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Original Investigation
Association of VA Surgeons
November 21, 2018

Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis

Author Affiliations
  • 1Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
JAMA Surg. Published online November 21, 2018. doi:10.1001/jamasurg.2018.4359
Key Points

Question  What is the association of the timing of colostomy reversal with postoperative outcomes in patients who underwent the Hartmann procedure for diverticulitis?

Findings  In this study of 1660 patients from State Inpatient Databases, less than one-third of patients underwent colostomy reversal within 1 year after end colostomy for diverticulitis. Socioeconomic disparities were seen in time to colostomy reversal, and prolonged length of stay and 90-day readmissions were significantly more likely in the late compared with the early reversal groups.

Meaning  Colostomy reversal is safe as early as 45 to 110 days after the Hartmann procedure for diverticulitis in selected patients.

Abstract

Importance  The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown.

Objective  To investigate the association of the timing of colostomy reversal with operative outcomes.

Design, Setting, and Participants  This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018.

Exposures  Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing.

Main Outcomes and Measures  Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age.

Results  In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups.

Conclusions and Relevance  Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.

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    1 Comment for this article
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    Snowbirds
    Carlos Alvarez, MD, FACS | Unaffiliated
    There is a very good likelihood that using databases from 2 states favored by retirees, Florida and California could explain the noted low rates of reversal. Working in NJ and PA, I often see patients who were living independently in these retiree havens, return to the Northeast after becoming ill. It also seems likely that many would have had emergency surgery in their retirement community, but move in with family for the recovery, in a different state, where they would see local experts for reversal consultations. This would also skew the age of reversals younger, if older reversals were missed. That said, I also incidentally come across many older patients with longstanding emergency Hartmanns who came back home and established follow-up only with a PCP who never considered a referral for reversal.
    CONFLICT OF INTEREST: None Reported
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