Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
Surg Endosc. 2024 May;38(5):2777-2787. doi: 10.1007/s00464-024-10752-8. Epub 2024 Apr 5.
Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge.
This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease.
Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137].
Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.
目前的指南建议，如果急性憩室炎的手术治疗被认为是安全的，应采用带有预防性回肠造口术的结肠切除术与 Hartmann 手术。本研究的主要目的是比较这些策略的应用，并描述全国性造口关闭模式和出院后 1 年内的再入院结局。
这是一项在美国医院进行的回顾性、基于人群的队列研究，这些医院的数据来自全国再入院数据库，时间范围为 2011 年 1 月至 2019 年 12 月。共纳入 35774 例因急性憩室炎行非选择性结肠切除术加预防性回肠造口术或 Hartmann 手术的患者。比较造口关闭、非计划性再入院和并发症的发生率。使用 Cox 比例风险和逻辑回归模型控制患者和医院水平的混杂因素以及疾病严重程度。
在 35774 例患者中，93.5%行 Hartmann 手术。其中 50.8%为女性，47.2%年龄在 46-65 岁之间，50.8%为女性，41.2%为公共保险，91.7%行开放性手术。行一期吻合术的患者 1 年内造口关闭率更高（83.6% vs. 53.4%，p<0.001），且造口关闭时间更短[中位数 72 天（四分位距 49-103） vs. 115 天（86-160）；p<0.001]。一期吻合术与非计划性再入院相关[风险比=2.83（95%置信区间 2.83-3.37）；p<0.001]，但造口关闭时并发症更少[比值比 0.51（95%置信区间 0.42-0.63）；p<0.001]。一期吻合术和 Hartmann 手术在指数住院期间的并发症无差异[比值比=1.13（95%置信区间 0.96-1.33）；p=0.137]。
接受一期吻合术治疗急性憩室炎的患者更有可能行造口还纳术，且在造口还纳术后发生并发症的风险较低。这些数据支持当前的国家指南，即建议在需要手术治疗的急性憩室炎的合适病例中采用一期吻合术。
