Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis
| Autor: | Johan Nordenstam, Carlos Amir Esparza Monzavi, Gerald Gantt, Vivek Chaudhry, Anders Mellgren, Samer A Naffouje |
|---|---|
| Rok vydání: | 2020 |
| Předmět: |
Male
Reoperation medicine.medical_specialty medicine.medical_treatment Operative Time Anastomotic Leak Hemorrhage Patient Readmission Postoperative Complications Sepsis Outcome Assessment Health Care Surgical Wound Dehiscence medicine Humans Minimally Invasive Surgical Procedures Colectomy Diverticulitis Aged Retrospective Studies Gynecology Perforated diverticulitis business.industry Anastomosis Surgical Gastroenterology General Medicine Length of Stay Middle Aged Elective Surgical Procedures Spontaneous Perforation Female Respiratory Insufficiency business |
| Zdroj: | Diseases of the Colon & Rectum. 64:319-327 |
| ISSN: | 0012-3706 |
| DOI: | 10.1097/dcr.0000000000001805 |
| Popis: | Background Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. Objective The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. Design This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. Settings Interventions were performed in hospitals participating in the national database. Patients Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. Main outcome measures Outcomes measures included length of stay and overall morbidity and mortality. Results Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. Limitations Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. Conclusions Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421. Abordaje abierto versus mnimamente invasivo para colectoma de emergencia en diverticulitis perforada ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomia con anastomosis primaria. La cirugia minimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el minimamente invasivo para la diverticulitis perforada emergente.DISENO:Esta fue una revision retrospectiva de la base de datos de colectomia dirigida del Programa Nacional de Mejoramiento de la Calidad Quirurgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propension.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomia emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus minimamente invasivo se definieron por intencion de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duracion de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusion (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos minimamente invasivos. El grupo minimamente invasivo se sometio a operaciones mas prolongadas y tuvo tasas mas bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duracion de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje minimamente invasivo se asocio con tiempos quirurgicos mas prolongados, pero tambien con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duracion de la estancia. No se detectaron diferencias en las tasas de fuga anastomotica, mortalidad, reintervencion o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, perdida de datos, falta de uniformidad, sesgo de seleccion y errores de codificacion.CONCLUSIONES:La anastomosis primaria minimamente invasiva emergente resulta en una estancia mas corta y una disminucion de la morbilidad a los 30 dias en comparacion con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y minimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizas debido a una tasa de conversion del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421. |
| Databáze: | OpenAIRE |
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