EP915 - Surgical Trends in Diverticulitis: Did the Pandemic Push Us in the Right Direction?

Purpose/Background: The Hartmann's procedure (HP) has historically been the standard operation for acute complicated diverticulitis in emergent setting. However, in recent years, there has been a shift toward primary anastomosis with diverting loop ileostomy (PADLI) and primary anastomosis (PA) as alternative, safe strategies. The COVID-19 pandemic introduced significant disruptions to surgical care pathways, further prioritizing approaches that minimize hospitalizations and length of stay. However, its impact on surgical procedures for diverticulitis remains unclear. Therefore, we aimed to describe national temporal trends of these three procedures in the management of diverticulitis.

Methods/Interventions: We queried the Healthcare Cost and Utilization Project (HCUP) database for New York and Florida states from 2016 to 2021 to identify patients who underwent the three procedures emergently for complicated diverticulitis using ICD-10 codes. The primary outcome was to evaluate temporal trends in the utilization of each surgical approach. Secondary outcomes were to compare postoperative outcomes across the three procedures.

Results/Outcomes: We identified a total of 21,410 patients who underwent the three procedures during the study period. The median age of patients was 66.0 years (IQR 56.0-76.0), and 45.0% were male. The majority of patients were White (77.8%), with Medicare as the primary payer in 55.1% of cases and private insurance in 29.8%. From 2016 to 2019, the proportion of HP's procedures remained stable until 2019 (55.4%), followed by a sharp decline in 2020 (51.0%, p< 0.001, Figure 1). PADLI procedures increased steadily from 2016 (5.4%) to 2020 (6.6%), with a slight further increase in 2021 (7.4%, p< 0.001). In contrast, PA procedures decreased from 2016 to 2019 (37.8%) but subsequently increased sharply in 2020 and 2021 (42.4% and 43.3%, respectively, p=0.01). Median length of stay was significantly shorter for patients undergoing PA compared with those undergoing HP's or PADLI (8.0 vs 11.0 and 12 days, respectively, p< 0.001). Readmission rates were 4.4% for PA, 11.1% for HP's, and 16.0% for PADLI (p < 0.001). Postoperative infections were also significantly lower for PA compared with PADLI and HP's (6.5% vs. 11.8% vs. 14.2% respectively, p< 0.001).

Conclusion/Discussion: We found a measurable decrease in HP's procedures and corresponding increase in PA in 2020 suggestive of a pandemic effect. We hypothesize that this was driven by an attempt to decrease hospital and healthcare resource utilization. The data suggests that this change was done appropriately as PA patients did not have an increase in readmissions or postoperative infections compared to PADLI and HP patients. This is a promising trend that is supported by the most recent ASCRS guidelines but future research is needed to see if this trend persists.

Figure 1: Procedure Types for Patients with Diverticulitis across the Study Period (2016-2021)
Trends in surgical procedure types for diverticulitis (2016-2021) showing variable changes over time.