ABSTRACT
Purpose/Background: Reported international variability in the index management of acute diverticulitis may contribute to the observed differences in short-term outcomes and drive disparities in guidelines. Hypothesis/Aim: Goal: To compare international practices in initial surgical management for acute diverticulitis Hypothesis: Decision making varies by region in comparable patients, impacting outcomes and guidelines Methods/Interventions: The DAMASCUS study was a 6-month prospective, global observational study on the management and short-term outcomes of patients presenting with acute diverticulitis. For this study, baseline patient and disease covariates were reviewed from the RedCap database for initial surgical decision making by region (North America, Europe, UK, Australasia and Asia/Africa/South America [LMIC's]). The main outcome was the international variation in acute surgical management by region. Results/Outcome(s): Of 5659 patients enrolled internationally, 4472 (79%) were admitted on initial presentation and included in this analysis. The admission rate was significantly lower in North America, where only 39% were admitted (p<0.001). 28% (n=1558) reported a prior diverticular episode;North America had significantly higher rates of prior episodes (47%;p<0.01). Prior episodes were mostly >12 months before current presentation in all regions. 709 patients (15.9%) had emergency surgery for diverticulitis. Rates for surgery at initial presentation varied significantly from 6% (North America) to 24% (LMIC's). Surgery was CT-driven in 98%. 95 patients (13.4%) had a laparoscopic lavage/washout, while 614 (86.6%) had resectional surgery. The most common resection was a Hartmann's procedure (71.6%), performed significantly more than a segmental resection in all regions except Europe (P<0.001). A primary anastomosis was performed in 174 overall (28.3%);rates were similar across regions. An end colostomy- whether described as a Hartmann's, anterior resection, or sigmoid colectomy- was the most common stoma overall at 87.3% (P<0.001). Excluding the Hartmann procedures, 24.1% left a covering stoma. Europe and LMIC were significantly less likely to divert (p=0.002). All other regions were comparable. 67.8% left a surgical drain. Nearly all reported treatment was not affected by Covid 19 (98%). Limitations: Audit design, with differences in definitions of procedures and bias possible from who completed the audit. Conclusions/Discussion: The DAMASCUS study confirmed substantial geographical variation in the index surgical decision making for emergency diverticulitis cases. Despite colorectal expersite, a Hartmann's procedure with end colostomy remains the most common procedure in emergency cases. Lower stoma rates in LMIC may be related to less available resources for subsequent cases. Further analysis will be performed to determine whether such variation is associated with short term clinical outcomes.