National Variation in Elective Colon Resection for Diverticular Disease

Is histopathological analysis necessary in patients undergoing sigmoidectomy for diverticular disease? A retrospective study

AIM

The purpose of this study was to assess the utility of routine histopathological examination in patients undergoing elective sigmoidectomy for diverticular disease after full colonoscopy 1 year prior to surgery.

METHODS

We retrospectively analysed medical records of all patients undergoing sigmoidectomy for diverticular disease with a documented colonoscopy within 1 year before surgery from January 2013 to December 2023. We collected preoperative, intraoperative and postoperative data of all patients. The primary endpoint was the percentage of patients with an unexpectedly abnormal histopathological report compared to colonoscopy.

RESULTS

During the study period, 207 patients undergoing sigmoidectomy for diverticular disease were included. Mean age was 62.7 ± 13.0 years and 97 (46.9%) patients were men. In eight (3.9%) cases an unexpected finding was noted on the histopathological examination: five (2.4%) of them were hyperplastic polyps with no dysplasia and no clinical relevance, two (1.0%) were polyps with low-grade dysplasia and in one case (0.5%) a diffuse large B-cell lymphoma was present in a patient with history of lymphoma treated in the past 10 years. The Goodman and Kruskal's G index was 0.953 (95% lower limit of 0.913), which indicated high concordance between the colonoscopy and the definitive histopathological examination.

CONCLUSIONS

In our series, the preoperative colonoscopy reliably predicted the result of the histopathological specimen findings in patients undergoing sigmoidectomy for diverticular disease. Only one (0.5%) high-risk patient had an unexpected clinically significant finding. Therefore, routine histopathological examination may not be justified for all patients.

Decision Aid for Colectomy in Recurrent Diverticulitis: Development and Usability Study

BACKGROUND

Diverticular disease is a common gastrointestinal diagnosis with over 2.7 million clinic visits yearly. National guidelines from the American Society of Colon and Rectal Surgeons state that "the decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized." However, tools to individualize this decision are lacking.

OBJECTIVE

This study aimed to develop an online educational decision aid (DA) to facilitate effective surgeon and patient communication about treatment options for recurrent left-sided diverticulitis.

METHODS

We used a modified design sprint methodology to create a prototype DA. We engaged a multidisciplinary team and adapted elements from the Ottawa Personal Decision Guide. We then iteratively refined the prototype by conducting a mixed methods assessment of content and usability testing, involving cognitive interviews with patients and surgeons. The findings informed the refinement of the DA. Further testing included an in-clinic feasibility review.

RESULTS

Over a 4-day in-person rapid design sprint, including patients, surgeons, and health communication experts, we developed a prototype of a diverticulitis DA, comprising an interactive website and handout with 3 discrete sections. The first section contains education about diverticulitis and treatment options. The second section clarifies the potential risks and benefits of both clinical treatment options (medical management vs colectomy). The third section invites patients to participate in a value clarification exercise. After navigating the DA, the patient prints a synopsis that they bring to their clinic appointment, which serves as a guide for shared decision-making.

CONCLUSIONS

Design sprint methodology, emphasizing stakeholder co-design and complemented by extensive user testing, is an effective and efficient strategy to create a DA for patients living with recurrent diverticulitis facing critical treatment decisions.

Butyrylcholinesterase levels correlate with surgical site infection risk and severity after colorectal surgery: a prospective single-center study

Introduction

Surgical site infections (SSIs) after colorectal surgery remain a significant concern, which warrants effective predictive markers for prompt diagnosis and treatment. Butyrylcholinesterase (BChE), a non-specific cholinesterase enzyme, has been correlated with the risk of hepatic dysfunction progression and, more recently, infectious diseases and septic shock with ongoing research into the utility of BChE in multiple systemic inflammatory conditions. Whether these preliminary results can be translated into predicting infection after colorectal surgery remains in remains in question. This prospective study aimed to assess BChE's potential as a predictive marker for surgical site infections and anastomotic leaks after colorectal surgery.

Materials and methods

This single-center prospective study (11/2019-05/2023) enrolled 402 patients who underwent colorectal surgery. BChE levels were measured at four postoperative time points. The primary endpoints focused on BChE's association with complications, particularly surgical site infections (SSIs). Further known predictors of SSI were utilized to construct multivariable models to assess for independent association with SSI development.

Results

During the third and fifth day postsurgery, SSI patients had significantly lower mean BChE levels (3.90 KU/L vs. 4.54 KU/L p-value < 0.05, and 4.14 KU/L vs. 4.73 KU/L, p-value < 0.05; t-test, respectively). However, multivariate analysis revealed that when adjusted for other factors, low BChE levels on the first postoperative day were associated with 2.6 times higher odds of developing SSI (OR: 2.6, 95%CI: 1.3-3.9, p-value < 0.05). Similar results were found for low BChE levels on the third postoperative day as they were associated with a. 2.53 times higher odds for developing SSI (OR: 2.5, 95%CI: 1.27-3.87, p-value < 0.05) when adjusted for other factors.

Conclusion

In conclusion, in this prospective observational study, low levels in the first and third postsurgery were associated with an increased risk for the development of SSIs but not sepsis.

The Patient Perspective on Colectomy for Recurrent Diverticulitis: A Qualitative Study

OBJECTIVE

Understand the patient's decision-making process regarding colectomy for recurrent diverticulitis.

BACKGROUND

The decision to pursue elective colectomy for recurrent diverticulitis is highly preference-sensitive. Little is known about the patient's perspective in this decision-making process.

METHODS

We performed a qualitative study utilizing focus groups of patients with recurrent diverticulitis at 3 centers across the United States. Using an iterative inductive/deductive approach, we developed a conceptual framework to capture the major themes identified in the coded data.

RESULTS

From March 2019 to July 2020, 39 patients were enrolled across 3 sites and participated in 6 focus groups. After coding the transcripts using a hierarchical coding system, a conceptual framework was developed. Major themes identified included participants' beliefs about surgery, such as normative beliefs (eg, subjective, value placed on surgery), control beliefs (eg, self-efficacy, stage of change), and anticipated outcomes (eg, expectations, anticipated regret); the role of behavioral management strategies (eg, fiber, eliminate bad habits); emotional experiences (eg, depression, embarrassment); current symptoms (eg, severity, timing); and quality of life (eg, cognitive load, psychosocial factors). Three sets of moderating factors influencing patient choice were identified: clinical history (eg, source of diagnosis, multiple surgeries), clinical protocols (eg, pre-op and post-op education), and provider-specific factors (eg, specialty, choice of surgeon).

CONCLUSIONS

Patients view the decision to undergo colectomy through 3 major themes: their beliefs about surgery, their psychosocial context, and moderating factors that influence participant choice to undergo surgery. This knowledge is essential both for clinicians counseling patients who are considering colectomy and for researchers studying the process to optimize care for recurrent diverticulitis.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Polygenic Risk Prediction in Diverticulitis

OBJECTIVE

To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making.

BACKGROUND

PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making.

METHODS

We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool.

RESULTS

Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42-2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04-2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (-63.3), outpatient management (-54.9), and patient preference (-39.6). PRS was predicted to have high utility (+71).

CONCLUSIONS

A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making.

Association of Insurance Coverage With Adoption of Sleeve Gastrectomy vs Gastric Bypass for Patients Undergoing Bariatric Surgery

IMPORTANCE

Instrumental variables can control for selection bias in observational research. However, valid instruments are challenging to identify.

OBJECTIVE

To evaluate regional variation in sleeve gastrectomy following insurance coverage implementation as an instrumental variable in comparative effectiveness research.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from 2012 to 2017. Data analysis was performed from January to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The association of the instrumental variable with treatment (ie, undergoing sleeve gastrectomy), as well as mortality, complications, emergency department visits, hospitalization, reinterventions, and surgical revision.

RESULTS

A total of 76 077 patients underwent bariatric surgery, of whom 44 367 underwent sleeve gastrectomy (mean [SD] age, 56.9 [11.9] years; 32 559 [73.5%] women) and 31 710 underwent gastric bypass (mean (SD) age, 55.9 (11.8) years; 23 750 [74.9%] women). After insurance coverage initiation, there was substantial regional and temporal variation in adoption of sleeve gastrectomy. Prior-year state-level utilization of sleeve gastrectomy was highly associated with undergoing sleeve gastrectomy (Kleibergen-Paap Wald F statistic, 910.3). All but 2 patient characteristics (race and diagnosis of depression) were well-balanced between the top and bottom quartiles of the instrumental variable. Regarding 1-year outcomes, compared with patients undergoing gastric bypass, patients undergoing sleeve gastrectomy had a lower 1-year risk of mortality (0.9%; 95% CI, 0.8%-1.1% vs 1.7%; 95% CI, 1.3%-2.0%), complications (11.6%; 95% CI, 10.9%-12.3% vs 14.1%; 95% CI, 13.0%-15.3%), emergency department visits (48.3%; 95% CI, 46.9%-49.8% vs 53.6%; 95% CI, 52.3%-55.0%), hospitalization (23.4%; 95% CI, 22.4%-24.4% vs 26.5%; 95% CI, 25.1%-28.0%), and reinterventions (8.7%; 95% CI, 8.0%-9.4% vs 12.2%; 95% CI, 11.2%-13.3%). The risk of revision was not different between groups (0.6%; 95% CI, 0.3%-0.8% vs 0.4%; 95% CI, 0.3%-0.6%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of patients undergoing bariatric surgery, there was significant geographic variation in the use of sleeve gastrectomy following initiation of insurance coverage, which served as a strong instrument to compare 2 bariatric surgical procedures. This approach could be applied to other areas of health services research to serve as a complement to clinical trials.

Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis

Objective

This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making.

Summary Background Data

The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions.

Methods

We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework.

Results

25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/].

Conclusions

Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.

Nationwide Analysis of Hospital admissions Prior to Hartmann's Procedure for Acute Diverticulitis

INTRODUCTION

Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann's procedure for complicated diverticulitis.

METHODS

The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann's procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates.

RESULTS

There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman's procedure. The mortality rate for patients with prior hospital admissions was 8.7% (P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% (P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40-1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001).

CONCLUSIONS

Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved.

Challenging Surgical Dogma: Controversies in Diverticulitis

Diverticulosis of the sigmoid colon is common in the developed world, affecting approximately 33% of persons older than 60 years. Up to 15% of these patients will develop diverticulitis at some point in their lifetime. The incidence of diverticulitis has increased in the last decade, accounting for nearly 300,000 US hospital admissions and $1.8 billion in annual direct medical costs. With such a wide prevalence and diverse spectrum of clinical presentation, there are bound to be multiple controversies regarding disease management. This article will serve to educate the reader on several important areas to consider when treating this ubiquitous disease.

Non-English Primary Language is Associated with Emergency Surgery for Diverticulitis

BACKGROUND

Language barriers can limit access to care for patients with a non-English primary language (NEPL). The objective of this study was to define the association between primary language and emergency versus elective surgery among diverticulitis patients.

MATERIALS AND METHODS

Retrospective cohort study of adult patients from the 2009-2014 New Jersey State Inpatient Database. Patients were included if they had primary language data and underwent a partial colon resection for diverticulitis. Primary language was dichotomized into NEPL versus English primary language (EPL). The primary outcome was surgical admission type - urgent/emergent (referred to as "emergency") versus elective. Descriptive and multivariable analyses were performed.

RESULTS

A total of 9,453 patients underwent surgery for diverticulitis, of which 592 (6.3%) had NEPL. Among NEPL patients, 300 (51%) had Spanish as primary language and 292 (49%) had another non-Spanish primary language. Patients with NEPL and EPL were similar in age (median age 58 versus 59 years; P = 0.54) and sex (52% versus 53% female; P = 0.45). Patients with NEPL were less likely to have commercial insurance (45% versus 59%; P <0.001). On multivariable analysis, compared to patients with EPL, NEPL was associated with increased odds of emergency surgery for diverticulitis (OR 1.35; 95% Confidence Interval 1.13-1.62; P = 0.001) CONCLUSION: Patients with NEPL have higher odds of emergency versus elective surgery for diverticulitis compared to patients with EPL. Further research is needed to examine differences in referral pathways, patient-provider communication, and health literacy that may hinder access to elective surgery in patients with diverticulitis.

Self-Expandable Metal Stents for Left Sided Colon Obstruction from Diverticulitis. A Single Center Retrospective Series

Background and Objectives: The incidence of diverticulitis is increasing in western countries. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Colonic symptomatic strictures are often treated with segmental colectomy. The aim of our study is to report our experience with Self Expandable Metal Stents (SEMS) placement to relieve sigmoid obstruction secondary to diverticulitis, either as a permanent solution or as a bridge to elective colectomy. Material and Methods: From January 2016 to December 2018, 21 patients underwent SEMS placement for sigmoid obstruction secondary to diverticulitis at our institution. In four patients with poor general conditions, SEMS was considered the definitive form of treatment. In 17 patients, the stent was placed as bridge to elective colectomy. Data were prospectively collected and retrospectively analyzed. Primary outcomes were postoperative mortality and morbidity after SEMS and subsequent elective colectomy. Results: There was no mortality or major morbidity after SEMS placement or subsequent elective colectomy. No stoma was performed. Conclusions: Placement of Colorectal Self Expandable Stent represents a useful tool to relieve obstruction in patients with left-sided colonic diverticulitis. SEMS placement makes it possible to transform an emergency clinical condition into an elective condition, giving time to resolve the inflammation and the infection inevitably associated with complicated diverticulitis.