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Sarmiento-Altamirano D, Neira-Quezada D, Willches-Encalada E, Cabrera-Ordoñez C, Valdivieso-Espinoza R, Himmler A, Di Saverio S. The influence of preoperative e intraoperative factors in predicting postoperative morbidity and mortality in perforated diverticulitis: a systematic review and meta-analysis. Updates Surg 2024; 76:397-409. [PMID: 38282071 DOI: 10.1007/s13304-023-01738-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
To determine if preoperative-intraoperative factors such as age, comorbidities, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and severity of peritonitis affect the rate of morbidity and mortality in patients undergoing a primary anastomosis (PA) or Hartmann Procedure (HP) for perforated diverticulitis. This is a systematic review and meta-analysis, conducted according to PRISMA, with an electronic search of the PubMed, Medline, Cochrane Library, and Google Scholar databases. The search retrieved 614 studies, of which 11 were included. Preoperative-Intraoperative factors including age, ASA classification, BMI, severity of peritonitis, and comorbidities were collected. Primary endpoints were mortality and postoperative complications including sepsis, surgical site infection, wound dehiscence, hemorrhage, postoperative ileus, stoma complications, anastomotic leak, and stump leakage. 133,304 patients were included, of whom 126,504 (94.9%) underwent a HP and 6800 (5.1%) underwent a PA. There was no difference between the groups with regards to comorbidities (p = 0.32), BMI (p = 0.28), or severity of peritonitis (p = 0.09). There was no difference in mortality [RR 0.76 (0.44-1.33); p = 0.33]; [RR 0.66 (0.33-1.35); p = 0.25]. More non-surgical postoperative complications occurred in the HP group (p = 0.02). There was a significant association in the HP group between the severity of peritonitis and mortality (p = 0.01), and surgical site infection (p = 0.01). In patients with perforated diverticulitis, PA can be chosen. Age, comorbidities, and BMI do not influence postoperative outcomes. The severity of peritonitis should be taken into account as a predictor of postoperative morbidity and mortality.
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Affiliation(s)
| | | | | | | | | | - Amber Himmler
- University of California San Francisco, San Francisco, USA
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
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Bezerra RP, Costa ACD, Santa-Cruz F, Ferraz ÁAB. HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2021; 33:e1546. [PMID: 33470376 PMCID: PMC7812685 DOI: 10.1590/0102-672020200003e1546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mortality after emergency surgery in randomized controlled trials. The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. AIM To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. METHOD Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. RESULTS There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. CONCLUSION Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.
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Affiliation(s)
| | | | | | - Álvaro A B Ferraz
- Department of Surgery, Federal University of Pernambuco, Recife, PE, Brazil
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Ryan OK, Ryan ÉJ, Creavin B, Boland MR, Kelly ME, Winter DC. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann’s procedure for the management of acute perforated diverticulitis with generalised peritonitis. Tech Coloproctol 2020; 24:527-543. [DOI: 10.1007/s10151-020-02172-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/07/2020] [Indexed: 12/29/2022]
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Gachabayov M, Oberkofler CE, Tuech JJ, Hahnloser D, Bergamaschi R. Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis 2018; 20:753-770. [PMID: 29694694 DOI: 10.1111/codi.14237] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
AIM It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.
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Affiliation(s)
- M Gachabayov
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - C E Oberkofler
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - R Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Tsuchiya A, Yasunaga H, Tsutsumi Y, Matsui H, Fushimi K. Mortality and Morbidity After Hartmann's Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study. World J Surg 2018; 42:866-875. [PMID: 28871326 DOI: 10.1007/s00268-017-4193-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The benefit of primary anastomosis (PA) without a diverting stoma over Hartmann's procedure (HP) for colorectal perforation remains controversial. We compared postoperative mortality and morbidity between HP and PA without a diverting stoma for colorectal perforation of various etiologies. METHODS Using the Japanese Diagnosis Procedure Combination database, we extracted data on patients who underwent emergency open laparotomy for colorectal perforation of various etiologies from July 1, 2010 to March 31, 2014. We compared 30-day mortality, postoperative complication rates, and postoperative critical care interventions between HP and PA groups using propensity score matching, inverse probability of treatment weighting, and instrumental variable analyses to adjust for measured and unmeasured confounding factors. RESULTS We identified 8500 eligible patients (5455 HP and 3045 PA). In the propensity score-matched model, a significant difference between the HP and PA groups was detected in 30-day mortality (7.7% vs. 9.6%; risk difference, 1.9%; 95% confidence interval [CI], 0.5-3.4). The inverse probability of treatment weighting showed similar results (8.8% vs. 10.7%; risk difference, 1.9%; 95% CI, 1.0-2.8). In the instrumental variable analysis, the point estimate suggested similar direction to that of the propensity score analyses (risk difference, 4.4%; 95% CI, -3.3 to 12.1). The PA group had significantly higher rates of secondary surgery for complications (4.6% vs. 8.4%; risk difference, 3.8%; 95% CI, 2.5-4.1) and slightly longer duration of postoperative critical care interventions. CONCLUSIONS This study revealed a significant difference in 30-day mortality between HP and PA without a diverting stoma.
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Affiliation(s)
- Asuka Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan. .,Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, 280, Sakuranosato, Ibarakimachi, Higahi-Ibarakigun, Ibaraki, 3113193, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, 280, Sakuranosato, Ibarakimachi, Higahi-Ibarakigun, Ibaraki, 3113193, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138510, Japan
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Roig JV, Salvador A, Frasson M, García-Mayor L, Espinosa J, Roselló V, Hernandis J, Ruiz-Carmona MD, Uribe N, García-Calvo R, Bernal JC, García-Armengol J, García-Granero E. Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico. Cir Esp 2018. [DOI: 10.1016/j.ciresp.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Grott M, Horisberger K, Weiß C, Kienle P, Hardt J. Resection enterostomy versus Hartmann's procedure for emergency colonic resections. Int J Colorectal Dis 2017; 32:1171-1177. [PMID: 28389778 DOI: 10.1007/s00384-017-2808-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND If a primary anastomosis is considered too risky after emergency colon resection either a resection enterostomy or an end stoma with closure of the distal bowel (Hartmann's procedure) is possible. This study analyzes the rate of restoration of intestinal continuity and other surgical outcomes after resection enterostomy placement versus Hartmann's procedure for emergency colon resections. METHODS All patients who underwent emergency colorectal resections between August 2009 and June 2014 at the University Medical Center Mannheim were reviewed in regard to therapeutic approach, rate of restoration of bowel continuity, and surgical morbidity after the primary operation and after reversal surgery. RESULTS Fifty-five patients in whom both studied interventions would have been technically feasible were further analyzed. The rate of revisional surgery was significantly higher in the resection enterostomy cohort after the primary operation. There were no significant differences regarding morbidity, mortality, and the rate of restoration of intestinal continuity. Overall, bowel continuity could be restored in 63% (29/46) of the surviving patients. The median time of surgery of the initial as well as of the reversal surgery was significantly longer in the Hartmann's group. Five of 13 patients underwent protective ileostomy placement in the Hartmann's group at the time of the reversal (vs. none in the resection enterostomy group). CONCLUSIONS The bowel continuity can be restored in the majority of patients after emergency colonic resection. Conclusive evidence which surgical option should be preferred when a primary anastomosis is considered too risky-Hartmann's procedure or resection enterostomy-is still lacking.
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Affiliation(s)
- M Grott
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - K Horisberger
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - C Weiß
- Department of Medical Statistics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - P Kienle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.
| | - J Hardt
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
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Abstract
Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.
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Affiliation(s)
- Karen L Sherman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
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Cirocchi R, Afshar S, Di Saverio S, Popivanov G, De Sol A, Gubbiotti F, Tugnoli G, Sartelli M, Catena F, Cavaliere D, Taboła R, Fingerhut A, Binda GA. A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine. World J Emerg Surg 2017; 12:14. [PMID: 28293278 PMCID: PMC5345194 DOI: 10.1186/s13017-017-0120-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/01/2017] [Indexed: 02/08/2023] Open
Abstract
The management of patients with colonic diverticular perforation is still evolving. Initial lavage with or without simple suture and drainage was suggested in the late 19th century, replaced progressively by the three-stage Mayo Clinic or the two-stage Mickulicz procedures. Fears of inadequate source control prompted the implementation of the resection of the affected segment of colon with formation of a colostomy (Hartman procedure) in the 1970’s. Ensuing development of the treatment strategies was driven by the recognition of the high morbidity and mortality and low reversal rates associated with the Hartman procedure. This led to the wider use of resection and primary anastomosis during the 1990’s. The technique of lavage and drainage regained popularity during the 1990’s. This procedure can also be performed laparoscopically with the advantage of faster recovery and shorter hospital stay. This strategy allows resectional surgery to be postponed or avoided altogether in many patients; and higher rates of primary resection and anastomosis can be achieved avoiding the need for a stoma. The three recent randomized controlled trials comparing laparoscopic peritoneal lavage alone to resectional surgery reported inconsistent outcomes. The aim of this review is to review the historical evolution and future reflections of surgical treatment modalities for diffuse purulent and feculent peritonitis. In this review we classified the various surgical strategies according to Krukowski et al. and Vermeulen et al. and reviewed the literature related to surgical treatment separately for each period.
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Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery, University of Perugia, Terni Hospital, Terni, Italy
| | - Sorena Afshar
- Department of General Surgery, Cumberland Infirmary, Carlisle, UK
| | - Salomone Di Saverio
- General (Colorectal) Emergency and Trauma Surgery Service, Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | | | | | | | - Gregorio Tugnoli
- General (Colorectal) Emergency and Trauma Surgery Service, Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | | | - Fausto Catena
- Department of Emergency Surgery, Parma Hospital, Parma, Italy
| | | | - Renata Taboła
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,First Department of Surgery, Hippokration University Hospital, University of Athens, Athens, Greece
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Daher R, Barouki E, Chouillard E. Laparoscopic treatment of complicated colonic diverticular disease: A review. World J Gastrointest Surg 2016; 8:134-142. [PMID: 26981187 PMCID: PMC4770167 DOI: 10.4240/wjgs.v8.i2.134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 10/11/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.
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Zafar SN, Changoor NR, Williams K, Acosta RD, Greene WR, Fullum TM, Haider AH, Cornwell EE, Tran DD. Race and socioeconomic disparities in national stoma reversal rates. Am J Surg 2016; 211:710-5. [PMID: 26852146 DOI: 10.1016/j.amjsurg.2015.11.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/01/2015] [Accepted: 11/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. METHODS Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. RESULTS The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001). CONCLUSIONS Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA.
| | - Navin R Changoor
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kibileri Williams
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
| | - Rafael D Acosta
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
| | - Wendy R Greene
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
| | - Terrence M Fullum
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
| | - Daniel D Tran
- Department of Surgery, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA
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Shaw D, Beaty JS, Thorson AG. Reoperative surgery for diverticular disease and its complications. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Hartmann’s procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation. Langenbecks Arch Surg 2015; 400:609-16. [DOI: 10.1007/s00423-015-1319-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/16/2015] [Indexed: 11/26/2022]
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Moore FA, Catena F, Moore EE, Leppaniemi A, Peitzmann AB. Position paper: management of perforated sigmoid diverticulitis. World J Emerg Surg 2013; 8:55. [PMID: 24369826 PMCID: PMC3877957 DOI: 10.1186/1749-7922-8-55] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 12/16/2022] Open
Abstract
Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.
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Affiliation(s)
- Frederick A Moore
- Acute Care Surgery, University of Florida, 1600 Southwest Archer Road, PO Box 100108, Gainesville, FL 32610-0108, USA
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Via Cracvia 23, Bologna 40139, Italy
| | - Ernest E Moore
- University of Colorado Health Science Center, Denver Health Science Center, 777 Bannock Street, Denver, CO 80204-4507, USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University of Helsinki, Haartmaninkatu 4, PO Box 340, Meilahi Hospital, FIN-00029 HUS, Helsinki, HUS 00290, Finland
| | - Andrew B Peitzmann
- University of Pittsburgh, F-1281, UPMC-Presbyterian, Pittsburgh, PA 15213, USA
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