EP422 - Adoption Rates of Primary Anastomosis After DIVERTI in a Single Community Hospital

Purpose/Background: Management of perforated diverticulitis with generalized peritonitis (Hinchey III or IV) has traditionally favored the Hartmann's procedure, which involves resection of the diseased sigmoid colon, closure of the rectal stump, and creation of an end colostomy. This approach was preferred due to concerns about anastomotic leak in a contaminated field and the need for rapid sepsis control. However, recent evidence supports primary resection with anastomosis, with or without a diverting ileostomy, as a safe alternative associated with improved long-term outcomes, including higher and earlier stoma reversal rates. In 2020, the American Society of Colon and Rectal Surgeons (ASCRS) updated its guidelines to recommend primary resection and anastomosis over the Hartmann procedure in appropriate candidates, largely based on findings from the DIVERTI trial. This study aims to evaluate the adoption of these recommendations within a community hospital of fewer than 500 beds, staffed by both general and colorectal-trained surgeons. To date, no published studies have examined the real-world implementation of the DIVERTI trial findings in community practice following the 2020 ASCRS guideline update.

Methods/Interventions: This retrospective review evaluated the adoption of the DIVERTI trial findings in a community hospital using data from the Michigan Surgical Quality Collaborative. Adult patients (>18 years) who underwent urgent or emergent surgery for Hinchey Stage III or IV diverticulitis were identified from electronic health records. Elective resections and delayed pelvic abscess washouts were excluded. Post–June 2020 cases, following the updated ASCRS guidelines, were analyzed to compare rates of Hartmann’s procedure versus primary anastomosis. Pre-implementation data will be collected to assess changes in surgical practice. IRB approval was obtained from Trinity Health Oakland.

Results/Outcomes: A total of 32 patients underwent emergent surgery for perforated diverticulitis with peritonitis between June 2020 and June 2025. Of these, 25 (78%) received a Hartmann procedure and 7 (22%) underwent sigmoid resection with primary anastomosis, including 3 (9%) with a diverting ileostomy. Selection of the Hartmann’s procedure was significantly associated with higher ASA class (p = 0.028) and Hinchey stage (p = 0.029). There were no significant differences between groups in rates of readmission, sepsis, and surgical site infection. Additional data collection is ongoing to assess changes in operative trends before and after the publication of updated colorectal surgery guidelines.

Conclusion/Discussion: Despite updated guidelines favoring primary anastomosis in select cases of perforated diverticulitis, our community surgeons continued to prefer the Hartmann’s procedure. This may reflect well-established practice patterns and individual comfort levels with anastomosis in contaminated fields. Interestingly, operative notes contained detailed explanations when surgeons opted against performing the Hartmann’s procedure compared with when it was chosen (n = 6, 85.6% primary anastomosis vs. n = 5, 15.6% Hartmann’s procedure). This suggests that Hartmann’s remains the default operative approach for many surgeons. Future efforts could include focus groups to explore surgeon perspectives and factors influencing the adoption of newer guideline recommendations.