QS125 - Adoption of Primary Anastomosis for Acute Diverticulitis: Are We Actually Doing It?

Sunday, June 2, 2024

11:39 AM – 11:42 AM ET, USA

Location: Room 327

Quick Shot Presenter(s)

MM

Moustafa Moussally, MD

General Surgery Resident
Cleveland Clinic Foundation
C;leveland, Ohio, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.

Author(s)

Maysoon Gamaleldin, MD

Resident
Cleveland Clinic Foundation
Cleveland Clinic Foundation
Beachwood, OH, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
Kristen A. Ban, MD

Colorectal Surgeon
Cleveland Clinic Foundation
C;leveland, Ohio, United States

Disclosure information not submitted.
AK

Ajaratu Keshinro, MD

Colorectal Surgeon
Cleveland Clinic Foundation
Cleveland, Ohio, United States

Disclosure information not submitted.
JT

Joseph Trunzo, MD

Colorectal Surgeon
Cleveland Clinic Foundation
C;leveland, Ohio, United States

Disclosure information not submitted.
Bradley J. Champagne, MD

Colorectal Surgeon
Cleveland Clinic Foundation
C;leveland, Ohio, United States

Disclosure information not submitted.
Stefan D. Holubar, MD, MS

Director of Research, Staff Surgeon
Department of Colorectal Surgery, Cleveland Clinic
Cleveland, Ohio, United States

Disclosure information not submitted.
Scott Steele, MD MBA

President, Chairman, Staff Surgeon
Department of Colorectal Surgery, Cleveland Clinic
Cleveland, Ohio, United States

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.

Senior Author(s)

David R. Rosen, MD

Colorectal Surgeon
Cleveland Clinic
Cleveland Clinic Lerner College of Medicine
Cleveland, Ohio, United States

Disclosure information not submitted.

Purpose/Background: Historically, a sigmoid colectomy with end colostomy (Hartmann’s procedure) is the most common procedure for urgent surgical management of acute diverticulitis. More recently, randomized control trials have established the safety and feasibility of primary anastomosis (PA) for the treatment of Hinchey 3 and Hinchey 4 diverticulitis. Our study's aim was to evaluate the adoption of PA in the urgent surgical management of diverticulitis.

Methods/Interventions: We queried a prospectively maintained institutional quality collaborative database for all patients with acute diverticulitis who required urgent surgical intervention during inpatient admission from January 2020-August 2023. A retrospective chart review of patient demographics, medical history, procedure performed, preoperative factors, intraoperative Hinchey classification, and patient outcomes was performed. Statistical analysis was performed using SPSS 23.0

Results/Outcomes: 72 patients underwent urgent surgery for acute diverticulitis. 55% of the patients were female. Mean age of the cohort was 61 years old with a mean BMI of 29. Hartmann’s procedure was the most commonly performed procedure (n=51, 71%). The remaining 21 patients (29%) underwent PA; 5 (7%) of which had a diverting loop ileostomy (DLI). Of the 32 patients with Hinchey 1 and Hinchey 2 diverticulitis, 17 (53%) underwent Hartmann’s resections and 15 PA (47%), one with DLI. Of the 31 patients with Hinchey 3 diverticulitis, 25 (81%) underwent Hartmann’s resections and 6 (19%) PA, four with DLI. All 9 (100%) patients with Hinchey 4 diverticulitis underwent Hartmann’s resection. The cases were equally distributed among general and colorectal surgeons with both groups performing the same number of PA. All DLI were performed by colorectal surgeons. Of note, 36 (71%) of the Hartmann’s patients underwent reversal while all five loop ileostomies were reversed; this difference was not statistically significant (p=0.16). All PA cases were performed by staff more than 3 years into practice. Hinchey classification and ASA score were found to impact the choice of surgery (p < 0.05) (Table 1). There was no association between surgeon perceived case complexity or timing of operation and surgical procedure performed. Although not statistically significant, no cases with PA took place after 10 PM.

Conclusion/Discussion: Although the literature supports PA as a safe alternative to Hartmann’s procedure for the urgent surgical management of acute diverticulitis, it remains an underutilized strategy. This was especially evident among patients with Hinchey 3 and 4 diverticulitis. Factors such as Hinchey classification and ASA class seem to deter the surgeon’s decision to perform a PA. Timing of surgery, surgeon specialty, and perceived case complexity did not affect intra-operative decision making.