Journal of Gastrointestinal Surgery

, Volume 14, Issue 12, pp 1867–1874

Elective Surgery for Diverticulitis is Associated with High Risk of Intestinal Diversion and Hospital Readmission in Older Adults

  • Anne O. Lidor
  • Eric Schneider
  • Jodi Segal
  • Qilu Yu
  • Richard Feinberg
  • Albert W. Wu
2010 SSAT Plenary Presentation

Abstract

Purpose

This study seeks to compare outcomes (in-hospital mortality, colostomy rates, and 30-day readmission rates) in older adult patients undergoing emergency/urgent versus elective surgery for diverticulitis.

Methods

Data were derived from the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004–2007. All patients 65 years of age and above with a primary diagnosis of diverticulitis that underwent left colon resection, colostomy, or ileostomy were included. The primary outcome variable was in-hospital mortality. Secondary outcome variables included intestinal diversion, 30-day post-discharge readmission rates, discharge destination, length of stay, and total charges. Patients were grouped in two categories for comparison: emergent/urgent (EU) versus elective surgery, as defined by admission type. Multivariate analysis was performed adjusting for age (categorized by five groups), gender, race, and medical comorbidity as measured by Charlson Index.

Results

Fifty-three thousand three hundred sixteen individuals were eligible for inclusion, with 23,764 (44.6%) in the elective group. On average, EU patients were older (76.8 vs. 73.9 years of age, p < 0.001) and less likely to be female (65.4% vs. 71.1%, p < 0.001). EU patients had higher in-hospital mortality (8.0% vs. 1.4%, p < 0.001), higher intestinal diversion rates (64.2% vs. 12.7%, p < 0.001), and higher 30-day readmission rates (21.4% vs. 11.9%, p < 0.001) and the worse outcomes persisted even after adjustment for risk factors. Unadjusted and adjusted mortality rates dramatically increased by age, although the affect of age on mortality was more pronounced in the elective group where mortality rates ranged from 0.56% in patients 65–69 years old to 6.5% in patients 85+ years old. The rates of ostomy and 30-day readmission generally increased with age, with worse outcomes noted particularly in the elective group.

Conclusions

As expected, older adults undergoing emergent/urgent surgical treatment for diverticulitis have significantly increased risks of poor outcomes compared with elective patients. While advancing age is associated with a substantial increase in mortality, intestinal diversion and 30-day readmission after surgery for diverticulitis, this affect is especially evident among patients undergoing elective colectomy. Our data suggest that given the considerable risk of prophylactic colon resection in elderly patients with sigmoid diverticulitis, a reappraisal of the proper role of elective colectomy in this population may be warranted.

Keywords

Diverticular disease Sigmoid diverticulitis Elderly Surgical outcomes Prophylactic colectomy 

References

  1. 1.
    Kozak LJ, Lees KA, DeFrances CJ. National Hospital Discharge Survey: 2003 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13 2006(160):1-206Google Scholar
  2. 2.
    Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49(7):939-44.CrossRefPubMedGoogle Scholar
  3. 3.
    Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140(7):681-5.CrossRefPubMedGoogle Scholar
  4. 4.
    Broderick-Villa G, Burchette RJ, Collins JC, et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005; 140(6):576-81; discussion 581-3CrossRefPubMedGoogle Scholar
  5. 5.
    Richards RJ, Hammitt JK. Timing of prophylactic surgery in prevention of diverticulitis recurrence: a cost-effectiveness analysis. Dig Dis Sci 2002; 47(9):1903-8.CrossRefPubMedGoogle Scholar
  6. 6.
    Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2004; 199(6):904-12.CrossRefPubMedGoogle Scholar
  7. 7.
    Frattini J, Longo WE. Diagnosis and treatment of chronic and recurrent diverticulitis. J Clin Gastroenterol 2006; 40 Suppl 3:S145-9.CrossRefPubMedGoogle Scholar
  8. 8.
    Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363(9409):631-9.CrossRefPubMedGoogle Scholar
  9. 9.
    Mueller MH, Glatzle J, Kasparek MS, et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 2005; 17(6):649-54.CrossRefPubMedGoogle Scholar
  10. 10.
    Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000; 43(3):290-7.CrossRefPubMedGoogle Scholar
  11. 11.
    Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol 1993; 46(10):1075-9; discussion 1081-90CrossRefPubMedGoogle Scholar
  12. 12.
    Etzioni DA, Mack TM, Beart RW, Jr., Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg 2009; 249(2):210-7.CrossRefPubMedGoogle Scholar
  13. 13.
    Jha AK, Fisher ES, Li Z, et al. Racial trends in the use of major procedures among the elderly. N Engl J Med 2005; 353(7):683-91.CrossRefPubMedGoogle Scholar
  14. 14.
    Morris AM, Billingsley KG, Baxter NN, Baldwin LM. Racial disparities in rectal cancer treatment: a population-based analysis. Arch Surg 2004; 139(2):151-5; discussion 156CrossRefPubMedGoogle Scholar
  15. 15.
    Lidor AO, Gearhart SL, Wu AW, Chang DC. Effect of race and insurance status on presentation, treatment, and mortality in patients undergoing surgery for diverticulitis. Arch Surg 2008; 143(12):1160-5; discussion 1165CrossRefPubMedGoogle Scholar
  16. 16.
    Thaler K, Baig MK, Berho M, et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003; 46(3):385-8.CrossRefPubMedGoogle Scholar
  17. 17.
    Leigh JE, Judd ES, Waugh JM. Diverticulitis of the colon. Recurrence after apparently adequate segmental resection. Am J Surg 1962; 103:51-4.CrossRefPubMedGoogle Scholar
  18. 18.
    Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151(2):269-71.CrossRefPubMedGoogle Scholar
  19. 19.
    Forgione A, Leroy J, Cahill RA, et al. Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg 2009; 249(2):218-24.CrossRefPubMedGoogle Scholar
  20. 20.
    Egger B, Peter MK, Candinas D. Persistent symptoms after elective sigmoid resection for diverticulitis. Dis Colon Rectum 2008; 51(7):1044-8.CrossRefPubMedGoogle Scholar
  21. 21.
    Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 2001; 134(8):637-43.PubMedGoogle Scholar
  22. 22.
    Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 2005; 53(3):424-9.CrossRefPubMedGoogle Scholar
  23. 23.
    Bender JS, Magnuson TH, Zenilman ME, et al. Outcome following colon surgery in the octagenarian. Am Surg 1996; 62(4):276-9.PubMedGoogle Scholar
  24. 24.
    Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001; 49(8):1080-5.CrossRefPubMedGoogle Scholar
  25. 25.
    Massarweh NN, Legner VJ, Symons RG, et al. Impact of advancing age on abdominal surgical outcomes. Arch Surg 2009; 144(12):1108-14.CrossRefPubMedGoogle Scholar
  26. 26.
    Robinson TN, Eiseman B, Wallace JI, et al. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 2009; 250(3):449-55.PubMedGoogle Scholar
  27. 27.
    Dasgupta M, Rolfson DB, Stolee P, et al. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr 2009; 48(1):78-83.CrossRefPubMedGoogle Scholar
  28. 28.
    Salem L, Flum DR. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47(11):1953-64.CrossRefPubMedGoogle Scholar
  29. 29.
    Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures. Ann Surg 2007; 245(1):94-103.CrossRefPubMedGoogle Scholar
  30. 30.
    Klarenbeek BR, Veenhof AA, Bergamaschi R, et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009; 249(1):39-44.CrossRefPubMedGoogle Scholar
  31. 31.
    Oomen JL, Engel AF, Cuesta MA. Outcome of elective primary surgery for diverticular disease of the sigmoid colon: a risk analysis based on the POSSUM scoring system. Colorectal Dis 2006; 8(2):91-7.CrossRefPubMedGoogle Scholar
  32. 32.
    Aydin HN, Remzi FH, Tekkis PP, Fazio VW. Hartmann's reversal is associated with high postoperative adverse events. Dis Colon Rectum 2005; 48(11):2117-26.CrossRefPubMedGoogle Scholar
  33. 33.
    Vermeulen J, Coene PP, Van Hout NM, et al. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11(6):619-24.CrossRefPubMedGoogle Scholar
  34. 34.
    Klabunde CN, Warren JL, Legler JM. Assessing comorbidity using claims data: an overview. Med Care 2002; 40(8 Suppl):IV-26-35Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2010

Authors and Affiliations

  • Anne O. Lidor
    • 1
  • Eric Schneider
    • 1
  • Jodi Segal
    • 2
  • Qilu Yu
    • 2
  • Richard Feinberg
    • 1
  • Albert W. Wu
    • 1
    • 2
    • 3
  1. 1.Department of SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

Personalised recommendations