BACK TO THE FUTURE-IS DIVERSION WITHOUT RESECTION A SAFE OPTION FOR COMPLICATED DIVERTICULITIS?

ABSTRACT

Purpose/Background: Historically, diversion was performed prior to resection of complex diverticular disease. This fell out of favor, but with the advent of laparoscopy, we investigated whether fecal diversion as a first step is a safe alternative in select patients who would otherwise undergo a Hartmann's procedure. Hypothesis/Aim: For select patients with acute medically-refractory diverticulitis, diversion without resection controls sepsis and is a safe option. Methods/Interventions: Single institution retrospective chart review of all patients presenting with acute complicated diverticulitis from July 2016- June 2021 was performed. The subset of patients who underwent diverting loop ileostomy or colostomy without initial resection were analyzed for demographics, reason for diversion alone and clinical course. Results/Outcome(s) Nineteen patients who underwent loop diverting ostomy (17 ileostomies, 2 colostomies) were identified. Seventeen of 19 were performed laparoscopically. The average patient age was 52.8 years old (SD 18.1) and 47% were men. Six patients had preoperative abscesses, one of which was amenable to percutaneous drainage. Several patients were initially admitted for another diagnosis and subsequently developed diverticulitis. Comorbidities included cases of severe COVID, recent bone marrow transplantation, and current chemotherapy for lymphoma. The average time from admission to operation was 3.3 days (SD 2.9), and the average postoperative length of stay was 10.1 days (SD 10.7). None of the 19 patients required resection for failure to improve during that hospitalization. Two patients (10.5%) required placement of a percutaneous drain post-operatively. Seventeen patients were discharged home (89.5%) and 2 were discharged to a rehabilitation facility. Six patients required emergency department visits or readmission, most often for dehydration. Since their diversion, 16 patients have subsequently undergone sigmoid resection (84.2%), 15 with primary anastomosis and subsequent diverting ostomy takedown, and one with conversion from loop colostomy to descending colostomy and Hartmann's pouch. Five of the 16 sigmoid resections were performed laparoscopically (31.3%). Limitations: This study is a single institution retrospective review with a small sample size. Conclusions/Discussion: Fecal diversion appears to be a safe initial surgical strategy, providing adequate control of local sepsis in patients who are felt to be poor candidates for sigmoid resection with primary anastomosis and diversion, and allows patients to avoid an initial Hartmann's procedure. All 19 patients were discharged without requiring additional surgery. For patients with severe acute confounding medical comorbidities, initial diversion may allow the patient to recover from their acute process, permit optimization of their health status, and allow an elective sigmoid resection at a more opportune time. (Table Presented).