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Carletta D, Popeskou SG, Mongelli F, Murgante N, Di Giuseppe M, Proietti F, Hübner M, Christoforidis D. A Decade of Follow-Up to Assess the Risk of Recurrence and Surgery after a First Episode of Uncomplicated Left-Sided Diverticulitis. J Clin Med 2024; 13:5854. [PMID: 39407913 PMCID: PMC11478256 DOI: 10.3390/jcm13195854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 09/18/2024] [Accepted: 09/27/2024] [Indexed: 10/20/2024] Open
Abstract
Background and aims: Acute uncomplicated diverticulitis (UD) of the left colon is common and mostly benign. Due to controversy over the definition of UD and the lack of adequate follow-up in most studies, good quality data to predict long-term outcomes after a first episode of UD are missing. The aim of this study was to assess the long-term risk for adverse outcomes after a first episode of UD. Methods: All consecutive patients with a CT-scan-documented first episode of acute UD (staged "uncomplicated" according to ESCP guidelines and/or modified Hinchey stages 0-1a, and/or CDD 1-2a) between January 2010 and June 2013 were included in the study. CT scans and clinical records were retrospectively reviewed. The primary endpoint was overall recurrence; the secondary endpoint was surgery for diverticular disease. Results: One hundred and five patients were included in the study with a median follow-up of 116.4 (4.9-154.7) months. Of these, 51 (48.5%) patients had a recurrence, 11 (10.4%) had 4 or more episodes. Twenty-one (20%) patients underwent sigmoidectomy, all in an elective setting, mostly due to multiple recurrent episodes. Male gender was the only independent risk factor for surgery (OR (95%CI): 0.301 (0.109-0.834), p = 0.021). Classification systems did not predict recurrence, but stage CDD 1a was protective for surgery (OR (95%CI): 0.201 (0.042-0.957), p = 0.044). Conclusions: After a decade of follow-up, almost half the patients experienced at least one recurrent episode after UD, higher than previously thought. None of those patients required emergency surgery, but one in five patients, mostly men, underwent elective sigmoidectomy for multiple recurrent episodes.
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Affiliation(s)
- Dario Carletta
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Lugano, Via Tesserete 46, 6900 Lugano, Switzerland; (S.G.P.); (D.C.)
| | - Sotirios Georgios Popeskou
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Lugano, Via Tesserete 46, 6900 Lugano, Switzerland; (S.G.P.); (D.C.)
| | - Francesco Mongelli
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Bellinzona e Valli, Via Ospedale 12, 6500 Bellinzona, Switzerland
| | - Nicole Murgante
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Lugano, Via Tesserete 46, 6900 Lugano, Switzerland; (S.G.P.); (D.C.)
| | - Matteo Di Giuseppe
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Locarno, Via dell’Ospedale 1, 6600 Locarno, Switzerland
| | - Francesco Proietti
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Locarno, Via dell’Ospedale 1, 6600 Locarno, Switzerland
| | - Martin Hübner
- Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1005 Lausanne, Switzerland
| | - Dimitrios Christoforidis
- Dipartimento di Chirurgia Viscerale, Ospedale Regionale di Lugano, Via Tesserete 46, 6900 Lugano, Switzerland; (S.G.P.); (D.C.)
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Domas E, Starks K, Kanneganti S. Current Management of Diverticulitis. Surg Clin North Am 2024; 104:529-543. [PMID: 38677818 DOI: 10.1016/j.suc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.
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Affiliation(s)
- Erik Domas
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Kiefer Starks
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Shalini Kanneganti
- Department of Colon and Rectal Surgery, Virginia Mason Franciscan Health, Franciscan Surgical Associates at St. Joseph, 1708 South Yakima Avenue, Suite 105 & 112, Tacoma, WA 98405, USA.
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3
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Stovall SL, Johnson MP, Evans ET, Kaplan JA, Law JK, Moonka R, Bahnson HT, Simianu VV. Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State. Am Surg 2023; 89:5720-5728. [PMID: 37144833 DOI: 10.1177/00031348231174002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions. METHODS A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients. RESULTS During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization). DISCUSSION Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.
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Affiliation(s)
- Stephanie L Stovall
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Meredith P Johnson
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ethan T Evans
- Diabetes Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Jennifer A Kaplan
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Henry T Bahnson
- Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Vlad V Simianu
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
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Stovall SL, Kaplan JA, Law JK, Flum DR, Simianu VV. Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care. World J Gastrointest Surg 2023; 15:1007-1019. [PMID: 37405108 PMCID: PMC10315108 DOI: 10.4240/wjgs.v15.i6.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
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.
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Affiliation(s)
- Stephanie Lee Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - David R Flum
- Department of Surgery, University of Washington Medical, Seattle, WA 98195, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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Weed CN, Bernier GV, Christante DH, Feldmann T, Flum DR, Kaplan JA, Moonka R, Thirlby RC, Simianu VV. Evaluating variation in enhanced recovery for colorectal surgery: a report from the Surgical Care Outcomes Assessment Program. Colorectal Dis 2022; 24:111-119. [PMID: 34610205 DOI: 10.1111/codi.15938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/19/2021] [Accepted: 09/12/2021] [Indexed: 12/18/2022]
Abstract
AIM Robust data demonstrate that enhanced recovery protocols (ERPs) decrease length of stay, complications and cost. However, little is known about the reasons for variation in compliance with ERPs. The aim of this work was to confirm the efficacy of ERPs in a regional network, and to determine factors that are associated with ERP delivery in diverse hospital settings. METHOD A prospective cohort of patients was created by recording all elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP). The delivery of 12 ERP components was tracked at all sites, and factors associated with ERP component delivery and affecting outcomes were reported. RESULTS From 2016 to 2019, 9274 elective colorectal operations were performed at 36 hospitals. Indications were 48% cancer, 23% diverticulitis and 8% inflammatory bowel disease. Minimally invasive surgery was used in 71%. The proportion of cases with six or more ERP components received increased from 23% in 2016 to 50% in 2019. An increase in components was associated with a shorter length of stay and fewer combined adverse events and reinterventions. Further, increasing numbers of ERP components provided an incremental benefit to patients even when delivered in a low-volume centre or by a low-volume surgeon, and regardless of patient presentation. CONCLUSION At SCOAP hospitals, the delivery of increasing numbers of ERP components was associated with improved perioperative outcomes and decreased complications after elective colorectal surgery. The variation in delivery of these evidence-based components in subsets of our cohort indicates an important opportunity for quality improvement initiatives.
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Affiliation(s)
- Christina N Weed
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Greta V Bernier
- Colon and Rectal Surgery Clinic, University of Washington Medicine - Valley Medical Center, Renton, Washington, USA
| | | | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA.,Surgical Care Outcomes Assessment Program, Seattle, Washington, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA.,Surgical Care Outcomes Assessment Program, Seattle, Washington, USA
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Baskin AS, Wang T, Miller J, Jagsi R, Kerr EA, Dossett LA. A Health Systems Ethical Framework for De-implementation in Health Care. J Surg Res 2021; 267:151-158. [PMID: 34153558 PMCID: PMC8678146 DOI: 10.1016/j.jss.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. METHODS To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. RESULTS AND DISCUSSION From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining "value," the proposed framework may increase the legitimacy and objectivity of de-implementation. CONCLUSIONS While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.
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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Reshma Jagsi
- Department of Radiation Oncology,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Eve A Kerr
- Department of Internal Medicine , Center for Clinical Management Research, Ann Arbor, MI
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
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7
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Comparison of two different techniques in emergency surgery of colon diverticulitis: Hartmann's procedure and resection with primary anastomosis. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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8
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Berlin NL, Skolarus TA, Kerr EA, Dossett LA. Too Much Surgery: Overcoming Barriers to Deimplementation of Low-value Surgery. Ann Surg 2020; 271:1020-1022. [PMID: 32209904 DOI: 10.1097/sla.0000000000003792] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.,National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.,VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Eve A Kerr
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.,Michigan Program for Value Enhancement, Ann Arbor, MI.,Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Lesly A Dossett
- Michigan Program for Value Enhancement, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728-747. [PMID: 32384404 DOI: 10.1097/dcr.0000000000001679] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Sohn M, Agha A, Iesalnieks I, Bremer S, Trum S, Di Cerbo F, Nerlich A, Lotz N, Klieser E, Hochrein A, Schredl P, Kalcheva D, Emmanuel K, Presl J. PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease: the PREDIC-DIV study protocol of a prospective multicentric transnational observational study. BMJ Open 2020; 10:e034385. [PMID: 32209628 PMCID: PMC7202696 DOI: 10.1136/bmjopen-2019-034385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Diverticulitis is among the most common abdominal disorders. The best treatment strategy for this complicated disease as well as for recurrent stages is still under debate. Moreover, little knowledge exists regarding the effect of different therapeutic strategies on the health-related quality of life (HrQoL). Therefore, the PREDIC-DIV (PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease) study aims to assess predictors of a change in HrQoL in patients after elective sigmoidectomy for diverticular disease. METHODS AND ANALYSIS A prospective multicentre transnational observational study was started in November 2017. Patients undergoing elective sigmoid resection for diverticular disease were included. Primary outcome includes HrQoL 6 months postoperatively, staged by the Gastrointestinal Quality of Life Index (GIQLI). Secondary outcomes include HrQoL 6 months after sigmoidectomy, assessed using the Short Form 36 Questionnaire and a custom-made Visual Analogue Scale-based inventory; HrQoL after 12 and 24 months; postoperative morbidity; mortality; influence of surgical technique (conventional laparoscopic multiport operation vs robotic approach); histological grading of inflammation and morphological characteristics of the bowel wall in the resected specimen; postoperative functional changes (faecal incontinence, faecal urge, completeness of emptying, urinary incontinence, sexual function); disease-specific healthcare costs; and changes in economic productivity, measured by the iMTA Productivity Cost Questionnaire. The total follow-up will be 2 years. ETHICS AND DISSEMINATION The protocol was approved by the medical ethical committee of the Bavarian Medical Council (report identification number: 2017-177). The study was conducted in accordance with the Declaration of Helsinki. The findings of this study will be submitted to a peer-reviewed journal (BMJ Open, Annals of Surgery, British Journal of Surgery, Diseases of the Colon and the Rectum). Abstracts will be submitted to relevant national and international conferences. TRIAL REGISTRATION NUMBER The study is registered with the ClinicalTrials.gov register as NCT03527706; Pre-results.
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Affiliation(s)
| | - Ayman Agha
- München Klinik Bogenhausen, Munich, Bayern, Germany
| | | | | | | | | | | | - Natalie Lotz
- München Klinik Bogenhausen, Munich, Bayern, Germany
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Hong MKY, Skandarajah AR, Joy MP, Hayes IP. Elective colectomy after acute diverticulitis: an international comparison. Colorectal Dis 2019; 21:1067-1072. [PMID: 30980588 DOI: 10.1111/codi.14648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/02/2019] [Indexed: 01/15/2023]
Abstract
AIM Routine elective colectomy after acute diverticulitis is not recommended, yet significant numbers are still being performed. Amidst global concern over the rising costs of surgery and the value of healthcare, acute diverticulitis is a disease that is amenable to optimization of strategies for operative intervention. We aim to compare rates of elective colectomy after acute diverticulitis in the USA, England and Australia. METHOD Index unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2012 for hospitals in the USA, England and Australia. Recurrent unplanned admissions for acute diverticulitis and any subsequent elective admissions for colectomy were found between 2008 and 2014 to allow a minimum 2-year follow-up period. The primary outcome measured was elective colectomy rate. Secondary outcomes included rates of emergency operative intervention and recurrence. Multivariable analysis was performed to control for patient and disease factors. RESULTS There were 7842 index unplanned admissions for acute diverticulitis over 4 years in selected hospitals from the USA, England and Australia. The elective colectomy rates were 13%, 5.4% and 3.4% for the USA, England and Australia, respectively. The propensity for elective colectomy was higher in the USA (OR 4.2, P < 0.001) and England (OR 1.8, P < 0.001) than in Australia. The recurrence rate in all patients with acute diverticulitis was 10% across the countries. CONCLUSION There is a higher propensity for elective colectomy after acute diverticulitis in the USA than in England and Australia. This highlights the possibilities for a less aggressive surgical approach to reduce resource utilization, but prospective analysis of information on quality of life is required to support this.
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Affiliation(s)
- M K-Y Hong
- Department of Surgery (Western Health), The University of Melbourne, Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of Surgery (Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - M P Joy
- School of Health Sciences, University of Surrey, Surrey, UK
| | - I P Hayes
- Department of Surgery (Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia
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Simianu VV, Kumar AS. Surgical Care and Outcomes Assessment Program (SCOAP): A Nuanced, Flexible Platform for Colorectal Surgical Research. Clin Colon Rectal Surg 2019; 32:25-32. [PMID: 30647543 DOI: 10.1055/s-0038-1673351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The Surgical Care and Outcomes Assessment Program (SCOAP) is a surgeon-led quality improvement (QI) initiative developed in Washington State to track and reduce variability in surgical care. It has developed into a collaboration of over two-thirds of the hospitals in the state, who share data and receive regular benchmarking reports. Data are abstracted at each site by trained abstractors. While there has some overlap with other national QI databases, the data captured by SCOAP has clinical nuances that make it pragmatic for studying surgical care. We review the unique properties of SCOAP and offer some examples of its novel applications.
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Affiliation(s)
- Vlad V Simianu
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
| | - Anjali S Kumar
- Elson S. Floyd College of Medicine, Washington State University, Everett, Spokane, Tri-Cities, and Vancouver, Washington
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Hoang SC, Klipfel AA, Roth LA, Vrees M, Schechter S, Shah N. Colon and rectal surgery surgical site infection reduction bundle: To improve is to change. Am J Surg 2018; 217:40-45. [PMID: 30025846 DOI: 10.1016/j.amjsurg.2018.07.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/16/2018] [Accepted: 07/06/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.
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Affiliation(s)
- Sook C Hoang
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
| | - Adam A Klipfel
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Leslie A Roth
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Mathew Vrees
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Steven Schechter
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Nishit Shah
- Division of Colon and Rectal Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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15
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Lin M, Raman SR. Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease. Clin Colon Rectal Surg 2018; 31:251-257. [PMID: 29942216 DOI: 10.1055/s-0037-1607969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.
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Affiliation(s)
- Mayin Lin
- Mercy Surgical Affiliates, Des Moines, Iowa
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Predicting Future Elective Colon Resection for Diverticulitis Using Patterns of Health Care Utilization. EGEMS 2018; 6:1. [PMID: 29881759 PMCID: PMC5983027 DOI: 10.5334/egems.193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Recurrent diverticulitis is the most common reason for elective colon surgery and, although professional societies now recommend against early resection, its use continues to rise. Shared decision making decreases use of low-value surgery but identifying which patients are most likely to elect surgery has proven difficult. We hypothesized that Machine Learning algorithms using health care utilization (HCU) data can predict future clinical events including early resection for diverticulitis. Study Design We developed models for predicting future surgery among patients with new diagnoses of diverticulitis (2009-2012) from the MarketScan® database. Claims data (diagnosis, procedural, and drug codes) were used to train three Machine Learning algorithms to predict surgery occurring between 52 and 104 weeks following diagnosis. Results Of 82,231 patients with incident diverticulitis (age 51 ± 8 years, 52% female), 1.2% went on to elective colon resection. Using maximal training data (152 consecutive weeks of claims), the Gradient Boosting Machine model predicted elective surgery with an area under the curve (AUC) of 75% (95% uncertainty interval [UI] 71-79%). Models trained on less data resulted in less accurate prediction (AUC: 68% [64-74%] using 128 weeks, 57% [53-63%] using 104 weeks). The majority of resections (85%) were identified as low-value. Conclusion By applying Machine Learning to HCU data from the time around a diagnosis of diverticulitis, we predicted elective surgery weeks to months in advance, with moderate accuracy. Identifying patients who are most likely to elect surgery for diverticulitis provides an opportunity for effective shared decision making initiatives aimed at reducing the use of costly low-value care.
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Phillips DR, Ellsperman SE, Matt BH, Zarzaur BL. Comparison of Automated Posttonsillectomy Bleed Capture With Self-report. JAMA Otolaryngol Head Neck Surg 2017; 143:764-768. [PMID: 28494056 DOI: 10.1001/jamaoto.2017.0148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Tonsillectomy is one of the most common procedures performed by otolaryngologists and is associated with postoperative bleeding. Bleed rates are usually monitored by self-report. Objective To evaluate whether using automated capture and reporting of pediatric posttonsillectomy bleeding is feasible and accurate compared with traditional self-reporting by the surgical team. Design, Setting, and Participants An automated complication-reporting algorithm was designed to query the local health information exchange and then tested against self-reported tonsillectomy complication data collected from January 1, 2014, through December 31, 2015, at a tertiary pediatric hospital. The algorithm identified patients undergoing tonsillectomy and searched their postoperative encounters for a hand-selected set of diagnosis codes from the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision and free-text words to identify complication events. Five months of the 2014-2015 data set were used to help design the algorithm. Data from the remaining 19 months were compared with self-reported complications. Main Outcomes and Measures Automated system findings compared with self-reported bleeding events. Results During the 19-month period, 1017 tonsillectomies were performed. We compared the algorithm's effectiveness in finding tonsillectomy and adenotonsillectomy procedures for the evaluated surgeons with the hand-reviewed master tonsillectomy list. The algorithm reported 51 false-positive (5.01% missed) and 74 false-negative (7.28% misidentified) procedures. The algorithm agreed with self-report for 986 tonsillectomies and disagreed on 31 cases (3.05%) (κ = 0.69; 95% CI, 0.66-0.73). The algorithm was found to be sensitive to correctly identifying 60.53% (95% CI, 48.63%-71.34%) of tonsillectomies as having bleeding complications, with a specificity of 98.30% (95% CI, 97.19%-98.99%). Conclusions and Relevance Capture of posttonsillectomy bleeding is possible through an automatic search of the medical record, although the algorithm will require continued refinement. Leveraging health information exchange data increases the possibilities of capturing complications at hospitals outside the local health system. Use of these algorithms will allow repeatable automated feedback to be provided to surgeons on a cyclical basis.
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Affiliation(s)
- D Ryan Phillips
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis
| | - Susan E Ellsperman
- currently a medical student at Indiana University School of Medicine, Indianapolis
| | - Bruce H Matt
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis
| | - Ben L Zarzaur
- Department of Surgery and Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis
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von Strauss Und Torney M, Thommen S, Dell-Kuster S, Hoffmann H, Rosenthal R, Young J, Kettelhack C. Surgical treatment of uncomplicated diverticulitis in Switzerland: comparison of population-based data over two time periods. Colorectal Dis 2017; 19:840-850. [PMID: 28371339 DOI: 10.1111/codi.13670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/06/2016] [Indexed: 12/13/2022]
Abstract
AIM The standard of care for acute uncomplicated diverticulitis used to be an elective colon resection after the second or third episode. This practice was replaced by a more conservative and individualized approach. This study investigates current surgical practice in the treatment of acute uncomplicated diverticulitis in Switzerland. METHOD Retrospective cross-sectional analysis of all hospital admissions due to uncomplicated diverticulitis in Switzerland using prospectively collected data from the Swiss Federal Statistical Office in two periods: 2004/2005 and 2010/2011. Treatment options were compared between the two periods with adjustment for baseline characteristics of patients and treating institutions. RESULTS A total of 24 497 patients (11 835 in 2004/2005; 12 662 in 2010/2011) were admitted to Swiss hospitals for uncomplicated diverticulitis. Between periods, the incidence increased from 81 to 85 admissions per 105 inhabitants per year. Elective admissions decreased from 46% (n = 5490) to 34% (n = 4294). The unadjusted resection rate decreased from 40% (n = 4730) to 34% (n = 4308). In the adjusted analysis, inpatients were more likely to have a resection in 2010/2011 than in 2004/2005 [odds ratio of 1.38 (95% confidence interval 1.25-1.54)]. In addition, private insurance, elective mode of admission and younger age increased the odds for resection while there was no evidence of an association between resection and either gender or comorbidities. CONCLUSION The probability of colon resection for patients hospitalized with acute uncomplicated diverticulitis increased between periods while the overall number of colon resections declined. A change of practice expected given the paradigm shift towards conservative treatment could not be confirmed in this analysis.
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Affiliation(s)
- M von Strauss Und Torney
- Department of Surgery, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Surgery, University Hospital Basel, Basel, Switzerland.,Colorectal Unit, Western General Hospital Edinburgh, Edinburgh, UK
| | - S Thommen
- Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - S Dell-Kuster
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - H Hoffmann
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - R Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - J Young
- Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - C Kettelhack
- Department of Surgery, University Hospital Basel, Basel, Switzerland
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Simianu VV, Fichera A, Bastawrous AL, Davidson GH, Florence MG, Thirlby RC, Flum DR. Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions. JAMA Surg 2017; 151:604-10. [PMID: 26864286 DOI: 10.1001/jamasurg.2015.5478] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Despite professional recommendations to delay elective colon resection for patients with uncomplicated diverticulitis, early surgery (after <3 preceding episodes) appears to be common. Several factors have been suggested to contribute to early surgery, including increasing numbers of younger patients, a lower threshold to operate laparoscopically, and growing recognition of "smoldering" (or nonrecovering) diverticulitis episodes. However, the relevance of these factors in early surgery has not been well tested, and most prior studies have focused on hospitalizations, missing outpatient events and making it difficult to assess guideline adherence in earlier interventions. OBJECTIVE To describe patterns of episodes of diverticulitis before surgery and factors associated with earlier interventions using inpatient, outpatient, and antibiotic prescription claims. DESIGN, SETTING, AND PARTICIPANTS This investigation was a nationwide retrospective cohort study from January 1, 2009, to December 31, 2012. The dates of the analysis were July 2014 to May 2015. Participants were immunocompetent adult patients (age range, 18-64 years) with incident, uncomplicated diverticulitis. EXPOSURE Elective colectomy for diverticulitis. MAIN OUTCOMES AND MEASURES Inpatient, outpatient, and antibiotic prescription claims for diverticulitis captured in the MarketScan (Truven Health Analytics) databases. RESULTS Of 87 461 immunocompetent patients having at least 1 claim for diverticulitis, 6.4% (n = 5604) underwent a resection. The final study cohort comprised 3054 nonimmunocompromised patients who underwent elective resection for uncomplicated diverticulitis, of whom 55.6% (n = 1699) were male. Before elective surgery, they had a mean (SD) of 1.0 (0.9) inpatient claims, 1.5 (1.5) outpatient claims, and 0.5 (1.2) antibiotic prescription claims related to diverticulitis. Resection occurred after fewer than 3 episodes in 94.9% (2897 of 3054) of patients if counting inpatient claims only, in 80.5% (2459 of 3054) if counting inpatient and outpatient claims only, and in 56.3% (1720 of 3054) if counting all types of claims. Based on all types of claims, patients having surgery after fewer than 3 episodes were of similar mean age compared with patients having delayed surgery (both 47.7 years, P = .91), were less likely to undergo laparoscopy (65.1% [1120 of 1720] vs 70.8% [944 of 1334], P = .001), and had more time between the last 2 episodes preceding surgery (157 vs 96 days, P < .001). Patients with health maintenance organization or capitated insurance plans had lower rates of early surgery (50.1% [247 of 493] vs 57.4% [1429 of 2490], P = .01) than those with other insurance plan types. CONCLUSIONS AND RELEVANCE After considering all types of diverticulitis claims, 56.3% (1720 of 3054) of elective resections for uncomplicated diverticulitis occurred after fewer than 3 episodes. Earlier surgery was not explained by younger age, laparoscopy, time between the last 2 episodes preceding surgery, or financial risk-bearing for patients. In delivering value-added surgical care, factors driving early, elective resection for diverticulitis need to be determined.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle
| | | | | | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle3Surgical Outcomes Research Center, University of Washington, Seattle
| | | | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle3Surgical Outcomes Research Center, University of Washington, Seattle
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When is elective resection after acute diverticulitis reasonable? Lancet Gastroenterol Hepatol 2017; 2:2-3. [DOI: 10.1016/s2468-1253(16)30112-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
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Albrecht R, Weirich T, Reichelt O, Settmacher U, Bochmann C. [Colovesical fistulas : An interdisciplinary challenge]. Chirurg 2016; 88:687-693. [PMID: 27995299 DOI: 10.1007/s00104-016-0347-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of treatment of patients with colovesical fistulas should be prompt elimination of the infection and the social burden. We focused on the question whether a minimally invasive surgical approach as a cooperation between surgeons and urologists is possible. This requires effective diagnostics prior to the operation. METHODS Since 2007 a total of 32 patients with the clinical suspicion of colovesical fistula have undergone extensive preoperative diagnostics. Operative treatment aimed primarily for a minimally invasive approach. In particular, the validity of preoperative diagnostics was analyzed and surgical results were characterized by clinical success, complications and long-term effects. RESULTS The medical history significant for colovesical fistula and detected urinary infection provided the best evidence for the specific diagnosis. Cystoscopy, computed tomography (CT) scan and colonoscopy were only partially effective for predicting a fistula as subsequently diagnosed by histopathological investigations. Fistulas due to diverticulitis of the sigmoid colon occurred in 28 cases, while in 3 subjects there was a gynecological and inflammatory cause (malignant tumor growth, n = 1). A laparoscopic approach achieving repair and healing of the fistula was possible in 29 cases including conversion in 3 subjects because of intraoperative complications. The remaining patients underwent conventional treatment. The disease-related complication rate as revealed during follow-up was 10%. DISCUSSION Laparoscopic repair and healing of a colovesical fistula is possible in the majority of cases by the recommended preoperative ureteral stenting. As part of diagnostic measures, the medical history significant for a fistula and detection of urinary infections are the most reliable aspects. In the case of this combination together with a further diagnostic measure, a laparoscopic approach is always recommended. The recurrency rate is 0%.
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Affiliation(s)
- R Albrecht
- Klinik für Allgemein-, Viszeral- und Minimal-invasive Chirurgie, HELIOS Klinikum Aue, Gartenstraße 6, 08280, Aue, Deutschland.
| | - T Weirich
- Klinik für Urologie und Kinderurologie, HELIOS Klinikum Aue, Aue, Deutschland
| | - O Reichelt
- Klinik für Urologie und Kinderurologie, HELIOS Klinikum Aue, Aue, Deutschland
| | - U Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - C Bochmann
- Klinik für Allgemein-, Viszeral- und Minimal-invasive Chirurgie, HELIOS Klinikum Aue, Gartenstraße 6, 08280, Aue, Deutschland
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Haas JM, Singh M, Vakil N. Mortality and complications following surgery for diverticulitis: Systematic review and meta-analysis. United European Gastroenterol J 2016; 4:706-713. [PMID: 27733913 PMCID: PMC5042306 DOI: 10.1177/2050640615617357] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 10/21/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The surgical treatment of diverticulitis is in a state of evolution. Clinicians across many disciplines need to counsel patients regarding surgical choices. OBJECTIVES A systematic review and meta-analysis was conducted to determine the mortality and complication rates following surgery for diverticulitis in both the emergent and elective setting. METHODS We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published from 1980 to 2012. The primary outcome of interest was the point estimate of mortality, following surgery for diverticulitis. RESULTS Of the 289 citations reviewed, we included 59 studies. Overall, the point estimate for mortality was 3.05%, with a 95% confidence intereval (CI) of 1.73-5.32 and p < 0.001. Mortality following emergent surgery was 10.64% (95% CI 7.95-14.11; p < 0.001), versus 0.50% (95% CI 0.46-0.54; p < 0.001) following elective operations. A laparoscopic approach had an estimated mortality of 0.75% (95% CI 0.35-1.58; p < 0.001), compared to an open surgical approach, which had a mortality of 4.69% (95% CI 2.29-9.36, p < 0.001). The mortality following a resection with primary anastomosis was 1.96% (95% CI 1.22-3.13; p < 0.001) and for the Hartmann's procedure was 14.18% (95% CI 9.83-20.03; p < 0.001). A comparative analysis found that the risk of post-operative mortality was significantly higher following emergent surgery, compared to elective surgery (odds ratio (OR): 6.12 with 95% CI 1.62-23.10; p = 0.008; Q = 2.56, p = 0.46 and I2 = 0); the open approach, compared to a laparoscopic approach (OR: 36.43 with 95% CI 9.94-133.6; p = 0.13; and Q = 2.79, p = 0.25 and I2 = 28.26); and for Hartmann's procedure, compared to primary anastomosis without diversion (OR: 25.45 with 95% CI 15.13-42.81, p < 0.001; and Q = 23.34, p = 0.14 and I2 = 27.16). The overall reported post-operative complication rate was 32.64% (95% CI 27.43-38.32; p < 0.00). The overall surgical and medical complication rates were 18.96% and 13.93%, respectively. CONCLUSIONS Urgent surgical treatment of diverticulitis has a significant complication rate. Even elective surgery has a significant complication rate that needs to be considered when doing the clinical decision-making for recurrent diverticulitis.
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Affiliation(s)
- Jason M Haas
- Department of Gastroenterology, Aurora Health Care, Milwaukee, WI, USA
| | - Maharaj Singh
- Aurora Research Institute, Aurora Sinai Medical Center, Milwaukee, WI, USA
| | - Nimish Vakil
- Division of Gastroenterology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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Schlussel A, Steele SR. Statewide quality improvement initiatives in colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE To determine the impact of elective colectomy on emergency diverticulitis surgery at the population level. BACKGROUND Current recommendations suggest avoiding elective colon resection for uncomplicated diverticulitis because of uncertain effectiveness at reducing recurrence and emergency surgery. The influence of these recommendations on use of elective colectomy or rates of emergency surgery remains undetermined. METHODS A retrospective cohort study using a statewide hospital discharge database identified all patients admitted for diverticulitis in Washington State (1987-2012). Sex- and age-adjusted rates (standardized to the 2000 state census) of admissions, elective and emergency/urgent surgical and percutaneous interventions for diverticulitis were calculated and temporal changes assessed. RESULTS A total of 84,313 patients (mean age 63.3 years and 58.9% female) were hospitalized for diverticulitis (72.2% emergent/urgent). Elective colectomy increased from 7.9 to 17.2 per 100,000 people (P < 0.001), rising fastest since 2000. Emergency/urgent colectomy increased from 7.1 to 10.2 per 100,000 (P < 0.001), nonelective percutaneous interventions increased from 0.1 to 3.7 per 100,000 (P = 0.04) and the frequency of emergency/urgent admissions (with or without a resection) increased from 34.0 to 85.0 per 100,000 (P < 0.001). In 2012, 47.5% of elective resections were performed laparoscopically compared to 17.5% in 2008 (when the code was introduced). CONCLUSIONS The elective colectomy rate for diverticulitis more than doubled, without a decrease in emergency surgery, percutaneous interventions, or admissions for diverticulitis. This may reflect changes in thresholds for elective surgery and/or an increase in the frequency or severity of the disease. These trends do not support the practice of elective colectomy to prevent emergency surgery.
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-626. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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The impact of delaying elective resection of diverticulitis on laparoscopic conversion rate. Am J Surg 2015; 209:913-8; discussion 918-9. [PMID: 25773308 DOI: 10.1016/j.amjsurg.2014.12.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/23/2014] [Accepted: 12/30/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Guideline-concordant delay in elective laparoscopic colectomy for diverticulitis may result in repeated bouts of inflammation. We aimed to determine whether conversion rates from elective laparoscopic colectomy are higher after multiple episodes of diverticulitis. METHODS Prospective cohort study evaluating laparoscopic colectomy conversion rates for diverticulitis from 42 hospitals was conducted. RESULTS Between 2010 and 2013, 1,790 laparoscopic colectomies for diverticulitis (mean age 57.8 ± 13; 47% male) resulted in 295 (16.5%) conversions. Conversion occurred more frequently in nonelective operations (P < .001) and with fistula indications (P = .012). Conversion rates decreased with surgeon case volume (P = .028). Elective colectomy exclusively for episode-based indications (n = 784) had a conversion rate of 12.9%. Increasing episodes of diverticulitis were not associated with higher conversion rates, even among surgeons with similar experience levels. CONCLUSIONS Conversion from laparoscopic colectomy for diverticulitis did not increase after multiple episodes of diverticulitis. Delaying elective resection appears to not prevent patients from the benefits of laparoscopy.
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Simianu VV, Flum DR. Rethinking elective colectomy for diverticulitis: A strategic approach to population health. World J Gastroenterol 2014; 20:16609-16614. [PMID: 25469029 PMCID: PMC4248204 DOI: 10.3748/wjg.v20.i44.16609] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/15/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient “episode counting” a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to “individualize” decisions for elective colectomy and there is an international focus on “appropriate” indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.
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