Surgery For Diverticulitis Research Articles

Surgery for diverticulitis is associated with high risk of in-hospital mortality and morbidity in older patients with end-stage renal disease

End-stage renal disease (ESRD) is associated with poor medical outcomes. This study aimed to compare early outcomes of elective and emergency operation for diverticulitis among older adults with and without a diagnosis of ESRD. Patients 65 years of age and older with a primary diagnosis of diverticulitis who underwent operative intervention were identified in the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004 to 2007. Outcomes between the ESRD and non-ESRD patients (elective and emergent) undergoing operation for diverticulitis were compared. A subgroup analysis in patients only undergoing elective or emergent operation was performed. Multivariable analyses were conducted. In addition, a propensity-matched analysis was applied comparing early outcomes between ESRD patients and well-matched controls consisting of non-ESRD patients. A total of 53,560 patients were identified, with 996 (1.86%) ESRD patients. After propensity matching, 962 ESRD and well-matched non-ESRD patients were identified. In the matched cohort, ESRD patients had greater rates of in-hospital mortality (30.9% vs 7.9%, P < .001), shock/sepsis, pulmonary compromise, wound infection, and acute myocardial infarction. An ostomy was placed more frequently in the ESRD patients (71.3% vs 58.7%, P < .001). Duration of stay and hospital charges also were greater in the ESRD group (18 vs 11 days, P < .001; $137,998.3 vs $67,502.2, P < .001). Similar results were seen when outcomes between matched elective ESRD and elective non-ESRD patients were compared. There was no difference on in-hospital mortality on subgroup analyses between elective versus emergent surgery in the ESRD population (25.4% vs 31.1%, P = .133). On multivariable analysis, ESRD patients had greater odds of in-hospital mortality, and most individual complications when compared with the non-ESRD patients. In addition, the odds of in-hospital mortality and morbidity were greater in the elective ESRD group when compared with elective non-ESRD group and also in the emergent ESRD group when compared with the emergent non-ESRD group. Given the high mortality and morbidity in both the emergent and elective setting that is associated with operative resection, we believe that, when possible, nonoperative management should be the preferred approach for acute diverticulitis in the setting of ESRD in patients older than 65 years.

The TNFSF15 gene single nucleotide polymorphism rs7848647 is associated with surgical diverticulitis.

To determine if single nuclear polymorphisms (SNPs) in the TFNSF15 gene play a role in patients requiring surgery for diverticulitis. A role for a genetic predisposition in diverticulitis is suggested by its association with hereditary connective tissue disorders, youthful onset in some patients, and the observation of families with multiple affected individuals. The TNFSF15 gene has been associated with other inflammatory diseases affecting the colon such as medically refractory ulcerative colitis (UC), aggressive Crohn's disease (CD), and pouchitis after restorative proctocolectomy. In the discovery phase of this study, 21 sporadic surgical diverticulitis (SD) patients (9 female, mean age = 52 ± 5) and 5 individuals from a single family with surgically managed diverticulitis [familial diverticulitis (FD), 4 female, mean age = 51.1 ± 7] were studied. SD patients were age and sex matched with 3 separate groups of healthy, CD and UC control patients. All patients were genotyped for 5 known TNFSF15-associated SNPs. The SNP discovered to be associated with diverticulitis (rs7848647) was then confirmed in a separate test group composed of 34 additional patients (20 female, mean age 57.7 ± 2) who also underwent surgical treatment for diverticulitis. These patients were age matched to a new control cohort of patients having no history of diverticulitis (26 female). Patients were genotyped using a TaqMan assay. In the discovery phase, logistical regression on matched subjects was performed to determine an association of TNFSF SNP with diverticulitis versus the control groups. In the test phase, significance for the rs7848647 SNP was assessed by the Fischer's exact test. In the discovery phase, the TNFSF15 SNP rs7848647 was significantly associated with SD (p = 0.0003) versus all control groups studied. The risk allele for this SNP (G substituted for A) was found in all SD patients. The homozygous GG allele was found in 62% (13/21) of SD patients versus only 5% (1/21) of healthy controls (p = 0.001) and 24% (10/42) of all UC + CD controls (p = 0.002). All 5 members of the FD cohort were homozygous for the at-risk "G" allele. In the test group, the homozygous GG genotype was found in 56% of SD patients compared with 17% of healthy controls (p = 0.006). Risk of SD seemed to increase with number of the G alleles with 8% of SD patients having AA homozygosity, 35% of SD patients having AG heterozygosity, and 56% of SD patients having GG homozygosity. The SNP rs7848647 associated with the TNFSF15 gene is associated with surgical diverticulitis. This finding suggests a fundamental role for TNFSF15, a T-cell receptor gene involved in T-cell maturation, in the pathophysiology of diverticulitis requiring surgery. This SNP may be a marker of diverticular disease severity that might assist in surgical decision making.

Surgery for Diverticulitis in the 21st Century

Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years. To review and classify the primary data published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis. We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines. We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms. The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.

Surgery for Diverticulitis is Associated with High Risk of In-Hospital Mortality and Postoperative Complications in Older End Stage Renal Disease Patients

Surgery for Diverticulitis is Associated with High Risk of In-Hospital Mortality and Postoperative Complications in Older End Stage Renal Disease Patients

Morbid Obesity and Diverticulitis: Results from the ACS NSQIP Dataset

We examined the relationship between morbid obesity, clinical presentation, and perioperative outcomes in patients offered surgery for diverticulitis. We queried the ACS NSQIP dataset from 2005 to 2010 for patients undergoing surgery for nonhemorrhaging diverticulitis. Univariate comparisons were made between normal weight (NL) and morbidly obese (MO) patients in terms of demographics, clinical presentation, and perioperative and postoperative outcomes variables using chi-square or rank tests. Multivariable regression was used to adjust for age in assessing the impact of MO on the likelihood of emergent surgery (ES), ostomy creation, open surgery, and undergoing procedures without an anastomosis. We identified 10,952 patients undergoing surgery for diverticulitis; morbidly obese (body mass index [BMI] ≥ 40 kg/m(2), n = 592, 5.7%), normal weight (BMI 18.5 to 25 kg/m(2), n = 2,530, 24.2%). Morbidly obese patients were younger than NL patients by an average of 9.4 years (p < 0.001). Morbidly obese patients underwent ES more frequently than NL patients (19.3% vs 15.4%; p = 0.025). Multivariable regression identified morbid obesity as an independent risk factor for ES (odds ratio [OR] 1.75, 95% CI 1.37 to 2.24, p < 0.001), ostomy creation (OR 1.67, 95% CI 1.34 to 2.08, p < 0.001), undergoing procedures without an anastomosis (OR 1.78, 95% CI 1.42 to 2.24, p < 0.001), and open surgery (OR 2.09, 95% CI 1.72 to 2.53, p < 0.001). Morbidly obese patients undergoing ES had more preoperative systemic inflammatory response syndrome/sepsis/septic shock than NL patients (72.8% vs 57.7%, p = 0.004). Morbidly obese patients undergoing surgery for diverticulitis are nearly 10 years younger than NL patients and are more likely to require ES, ostomy creation, open surgery, and to undergo procedures without an anastomosis. Morbidly obese patients undergoing ES also have more preoperative systemic inflammatory response syndrome/sepsis/septic shock.

Introduction to the minimal access colorectal surgery supplement of Techniques in Coloproctology

I am delighted to introduce our readers to this special supplemental issue of Techniques in Coloproctology. This issue is comprised of contributions from some of the world’s most respected leading luminaries in minimally invasive surgery. It opens with a beautiful description of laparoscopic right hemicolectomy by Dr. Jason Wong and Dr. Maher Abbas. The step-by-step description is accompanied by a cogent explanation of why and how the authors perform these procedures. In a similar manner, Dr. Amit Khanna discusses laparoscopic total mesorectal excision. Dr. John Migaly and coauthors detail the history and current status of minimally invasive surgery for diverticulitis, and Dr. Meagan Costedio and Dr. Feza Remzi very deftly elucidate the current status of laparoscopic single-port colectomy. Dr. Mario Morino and coauthors provide an elegant overview of the development and resurgence of interest in transanal endoscopic microsurgery. Dr. Morris Franklin and coauthors detail not only the development and rationale behind natural orifice surgery, but also describe their own large personal series of natural orifice specimen extraction procedures. Along with his coauthors, Dr. Peter Marcello discusses his widely acclaimed technique of hand-assisted laparoscopic colorectal surgery and argues very compellingly for its adoption. Dr. Seth Stein and Dr. Roberto Bergamaschi offer us a comprehensive description of both intracorporeal and extracorporeal anastomosis and explain their own personal preferences. Dr. Seon Hahn Kim and Dr. Jung Myun Kwak expertly describe robotic total mesorectal excision. I would like to extend an extra note of appreciation to Drs. Khanna, Morino, Marcet, and Remzi, all of whom provided highquality videos which further enhance the educational value of this volume. I wish to thank each and every author for their energy, efforts, time, and devotion to their respective subject matter. Together, they have elegantly created this issue which offers just the right amount of overlap to ensure complete comprehension while minimizing unnecessary redundancy. I am quite confident that every surgeon will enjoy reading this issue as much as I have enjoyed editing it. I wish to also thank my editor-in-chief, Dr. Mario Pescatori, and his co-editors Drs. Alberto Arezzo and Giuseppe Gagliardi for entrusting me with this important task. Lastly, I express my appreciation to my good friend, alumnus, and colleague Dr. Fabio M. Potenti for his invaluable assistance and expertise.

Minimally invasive surgery for diverticulitis

The realm of minimally invasive surgery now encompasses the majority of abdominal operations in the field of colorectal surgery. Diverticulitis, a common pathology seen in most colorectal practices, poses unique challenges to surgeons implementing laparoscopic surgery in their practices due to the presence of an inflammatory phlegmon and distorted anatomical planes, which increase the difficulty of the operation. Although the majority of colon resections for diverticulitis are still performed through a standard laparotomy incision, laparoscopic techniques are becoming increasingly common. A large body of literature now supports laparoscopic surgery to be safe and effective as well as to provide significant advantages over open surgery for diverticular disease. Here, we review the most current literature supporting laparoscopic surgery for elective and emergent treatment of diverticulitis.

Sigmoidectomy Syndrome? Patients’ Perspectives on the Functional Outcomes Following Surgery for Diverticulitis

Mari, Francesco Saverio M.D.; Nigri, Giuseppe M.D.; Berardi, Giammauro; Gasparrini, Marcello M.D.; Brescia, Antonio M.D. Author Information

Case‐matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients

To compare the perioperative outcomes following surgery for sigmoid diverticulitis in transplant recipients and immunocompetent patients. Solid organ transplant recipients operated on for sigmoid diverticulitis from 1995 to 2010 were case-matched to immunocompetent patients based on surgical procedure, American Society of Anesthesiologists classification, Hinchey score, elective vs urgent surgery, age ± 10 years and year of surgery ± 5 years. Demographics, clinical presentation and perioperative outcomes were assessed. Of 5329 consecutive patients undergoing heart, lung, kidney and liver transplantation since 1995, 51 (0.6%) underwent surgery for diverticulitis between 1995 and 2010 with 14% mortality and 45% morbidity. Urgent surgery in 37/51 patients [Hartmann's procedure 28, sigmoidectomy with diverting ileostomy 8, loop ileostomy 1 (9 cases within 2 months after transplantation)] was associated with significantly increased postoperative mortality (19%vs 0%, P = 0.01), increased morbidity (51%vs 24%, P = 0.03) and longer mean hospital stay (19 vs 13 days, P = 0.1) when compared with immunocompetent patients. Four patients undergoing urgent surgery had suffered previous episodes of diverticulitis treated nonoperatively. Elective surgery was associated with no mortality in 14 transplant recipients (nine sigmoidectomy with diverting ileostomy, five sigmoidectomy without diversion) or in immunocompetent controls. Following elective procedures, transplant recipients had similar morbidity and increased hospital stay (29% and 9.6 vs 6.5 days, P = 0.2, respectively). Permanent stoma rates and postoperative morbidity after stoma takedown were comparable in the two groups. All living patients except one (kidney) retained their graft function. Urgent surgery for sigmoid diverticulitis in transplant recipients is associated with worse postoperative outcomes when compared with immunocompetent patients, unlike elective surgery. Future studies will need to clarify the role of early surgery after the first diverticulitis episode.

Laparoscopic Lavage for Perforated Diverticulitis

Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies. This study investigated national trends in management of perforated diverticulitis. This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008. The study was conducted in Ireland. Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included. The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications. Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p < 0.001), complications (14.1% vs 25.0%, p < 0.001), and length of stay (10 days vs 20 days, p < 0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p < 0.001), as were those with connective tissue disease (OR 7.3, p < 0.05) or chronic kidney disease (OR 8.0, p < 0.001). This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group. The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.

Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis

The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients. All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors. We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure. Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.

Morbid obesity and outcomes of surgery for diverticulitis: Results from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset

METHODS: A consecutive series of 119 rectal cancer patients were analyzed. Twenty match pairs were established identical regarding gender, tumor site, tumor stage, neoadjuvant radiotherapy and type of surgery. Urogenital and anorectal function was evaluated prospectively using standardized questionnaires (International Prostate Symptom Score, Quality of life due to urinary symptoms, Wexner score, International Index of Erectile Function and Female Sexual Function Index), measurement of residual urine volume and longterm-catheterization.

Emergency diverticulitis surgery victim of the weekend effect

Emergency diverticulitis surgery victim of the weekend effect

The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis

BackgroundMechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis.MethodsA subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality.ResultsOut of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality.ConclusionMechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Surgical Treatment of Acute Recurrent Diverticulitis: Early Elective or Late Elective Surgery. An Analysis of 237 Patients

The optimal timing of elective surgery in diverticulitis remains unclear. We attempted to investigate early elective versus late elective laparoscopic surgery in acute recurrent diverticulitis in a retrospective study. Data of patients undergoing elective laparoscopic surgery for diverticulitis were retrospectively gathered, including Hinchey stages I-II a/b. the primary endpoint was in-hospital complications according to the Clavien-Dindo classification. Secondary endpoints were surgical complications, operative time, conversion rate, and length of hospital stay. Of 237 patients, 81 (34%) underwent early elective operation (group A) and 156 (66%) underwent late elective operation (group B). In-hospital complications developed in 32% in group A and in 34% in group B (risk difference 2%, 95% Confidence Interval (95% CI): -11%, 14%). Higher age (p=0.048) and borderline higher American Society of Anesthesiologists score (p=0.056) were risk factors for in-hospital complications. Severe surgical complications occurred in 9% of patients in group A and 10% in group B (risk difference 2%, 95% CI: -6%, 9%). Conversion rate was 9% in group A and 3% in group B (p=0.070). Severity of disease did not seem to have an impact on complications or length of hospital stay. The median postoperative hospital stay was 8days in both groups (interquartile range 6-10). Mean operative time was 220min (SD 64) in group A and 202min (SD 48) in group B. This is the first study comparing early versus late elective surgery for diverticulitis in terms of the postoperative outcome using a validated classification. Although the retrospective setting and large confidence intervals don't allow definitive recommendations, these results are of utmost importance for the design of future prospective, randomized controlled trials.

Advanced Age is an Independent Predictor for Increased Morbidity and Mortality After Emergent Diverticulitis Surgery.

Advanced Age is an Independent Predictor for Increased Morbidity and Mortality After Emergent Diverticulitis Surgery.

Sigmoidectomy Syndrome? Patients' Perspectives on the Functional Outcomes Following Surgery for Diverticulitis

Bowel function following surgery for diverticulitis has not previously been systematically described. This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis. This study is a retrospective analysis. This study was conducted at a large, academic medical center. Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument. Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function. Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥ 24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥ 4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥ 4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05). This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms. One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.

Sigmoidectomy Syndrome? Patients' Perspectives on the Functional Outcomes Following Surgery for Diverticulitis

Sigmoidectomy Syndrome? Patients' Perspectives on the Functional Outcomes Following Surgery for Diverticulitis

Racial Differences in Short-term Surgical Outcomes Following Surgery for Diverticulitis

BackgroundDiverticular disease ranks as one of the more common gastrointestinal disorders among westernized nations. Few studies have examined racial differences in the care and surgical outcomes of diverticulitis. The aim of this study was to determine if race is a predictor of peri-operative morbidity and mortality following surgery for diverticulitis. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (2005–2008) was queried with the primary dependent variables being 30-day morbidity and mortality. Differences in morbidity and mortality between races were compared using χ2 and Student t tests. Logistic regression was used to calculate odds ratios for morbidity and mortality. To determine if the effect of race is modified by insurance status and case complexity, additional models were developed across age subgroups (<65 vs ≥65) and levels of case complexity. ResultsWe identified 4,709 white and 360 African American patients. Despite being younger (57.6±0.74 vs 59 ± 0.2, p < 0.05), African Americans were more likely to present with hypertension, diabetes, renal failure, dependent functional status, American Society of Anesthesiology class ≥3 (all p < 0.0001) and were more likely to require urgent surgery (p < 0.05), intra-operative blood transfusions(p < 0.0001), and undergo open colectomy (p < 0.0001). On adjusted analysis, African American race emerged as an independent predictor of morbidity (p < 0.05) and mortality (p < 0.05), without differences across insurance categories and less complex procedures. African American race remained a strong predictor of morbidity in more complex procedures (p < 0.05). ConclusionAfrican Americans undergoing surgery for diverticulitis are more likely to have associated co-morbidities, require urgent surgery, undergo open surgery, and are at increased risk of morbidity and mortality. These findings highlight a need to address the root cause for disparities in care and outcomes after surgery.

Congestive Heart Failure and Chronic Obstructive Pulmonary Disease Predict Poor Surgical Outcomes in Older Adults Undergoing Elective Diverticulitis Surgery

Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain. This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups. This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis. Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007. Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy. The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications. Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality. Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors. Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.