Acute diverticulitis: Call in the surgical specialist, or maybe not?

Key clinical point: Major outcomes of acute, complicated diverticulitis were comparable regardless of surgeon specialization.

Major finding: Patients with diverticulitis treated by colorectal and general surgeons had similar 90-day morbidity (26% vs 28%; P = .76), readmissions (32% vs. 25%; P = .48), and LOS (both median 9 days;P = .82).

Data source: Retrospective study in 115 patients with acute complicated diverticulitis.

Disclosures: Dr. Wright and his coauthors reported having no financial conflicts.




CHICAGO – Surgical outcomes of acute, complicated diverticulitis are equivalent regardless of whether a colorectal or general surgeon wields the scalpel, a multicenter study showed.

There was no difference between the colorectal surgery (CRS) and general surgery groups for the primary outcomes of 90-day morbidity (26% vs 28%; P = .76), readmission (32% vs. 25%; P = .48), and length of stay (both median 9 days; P = .82).

Capt. G. Paul Wright Patrice Wendling/Frontline Medical News
Capt. G. Paul Wright

Surgeon specialization was not associated with any of the outcomes in multivariate regression that accounted for patient demographics, surgeon type, and disease characteristics, study author Capt. G. Paul Wright, U.S. Army Reserve Medical Corps, reported at the annual meeting of the Central Surgical Association.

The authors tackled the controversial issue in light of recent data suggesting improved acute, complicated diverticulitis surgery outcomes in the hands of specialized surgeons. A 2014 study reported that colorectal surgeons were less likely than general surgeons to use a Hartmann’s procedure and had reduced LOS and time to stoma reversal (J. Am. Coll. Surg. 2014;218:1156-61).

The current analysis involved 115 consecutive patients with acute, complicated diverticulitis who underwent emergent surgery with either a colorectal surgeon (n = 62) or general surgeon (n = 53) at two university-affiliated hospitals from 2006 to 2013. Age, Charlson Comorbidity Index, and American Society of Anesthesiologists class were similar between groups.

The colorectal surgeon group (CRS), however, was significantly more likely to have had previous episodes of diverticulitis (58% vs. 25%; P < .001), likely representing a referral bias or preexisting relationship with their surgeon, Dr. Wright said.

The general surgeon (GS) group had a significantly higher number of Systemic Inflammatory Response Syndrome criteria (P = .009 for all groups), higher rates of Hinchey class 3 disease (59% vs. 32%: P = .02), and ICU admissions (25% vs. 7%; P = .006).

The most common procedure among general surgeons was a Hartmann’s procedure (64% vs. 34%; P < .001), whereas colorectal surgeons favored primary anastomosis with diverting ileostomy (45% vs. 0%; P < .001), Dr. Wright, from Grand Rapids Medical Education Partners and Michigan State University, both in Grand Rapids, reported.

General surgeons were more likely to close the skin (85% vs. 50%), while in the CRS group the skin was left partially or completely open in 50% of patients. Operative time at the index admission was an average of 36 minutes longer in the CRS group (mean 164 minutes vs. 128 minutes; P = .005).

The CRS group had a higher rate of stoma reversal (78% vs 65%) and shorter time to stoma reversal (4 months vs. 4.7 months), but the difference was not statistically significant. The CRS group had a significantly shorter stoma reversal OR duration (mean 106 minutes vs. 182 minutes; P = .0010) and stoma reversal length of stay (mean 4 days vs. 7 days; P < .001).

“As general surgeons will no doubt continue to care for acute diverticulitis, increased use of primary anastomosis with proximal diversion when appropriate may be warranted due to the secondary benefits seen in stoma reversal,” Dr. Wright said.

Mortality was low and similar, at just one death in the CRS and two in the GS group.

Invited discussant William Cirocco, from Ohio State University in Columbus, said the type of surgical intervention is just one aspect in the management of patients with diverticulitis.

“An additional nonoperative approach may lead to conversion of an emergent to a nonemergent single-stage dissection. These critical decisions require experience and training,” Dr. Cirocco said. “For patients who require emergent operation for diffuse peritonitis, I believe that background and experience of the individual surgeon trumps the presence or absence of specialty training.”

Dr. Wright and his coauthors reported having no financial conflicts.

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