. Other factors associated with the use of MIS and PA are presented in Figure 1.

Conclusion/Discussion: Delayed in-patient emergency surgery for diverticulitis was associated with higher rates of MIS and/or PA, which may be a result of better pre-operative medical management and patient optimization.