Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis

Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis

BACKGROUND

The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes.

METHODS

Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO).

RESULTS

Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; β -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (β -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open.

DISCUSSION

Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study

AIM

This study reports venous thromboembolism (VTE) rates following colectomy for diverticular disease to explore the magnitude of postoperative VTE risk in this population and identify high risk subgroups of interest.

METHOD

English national cohort study of colectomy patients between 2000 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type, absolute incidence rates (IR) per 1000 person-years and adjusted incidence rate ratios (aIRR) were calculated for 30- and 90-day post-colectomy VTE.

RESULTS

Of 24,394 patients who underwent colectomy for diverticular disease, over half (57.39%) were emergency procedures with the highest VTE rate seen in patients ≥70-years-old (IR 142.27 per 1000 person-years, 95%CI 118.32-171.08) at 30 days post colectomy. Emergency resections (IR 135.18 per 1000 person-years, 95%CI 115.72-157.91) had double the risk (aIRR 2.07, 95%CI 1.47-2.90) of developing a VTE at 30 days following colectomy compared to elective resections (IR 51.14 per 1000 person-years, 95%CI 38.30-68.27). Minimally invasive surgery (MIS) was shown to be associated with a 64% reduction in VTE risk (aIRR 0.36 95%CI 0.20-0.65) compared to open colectomies at 30 days post-op. At 90 days following emergency resections, VTE risks remained raised compared to elective colectomies.

CONCLUSION

Following emergency colectomy for diverticular disease, the VTE risk is approximately double compared to elective resections at 30 days while MIS was found to be associated with a reduced risk of VTE. This suggests advancements in postoperative VTE prevention in diverticular disease patients should focus on those undergoing emergency colectomies.

Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula

Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46, $P=0.02$ ) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min, $P<0.01$ ). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%, $P=0.77$ ) but a decrease in conversion rate (8.1% vs. 13.8%, $P<0.01$ ) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min, $P<0.01$ ) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%, $P=0.14$ ) and between laparoscopic and robotic approaches (2.8% vs. 3.8%, $P=0.99$ ). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.

Racial Disparity in the Surgical Management of Diverticular Disease

INTRODUCTION

Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race.

METHODS

Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race.

RESULTS

Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001.

CONCLUSION

There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.