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Mortality and Morbidity After Hartmann’s Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study

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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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Acknowledgement

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (H29-Policy-Designated-009 and H29-ICT-General-004); Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141); and the Japan Agency for Medical Research and Development (AMED). Drs Yasunaga and Fushimi received grants from the Ministry of Health, Labour and Welfare, Japan, and Dr. Yasunaga received grants from the Japan Agency for Medical Research and Development.

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Authors and Affiliations

  1. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan

    Asuka Tsuchiya, Hideo Yasunaga & Hiroki Matsui

  2. Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, 280, Sakuranosato, Ibarakimachi, Higahi-Ibarakigun, Ibaraki, 3113193, Japan

    Asuka Tsuchiya & Yusuke Tsutsumi

  3. Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138510, Japan

    Kiyohide Fushimi

Authors
  1. Asuka Tsuchiya
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  2. Hideo Yasunaga
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Correspondence to Asuka Tsuchiya.

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Supplemental Text

Independent variables using to calculate the propensity score (PDF 71 kb)

Supplemental Table 1

International Classification of Diseases, 10th Revision Codes (XLSX 40 kb)

Supplemental Table 2

Patient characteristics and covariate balance for the pooled sample and instrumental variable analysis (XLSX 32 kb)

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Tsuchiya, A., Yasunaga, H., Tsutsumi, Y. et al. Mortality and Morbidity After Hartmann’s Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study. World J Surg 42, 866–875 (2018). https://doi.org/10.1007/s00268-017-4193-2

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  • DOI: https://doi.org/10.1007/s00268-017-4193-2

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