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.
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References
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):1-206
Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49(7):939-44.
Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140(7):681-5.
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 581-3
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.
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.
Frattini J, Longo WE. Diagnosis and treatment of chronic and recurrent diverticulitis. J Clin Gastroenterol 2006; 40 Suppl 3:S145-9.
Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363(9409):631-9.
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.
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.
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 1081-90
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.
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.
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 156
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 1165
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.
Leigh JE, Judd ES, Waugh JM. Diverticulitis of the colon. Recurrence after apparently adequate segmental resection. Am J Surg 1962; 103:51-4.
Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151(2):269-71.
Forgione A, Leroy J, Cahill RA, et al. Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg 2009; 249(2):218-24.
Egger B, Peter MK, Candinas D. Persistent symptoms after elective sigmoid resection for diverticulitis. Dis Colon Rectum 2008; 51(7):1044-8.
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.
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.
Bender JS, Magnuson TH, Zenilman ME, et al. Outcome following colon surgery in the octagenarian. Am Surg 1996; 62(4):276-9.
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.
Massarweh NN, Legner VJ, Symons RG, et al. Impact of advancing age on abdominal surgical outcomes. Arch Surg 2009; 144(12):1108-14.
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.
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.
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.
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.
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.
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.
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.
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.
Klabunde CN, Warren JL, Legler JM. Assessing comorbidity using claims data: an overview. Med Care 2002; 40(8 Suppl):IV-26-35
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Dr. Bridget N. Fahy (Houston, TX): I congratulate Dr. Lidor and her colleagues for a really important study. I do surgical oncology, and I think second only to breast, diverticulitis is the biggest moving target that any of us are facing right now. So I really applaud you for focusing on a very important topic. And I have a couple of questions.
Did you have any information about the time from which the patients were admitted to the time that they went to their operation? It may have been that that emergent group had failed IV antibiotics for a while and had a percutaneous drainage that failed to resolve thereafter, so on and so forth.
And my second question is, you mentioned, particularly in the paper, which is very nicely written, about thethat marked difference in mortality, particularly in the elective group. And I'm wondering if you can comment on why you think that the that mortality was even more pronounced than what you saw in the emergency group.
Closing discussant
Dr. Anne O. Lidor: For the first question, we broke our patients into two groups: an elective group and an emergency/urgent group. The elective group included patients who had a primary diagnosis of diverticulitis, were admitted on an elective basis, and had their surgery on the same day as their admission.
The emergency/urgent group included patients that were classified as having an emergency admission or an urgent admission. That would actually include patients who came in with fecal peritonitis and went right to the operating room, but it also includes patients that were admitted and failed intravenous antibiotics or some other type of therapy prior to going to the operating room.
As far as the second question: the emergency group likely includes patients that were thought to be too high risk to have been offered elective surgery and are only presenting as emergencies, which leads to uniformly worse outcomes across the board. The patients in the elective group are obviously a highly selected group of patients, because those are patients that, by definition, are already thought to be healthy enough to undergo surgery. Therefore I think that the most likely explanation for the more pronounced effect noted in the elective group is secondary to multiple factors that you can't adjust for, such as lack of physiologic reserve, or inability to cope with intraoperative or postoperative stress. That's actually very hard to account for when you are looking at a claims-based database.
Discussant
Dr. Shimul A. Shah (Worchester, MA): I guess the question that I have would be, how do we know that a 12% intestinal diversion rate in the elderly people is actually high? Maybe in this age group that would be expected as well as a high of 30% readmission rate for the elective group. Maybe those are normal numbers.
Closing discussant
Dr. Anne O. Lidor: If you look in the literature, the reported range for an ostomy during an elective colectomy ranges anywhere from 2% to 10.5%. So even if we look at all comers, almost 13%, that's already higher than what is in the literature.
One thing that I should mention, however, is that it's a little bit difficult using this database to clarify which of those patients actually got their ostomies at the time of their initial operation and which patients received an ostomy during a subsequent operation during the same admission. That is, let's say you did the operation, you weren't happy with the anastomosis, and you gave them a diverting ostomy; but it also includes patients on whom you did the surgery, they may have leaked while they were still in the hospital, and went back to the operating room and got an ostomy. So it's a little bit hard to look at that as a strict number.
This study was funded in part by the 2009 American Gastroenterological Association Foundation’s Designated Outcomes Award in Geriatric Gastroenterology.
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Lidor, A.O., Schneider, E., Segal, J. et al. Elective Surgery for Diverticulitis is Associated with High Risk of Intestinal Diversion and Hospital Readmission in Older Adults. J Gastrointest Surg 14, 1867–1874 (2010). https://doi.org/10.1007/s11605-010-1344-2
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DOI: https://doi.org/10.1007/s11605-010-1344-2