Recent Trends in Diverticulitis Management in the United States
Diverticulitis is increasingly managed with laparoscopic techniques for elective operations and primary anastomosis for urgent operations, according to a new study published in the April issue of the Archives of Surgery.
Diverticulitis is swelling (inflammation) of an abnormal pouch (diverticulum) in the intestinal wall. These pouches are usually found in the large intestine (colon). The presence of the pouches themselves is called diverticulosis. Diverticulosis is found in more than half of Americans over age 60. Only a small percentage of these people will develop the complication of diverticulitis.
Michael J. Stamos, MD, University of California, Irvine, Division of Colon and Rectal Surgery,and colleagues sought to demonstrate the recent trends of admission and surgical management for diverticulitis in the United States using a retrospective analysis of the Nationwide Inpatient Sample (NIS) database from 2002 until 2007.
To identify hospitalizations resulting from diverticulitis, all discharges with International Classification of Diseases, (ICD) diagnosis codes 562.11 and 562.13 (diverticulitis with and without mention of hemorrhage) as the first diagnosis from 2002 to 2007 were selected. These patients were then divided into emergent and elective groups based on their admission type.
Type of surgical procedure was identified using ICD-9 procedure codes: resection (sigmoidectomy or anterior resection) with primary anastomosis (with or without diverting ileostomy) and resection with colostomy only. Because there was no distinct ICD-9 procedure code for laparoscopic colectomy during these years, the researchers identified procedures that were done laparoscopically by identifying additional ICD-9 procedure codes for diagnostic laparoscopy or laparoscopic lysis of adhesion in combination with open procedure codes.
Patient characteristics of interest included age, sex, and race/ethnicity. Based on the incidence of diverticulitis, age was divided into 3 groups (70 years). Other data of interest included LOS and in-hospital mortality.
The researchers identified a total of 1,073,397 patients admitted with diverticulitis (emergent: 78.3%, elective: 21.7%) during 2002 to 2007.
The emergent admission rate increased by 9.5% over the study period. Of these emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%.
Stamos and colleagues write, “The frequency of elective surgical resection for diverticulitis has dramatically increased by 38%, which is nearly 9 times greater than the relative increase in urgent surgical resection. This may reflect the influence of the American Society of Colon and Rectal Surgeons guidelines from 2000.”
The guidelines recommend elective colectomy after the first attack in patients younger than 50 years and after the second episode in patients older than 50 years.
The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P
Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P
In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P = .001; urgent: 4.5% in 2002 to 2.5% in 2007; P
Diverticulitis continues to be a source of significant morbidity in the United States. Common signs and symptoms of diverticulitis include lower abdominal pain, change in bowel habits (constipation, diarrhea), fever, and nausea and vomiting.
Stamos and colleagues write, “Use of laparoscopy in diverticulitis continues to increase because surgeons are becoming more familiar with this technique and previous data have proven its feasibility and safety. All of these changes have culminated in decreased observed mortality in patients presenting with diverticular disease. Such findings will hopefully help physicians gain a better understanding of the disease process and guide them in its prevention and treatment.”
Trends in Diverticulitis Management in the United States From 2002 to 2007; Hossein Masoomi; Brian S. Buchberg; Cheryl Magno; Steven D. Mills; Michael J. Stamos; Arch Surg. 2011;146(4):400-406.