Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis

BACKGROUND: Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. OBJECTIVE: The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. DESIGN: This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. SETTINGS: Interventions were performed in hospitals participating in the national database. PATIENTS: Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. MAIN OUTCOME MEASURES: Outcomes measures included length of stay and overall morbidity and mortality. RESULTS: Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. LIMITATIONS: Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. CONCLUSIONS: Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421.