EP705 - Failure to Adopt the New ASCRS Guidelines for Surgery in Young Patients with Diverticulitis

Purpose/Background: Diverticulitis in young patients has traditionally been considered more aggressive compared to older adults, and early elective colectomy was often recommended after the first attack in young patients. However, emerging evidence has challenged this paradigm, suggesting a less aggressive clinical course. In response, the American Society of Colon and Rectal Surgeons (ASCRS) updated its guidelines in 2020, recommending individualized decision-making rather than surgery based on age alone. We aim to describe the operative trends of young patients with diverticulitis before and after guideline changes. We hypothesized that there would be a decrease in the total number of resections for diverticulitis after the guidelines were changed and that elective operations would make up a smaller proportion of surgeries compared to emergent and urgent surgeries.

Methods/Interventions: We queried the ACS-NSQIP database to identify patients undergoing Hartmann's procedure, primary anastomosis with or without diverting loop ileostomy for diverticulitis between 2015 and 2023. Young patients were defined as those < 50 years old and old patients >50. The primary outcome was to evaluate temporal trends in surgical treatment, and secondary outcomes were to analyze perioperative characteristics over time in this population.

Results/Outcomes: A total of 94,934 patients were identified, of which 22,634 young patients were included. The median age for young patients was 43 years (IQR 37-46), and 64.8% were male. The proportion of patients with obesity (BMI >35) increased from 27.2% to 34.0% (p < 0.001), ASA class III-V from 26.0% to 37.8% (p < 0.001), and preoperative systemic sepsis from 11.6% to 16.5% (p < 0.001). The total number of colectomies in young patients from 2015 to 2023 remained stable except for a small decrease in 2020 (Figure 1). This was likely due to a small increase in elective surgeries (increased from 76.3% to 77.5%, p< 0.001) though emergent surgeries remained stable and urgent surgeries decreased by 2.3% (p=0.1 and p< 0.001, respectively). Conversely, older patients showed a different pattern - colectomy numbers increased in 2015-2019 and decreased in 2020. In 2021 and 2022 the numbers increased again but plateaued in 2023. Older adults also saw an increase in the percentage of patients undergoing elective colectomy from 72.1% in 2015 to 75.2% in 2023 (p < 0.001). In contrast, emergent surgeries remained stable and urgent surgeries decreased by 3.8% (p=0.3 and p< 0.001, respectively).

Conclusion/Discussion: Since the updated ASCRS 2020 guidelines, there has not been a significant change in the number of surgical interventions for diverticulitis in young patients, aside from the small decrease seen in 2020 which was also observed in older patients. However, there was an increase in the percentage of patients undergoing elective surgery during the study period, suggesting there was no change in elective colectomy practices for diverticulitis in young patients. These findings highlight a persistent gap between guideline recommendations and real-world practice, emphasizing the need for strategies to dissemination and adoption of guideline concordant care.

Figure 1: Number of Surgical Patients with Diverticulitis by Age Group (2015-2023)
Trends in the number of surgical patients with diverticulitis by age group from 2015 to 2023, showing stable trends in young patients.