QS127 - Surgeon Perspective on the Operative Treatment of Acute Diverticulitis: Hartmann’s Procedure vs Primary Anastomosis

Purpose/Background: Acute left sided diverticulitis is one of the most common benign colonic diseases. However, up to 15% of patients may require an emergency operation. Historically, a segmental colectomy with rectal stump and colostomy (Hartmann’s Procedure, HP) has been the surgery of choice in these cases, but recently, literature has shown equivalent recovery and an increase in ostomy freedom with a Primary Anastomosis (PA) with or without diverting loop ileostomy. Current guidelines recommend the decision on operative treatment depend on surgeon experience and preference. This study aims to investigate factors affecting surgeon decision making in the operative treatment of acute diverticulitis.

Methods/Interventions: We conducted a survey based mixed-method study of surgeons treating acute diverticulitis. We surveyed surgeons in two organizations: the American Society of Colon and Rectum (ASCRS) and The American Association for the Surgery of Trauma (AAST). Survey questions focused on decision-making process, patient considerations, personal experience, and practice structure using a mixed methods design structure based on a theoretical domain framework for adoption of healthcare practices. Additional individual semi-structured interviews were conducted to build on survey responses. Surgeons were categorized as “PA Majority” if they self-reported performing PA greater than 50% of the time for acute diverticulitis. Group comparisons of demographic variables between groups were performed using Chi-squared tests. Fisher’s exact test was used in the instance of small cell counts ( < 5). P-value of < 0.05 was considered significant.

Results/Outcomes: Over the study period, 5,347 surveys were distributed. 385 surgeons responded with a 7.2% response rate. Of the 385 surgeon responses, 33% (n=128) responded that they performed PA for acute diverticulitis in more than 50% of cases. Of the surgeons who performed PA in the setting of acute diverticulitis, the majority practiced in an academic setting (56%, n=72) and completed subspecialty training (93%, n=118). Compared to physicians who performed majority HP, they reported having significant colorectal (CRS) experience: either completing a CRS residency (82% vs 60%, p < 0.001), reporting >50% CRS practice (77% vs 58%, p < 0.001), or having performed more than 50 CRS anastomoses in the past year (48% vs 37%, p=0.005). During interviews and qualitative analysis, surgeons discussed environmental resources—such as availability of skilled assistance or 24-hour availability of laparoscopic or robotic equipment—and level of training as major influences in favor of performing PA. Surgeons mentioned clinical factors—such as degree of contamination—, patient social factors—such as distance from hospital and inability to care for ileostomy—, and lack of resources as major influences against performing PA.

Conclusion/Discussion: Other than patient clinical factors, both surgeon training and environmental resources were the major influences on surgeon decision making in the choice of HP vs PA. Targeting these areas may improve surgeon confidence in implementing PA for acute diverticulitis.