Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
JAMA Surg. 2019 Mar 1;154(3):218-224. doi: 10.1001/jamasurg.2018.4359.
The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown.
To investigate the association of the timing of colostomy reversal with operative outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018.
Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing.
Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age.
In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups.
Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.
Hartmann 手术（结肠造口术）仍然是用于需要手术的憩室炎的常见手术。然而，随后结肠造口术逆转的时机仍然存在很大差异，最佳时机仍不清楚。
研究结肠造口术逆转时机与手术结果的关系。
设计、地点和参与者：这项对加利福尼亚州、佛罗里达州和马里兰州的医疗保健成本和利用项目州住院数据库的回顾性分析包括与结肠造口术逆转相关的憩室炎的结肠造口术患者。排除了指数手术和逆转之间再次入院的患者，留下了 1660 名最终队列患者。数据收集于 2010 年 1 月 1 日至 2016 年 12 月 31 日，并于 2017 年 12 月 1 日至 2018 年 5 月 31 日进行分析。
患者根据指数手术后结肠造口术逆转的时间分为早期（45-110 天）、中期（111-169 天）和晚期（≥170 天）逆转时间。
逆转后主要关注的结果包括死亡率、发病率和再入院率，并使用多变量逻辑回归调整合并症和年龄进行比较。
共确定了 7165 名至少随访 1 年的患者，其中 2028 名（28.3%）在 1 年内进行了逆转。在 1 年内进行逆转的患者中，1660 名患者在逆转前没有再入院（860 名男性[51.8%]；中位年龄为 61 岁[四分位距 {IQR} ，51-70 岁]）。中位逆转时间为 129 天（IQR，99-182 天）。多变量分析显示，与早期逆转相关的患者特征包括 60 岁或以下（比值比[OR]，1.31；95%CI，1.00-1.70；P = .0497）、白种人（OR，1.32；95%CI，1.05-1.67；P = .02）和私人保险与医疗补助（OR，2.45；95%CI，1.67-3.60；P < .001）。在逆转时间组之间，死亡率、输血、肠梗阻和主要并发症无显著差异。然而，晚期组的住院时间延长（OR，1.62；95%CI，1.19-2.21；P = .002）和 90 天再入院率（OR，1.61；95%CI，1.18-2.22；P = .003）显著高于早期组。
不到三分之一的憩室炎患者在结肠造口术结束后 1 年内进行结肠造口术逆转，逆转时机与社会经济差异有关。在病情简单的患者中，较早的逆转与更好的结果相关，并且在初次手术后 45 至 110 天即可安全进行结肠造口术逆转。
