EP348 - Understanding Operative Approach in Emergent Diverticulitis Surgery for Patients with Obesity: Predictors of Diversion Versus Primary Anastomosis

Purpose/Background: The optimal operative strategy for diverticulitis in the emergency setting remains controversial. Options include colectomy with primary anastomosis, with or without diversion, or colectomy with end colostomy. Some recent data suggest improved outcomes with primary anastomosis in selected patients, though surgeon decision-making is influenced by multiple complex patient and disease factors at the time of patient presentation. Data is lacking in the subset of patients with obesity, which is becoming an increasingly more common comorbidity. We aimed to identify clinical predictors associated with the choice of diversion versus primary anastomosis among patients with obesity undergoing emergent colectomy for diverticulitis.

We hypothesized that surgeons choose diversion for patients with higher preoperative ASA class or preoperative sepsis as well as comorbidities like COPD and diabetes mellitus.

Methods/Interventions: A retrospective analysis was performed using the American College of Surgeons National Surgical Quality Improvement Program from 2015-2023. Patients with obesity (BMI>30) who underwent emergent colectomy for diverticulitis were identified using relevant CPT and ICD codes. Patients were categorized into two groups: (1) colectomy with primary anastomosis alone and (2) colectomy with ostomy placement. Demographic and clinical characteristics were compared between groups. Multivariable logistic regression was used to identify independent predictors of diversion, adjusting for age, sex, race, comorbidities, preoperative sepsis, and ASA class.

Results/Outcomes: A total of 8,305 patients met inclusion criteria, of whom 36% underwent primary anastomosis alone and 64% underwent anastomosis with diversion or end ostomy placement. Patients selected for ostomy placement were older (mean age 59 vs 55 years, P< 0.001), had higher proportion ASA class ≥III (75 vs 63%, P< 0.001), and were more frequently septic or hemodynamically unstable preoperatively (55 vs 28%, P< 0.001). On multivariable analysis, age over 65 years (OR 1.36, 95% CI 1.20-1.54, P< 0.001), ASA class IV (OR 1.83, 95% CI 1.06-3.12, p< 0.05), history of COPD (OR 1.32, 95% CI 1.08-1.63, P< 0.01), preoperative sepsis (OR 3.25, 95% CI 2.93-3.61 , P< 0.001), and shock on presentation (OR 2.71, 95% CI 2.09-3.54 , P< 0.001) were independent predictors of diversion or end ostomy.

Conclusion/Discussion: In emergent surgery for diverticulitis in patients with obesity, poor preoperative health status, particularly older age, high ASA class, and systemic sepsis are strongly associated with surgeons' operative selection of diversion rather than primary anastomosis. These findings suggest that in the setting of factors associated with anastomotic complications, surgeons are continuing to favor fecal diversion with or without anastomosis. Future studies should explore whether improved perioperative optimization or standardized risk assessment tools can safely expand the use of primary anastomosis in selected emergent cases.