Laparoscopic Versus Open Hartmann Procedure for the Emergency Treatment of Diverticulitis: A Propensity-Matched Analysis
1 Department of General Surgery, Duke University Medical Center, Durham, North Carolina 2 Division of Colorectal Surgery, Duke University Medical Center, Durham, North Carolina.Diseases of the Colon & Rectum (Impact Factor: 3.75). 01/2013; 56(1):72-82. DOI: 10.1097/DCR.0b013e3182749cf5
BACKGROUND:: A laparoscopic approach has been proposed to reduce the high morbidity and mortality associated with the Hartmann procedure for the emergency treatment of diverticulitis. OBJECTIVE:: The objective of our study was to determine whether a laparoscopic Hartmann procedure reduces early morbidity or mortality for patients undergoing an emergency operation for diverticulitis. DESIGN:: This is a comparative effectiveness study. A subset of the entire American College of Surgeons National Surgical Quality Improvement Program patient sample matched on propensity for undergoing their procedure with the laparoscopic approach were used to compare postoperative outcomes between laparoscopic and open groups. SETTING:: This study uses data from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2009. PATIENTS:: All patients who underwent an emergency laparoscopic or open partial colectomy with end colostomy for colonic diverticulitis were reviewed. MAIN OUTCOME MEASURES:: The main outcome measures were 30-day mortality and morbidity. RESULTS:: Included in the analysis were 1186 patients undergoing emergency partial colectomy with end colostomy for diverticulitis. Among the entire cohort, the laparoscopic group had fewer overall complications (26% vs 41.7%, p = 0.008) and shorter mean length of hospitalization (8.9 vs 11.6 days, p = 0.0008). Operative times were not significantly different between groups. When controlling for potential confounders, a laparoscopic approach was not associated with a decrease in morbidity or mortality. In comparison with a propensity-match cohort, the laparoscopic approach did not reduce postoperative morbidity or mortality. LIMITATIONS:: This study is limited by its retrospective nature and the absence of pertinent variables such as postoperative pain indices, time for return of bowel function, and rates of readmission. CONCLUSIONS:: A laparoscopic approach to the Hartmann procedure for the emergency treatment of complicated diverticulitis does not significantly decrease postoperative morbidity or mortality in comparison with the open technique.
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ABSTRACT: The optimal management of fulminant or complicated diverticulitis is the subject of debate in recent literature. The most common management strategy remains resection and end colostomy or Hartmann’s procedure, first introduced in the 1940s, despite the introduction of more current approaches supported by decreased morbidity and mortality by various studies. The purpose of this paper is to provide a review of the strategies described for the management of fulminant diverticulitis and the most recent evidence available to support these approaches. We discuss the advantages and disadvantages of the Hartmann’s procedure approach, as well as the most current management strategies, and offer both citation and review of relevant recent studies.
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ABSTRACT: Elective laparoscopic colectomy (LC) has been shown to provide short term results comparable with open colectomy (OC), but there is potential selection bias whereby LC patients may be healthier and more likely, therefore to have a superior outcome. The aim of this study was to compare the incidence of postoperative complications between matched laparoscopic and open colectomy cohorts, while controlling for differences in comorbidity.. A retrospective cohort study (2005-2010) using NSQIP data was performed, identifying laparoscopic and open partial colectomy patients through CPT codes. Patient having rectal resection were excluded. The cohorts were matched 1:1 on a propensity score to control for observable selection bias due to patient characteristics, comparing overall complication rates, length of hospital stay (LOS), the incidence of superficial (S-SSI) surgical-site infection, urinary tract infection (UTI) and deep venous thrombosis (DVT). 37,249 patients were analyzed. After propensity score matching the LC group had a significantly lower overall incidence of postoperative complications (29.1% vs. 21.2%; p<0.0001), S-SSI (9.0% vs. 5.9%; p=0.003) and DVT (1.2% vs. 0.3%; p=0.001). The LC group had a shorter LOS (8.7d vs. 6.4d; p<0.0001), while mortality was comparable between the two groups (4.0% vs. 4.1%; p=0.578). LC is associated with a lower incidence of S-SSI and DVT compared with OC. Previously suggested advantages for laparoscopy, such as shorter length of stay and overall rate of complications, were observed even after controlling for differences in comorbidity. This article is protected by copyright. All rights reserved.
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ABSTRACT: Laparoscopic surgery (LS) has become standard practice for a range of elective general surgical operations. Its role in emergency general surgery is gaining momentum. This study aimed to assess the outcomes of LS compared with open surgery (OS) for colorectal resections in the emergency setting. A systematic review was performed of studies reporting outcomes of laparoscopic colorectal resections in the acute or emergency setting in patients aged over 18 years, between January 1966 and January 2013. Twenty-two studies were included, providing outcomes for 5557 patients: 932 laparoscopic and 4625 open emergency resections. Median (range) operating time was 184 (63-444) min for LS versus 148 (61-231) min for OS. Median (range) length of stay was 10 (3-23) and 15 (6-33) days in the LS and OS groups respectively. The overall median (range) complication rate was 27·8 (0-33·3) and 48·3 (9-72) per cent respectively. There were insufficient data to detect differences in reoperation and readmission rates. Emergency laparoscopic colorectal resection, where technically feasible, has better short-term outcomes than open resection.
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