Can We Predict Surgically Complex Diverticulitis in Elective Cases

BACKGROUND: Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of their initial attack of acute diverticulitis. OBJECTIVE: The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and characterize outcomes in this patient population. DESIGN: This was a retrospective review of the 2010-2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS: Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS: A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS: We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES: The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS: The patients with complex diverticulitis were older (p <0.001), had worse functional status (p <0.001), more comorbidities (diabetes and hypertension), and a higher Charlson comorbidity index (2.7 vs. 1.6, p<0.001). They were more likely to have a history of tobacco or alcohol use (p <0.001), and be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than uncomplicated patients (p=0.67). Surgical time was longer in complex diverticulitis and they were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under curve from the test set was (0.75, 95%confidence interval 0.72-0.78), sensitivity and specificity were 0.890 (95% confidence interval; 0.870-0.891) and 0.450 (95% confidence interval; 0.410-0.490), respectively. LIMITATIONS: The study was limited by its retrospective review and observational bias. CONCLUSIONS: Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183.