Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis | Colorectal Surgery | JAMA Surgery | JAMA Network
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Figure.  Timing of Colostomy Reversal
Timing of Colostomy Reversal

Line graph depicts the number of colostomies reversed by the number of days after the index operation for diverticulitis.

Table 1.  Patient Characteristics by Reversal Timing
Patient Characteristics by Reversal Timing
Table 2.  Multivariable Analysis of Patient Characteristics Associated With Early Reversal
Multivariable Analysis of Patient Characteristics Associated With Early Reversal
Table 3.  Complications by Reversal Timing
Complications by Reversal Timing
Table 4.  Complications by Reversal Timing Adjusted for Age and Comorbidity Index
Complications by Reversal Timing Adjusted for Age and Comorbidity Index
1.
Etzioni  DA, Mack  TM, Beart  RW  Jr, Kaiser  AM.  Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.  Ann Surg. 2009;249(2):210-217. doi:10.1097/SLA.0b013e3181952888PubMedGoogle ScholarCrossref
2.
Boermeester  MA, Humes  DJ, Velmahos  GC, Søreide  K.  Contemporary review of risk-stratified management in acute uncomplicated and complicated diverticulitis.  World J Surg. 2016;40(10):2537-2545. doi:10.1007/s00268-016-3560-8PubMedGoogle ScholarCrossref
3.
Stocchi  L.  Current indications and role of surgery in the management of sigmoid diverticulitis.  World J Gastroenterol. 2010;16(7):804-817.PubMedGoogle Scholar
4.
Cirocchi  R, Trastulli  S, Desiderio  J,  et al.  Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis.  Int J Colorectal Dis. 2013;28(4):447-457. doi:10.1007/s00384-012-1622-4PubMedGoogle ScholarCrossref
5.
Horesh  N, Rudnicki  Y, Dreznik  Y,  et al.  Reversal of Hartmann’s procedure: still a complicated operation.  Tech Coloproctol. 2018;22(2):81-87. doi:10.1007/s10151-017-1735-4PubMedGoogle Scholar
6.
Pearce  NW, Scott  SD, Karran  SJ.  Timing and method of reversal of Hartmann’s procedure.  Br J Surg. 1992;79(8):839-841. doi:10.1002/bjs.1800790844PubMedGoogle ScholarCrossref
7.
Roe  AM, Prabhu  S, Ali  A, Brown  C, Brodribb  AJ.  Reversal of Hartmann’s procedure: timing and operative technique.  Br J Surg. 1991;78(10):1167-1170. doi:10.1002/bjs.1800781006PubMedGoogle ScholarCrossref
8.
Fleming  FJ, Gillen  P.  Reversal of Hartmann’s procedure following acute diverticulitis: is timing everything?  Int J Colorectal Dis. 2009;24(10):1219-1225. doi:10.1007/s00384-009-0747-6PubMedGoogle ScholarCrossref
9.
Keck  JO, Collopy  BT, Ryan  PJ, Fink  R, Mackay  JR, Woods  RJ.  Reversal of Hartmann’s procedure: effect of timing and technique on ease and safety.  Dis Colon Rectum. 1994;37(3):243-248. doi:10.1007/BF02048162PubMedGoogle ScholarCrossref
10.
Khan  AL, Ah-See  AK, Crofts  TJ, Heys  SD, Eremin  O.  Reversal of Hartmann’s colostomy.  J R Coll Surg Edinb. 1994;39(4):239-242.PubMedGoogle Scholar
11.
Zafar  SN, Changoor  NR, Williams  K,  et al.  Race and socioeconomic disparities in national stoma reversal rates.  Am J Surg. 2016;211(4):710-715. doi:10.1016/j.amjsurg.2015.11.020PubMedGoogle ScholarCrossref
12.
Gunnells  DJ, Wood  LN, Goss  L,  et al.  Racial disparities after stoma construction exist in time to closure after 1 year but not in overall stoma reversal rates.  J Gastrointest Surg. 2018;22(2):250-258. doi:10.1007/s11605-017-3514-yPubMedGoogle Scholar
13.
Aquina  CT, Probst  CP, Becerra  AZ,  et al.  The impact of surgeon volume on colostomy reversal outcomes after Hartmann’s procedure for diverticulitis.  Surgery. 2016;160(5):1309-1317. doi:10.1016/j.surg.2016.05.008PubMedGoogle ScholarCrossref
14.
Sier  MF, van Gelder  L, Ubbink  DT, Bemelman  WA, Oostenbroek  RJ.  Factors affecting timing of closure and non-reversal of temporary ileostomies.  Int J Colorectal Dis. 2015;30(9):1185-1192. doi:10.1007/s00384-015-2253-3PubMedGoogle ScholarCrossref
15.
Roig  JV, Cantos  M, Balciscueta  Z,  et al; Sociedad Valenciana de Cirugía Cooperative Group.  Hartmann’s operation: how often is it reversed and at what cost? a multicentre study.  Colorectal Dis. 2011;13(12):e396-e402. doi:10.1111/j.1463-1318.2011.02738.xPubMedGoogle ScholarCrossref
16.
Herrle  F, Sandra-Petrescu  F, Weiss  C, Post  S, Runkel  N, Kienle  P.  Quality of life and timing of stoma closure in patients with rectal cancer undergoing low anterior resection with diverting stoma: a multicenter longitudinal observational study.  Dis Colon Rectum. 2016;59(4):281-290. doi:10.1097/DCR.0000000000000545PubMedGoogle ScholarCrossref
17.
Lasithiotakis  K, Aghahoseini  A, Alexander  D.  Is early reversal of defunctioning ileostomy a shorter, easier and less expensive operation?  World J Surg. 2016;40(7):1737-1740. doi:10.1007/s00268-016-3448-7PubMedGoogle ScholarCrossref
18.
Alves  A, Panis  Y, Lelong  B, Dousset  B, Benoist  S, Vicaut  E.  Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy.  Br J Surg. 2008;95(6):693-698. doi:10.1002/bjs.6212PubMedGoogle ScholarCrossref
19.
Khan  S, Alvi  R, Awan  Z, Haroon  N.  Morbidity of colostomy reversal.  J Pak Med Assoc. 2016;66(9):1081-1083.PubMedGoogle Scholar
20.
Hodgson  R, An  V, Stupart  DA, Guest  GD, Watters  DA.  Who gets Hartmann’s reversed in a regional centre?  Surgeon. 2016;14(4):184-189. doi:10.1016/j.surge.2014.11.001PubMedGoogle ScholarCrossref
21.
Horesh  N, Lessing  Y, Rudnicki  Y,  et al.  Considerations for Hartmann’s reversal and Hartmann’s reversal outcomes: a multicenter study.  Int J Colorectal Dis. 2017;32(11):1577-1582. doi:10.1007/s00384-017-2897-2PubMedGoogle ScholarCrossref
22.
Hallam  S, Mothe  BS, Tirumulaju  R.  Hartmann’s procedure, reversal and rate of stoma-free survival.  Ann R Coll Surg Engl. 2018;100(4):301-307. doi:10.1308/rcsann.2018.0006PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    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
    READ MORE
    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. 2019;154(3):218-224. 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.

    Introduction

    Acute diverticulitis is a significant health care burden in the United States, representing more than 300 000 hospital admissions each year.1 Although many patients successfully undergo nonoperative management, a small proportion will require surgical intervention owing to medically refractory or aggressive disease.2,3 Patients requiring surgery for diverticulitis will often undergo the Hartmann procedure, which entails the creation of an end colostomy.1,4 This procedure can be lifesaving, but patients are left with the challenges of managing an end colostomy, and thus, early restoration of bowel continuity is a subsequent priority for many patients.5

    Timing to colostomy reversal is largely surgeon based, and common practice includes waiting a period of several months before colostomy reversal to allow postsurgical inflammation to subside and to mitigate difficult reoperations owing to intra-abdominal adhesions.5-9 Given the lack of guidelines, timing to reversal is widely variable. Several small, institutional studies6-10 have had contradictory results, with conclusions advocating for reversal after 3 months, after 4 months, after 6 months, before 4 months, and before 9 months.

    Optimal timing to colostomy reversal is unknown and has been difficult to study owing to the inability to track patients across hospital admissions and years in large databases. This situation has limited the study of outcomes of independent patients undergoing multiple procedures across multiple years. However, the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases have emerged as an important tool to track patients across multiple admissions through multiple years. Therefore, the state databases were used to investigate the association of timing of colostomy reversal after diverticulitis with operative outcomes and patient characteristics. We hypothesized that early reversal was no different than later reversal in terms of mortality and complications.

    Methods
    Study Design

    This study was a retrospective study of the HCUP State Inpatient Databases. This study was approved by the investigational review board of Yale University, New Haven, Connecticut, which waived the need for informed consent for use of deidentified patient data.

    Data Source

    Quiz Ref IDThe State Inpatient Databases for California (January 1, 2010, through December 31, 2012), Florida (January 1, 2013, through December 31, 2016), and Maryland (January 1, 2013, through December 31, 2015) were pooled in this analysis. Not all states have variables available to link patients between admissions. Therefore, California, Florida, and Maryland were selected as states with geographically, socioeconomically, and regionally diverse representation, large populations, and the necessary variables available. In addition, the State Inpatient Databases allow tracking of patients from the index operation through all subsequent readmissions within each state. The most recent available years were obtained for each state. The State Inpatient Databases are curated by the Agency for Healthcare Research and Quality, and this project was conducted with their approval.

    Data Elements

    The HCUP State Inpatient Databases include information on patient demographics (age, sex, race, insurance, etc) and hospitalization (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes for ≤25 diagnoses and procedures, length of stay [LOS], in-hospital death, etc). Race is a variable collected by HCUP and was included as a variable in this study to address findings of disparities in colostomy reversal that have been previously observed.11,12 Primary outcomes of interest in this study after colostomy reversal were mortality, hospital LOS, transfusion, ileus, major complications, and 90-day readmissions. Major complications were assigned by ICD-9-CM diagnosis codes as previously demonstrated13 and included intra-abdominal abscess, anastomotic leak, sepsis, pneumonia, pulmonary failure, myocardial infarction, venous thromboembolism, acute renal failure, postoperative hemorrhage, and gastrointestinal tract bleeding. Prolonged LOS was defined as LOS in the top quartile for colostomy reversal (>7 days).

    Patient Selection

    Patients with colostomy (ICD-9-CM codes 46.10, 46.11, and 46.13) for diagnosis of diverticulitis (ICD-9-CM code 562.11) were linked to their colostomy reversal (ICD-9-CM codes 46.50 and 46.52). To describe the proportion of patients with at least 1 year of follow-up who underwent reversal within 1 year, a descriptive cohort of patients was selected who had their index surgery more than 1 year before the end of data in each state (n = 7165). To compare outcomes of patients who underwent reversal, the prognostic cohort contained all who underwent the procedure regardless of follow-up time (n = 3711). To select for only patients who did not have complications as a result of their index procedure, patients who were readmitted between the index operation and reversal were excluded. Patients undergoing reversal after 365 days were also excluded, for a final prognostic cohort of 1660 patients.

    Time to Reversal

    To assess the association of timing with outcomes, time to reversal was divided into early, middle, and late categories. Quiz Ref IDIn the absence of any formally accepted guidelines, these categories were chosen statistically, by tercile group, to remain impartial and describe the entire breadth of practice. Early reversal was defined as 45 to 110 days; middle reversal, 111 to 169 days; and late reversal, 170 to 360 days. Given that less than 1% of individuals underwent reversal before 45 days, these individuals were excluded as outliers. To address a direct comparison of earlier and later reversal groups, 2 sensitivity analyses were performed for reversals before 90 days and before 60 days vs later reversal.

    Statistical Analysis

    Data were analyzed from December 1, 2017, through May 31, 2018. Outcomes were compared among all groups using logistic regression adjusted for Charlson comorbidity index and age. To determine patient characteristics associated with reversal timing, additional multivariable logistic regression analysis was performed with adjusting for age, sex, race, comorbidity, and insurance status. Two-tailed P < .05 was considered statistically significant. Analysis was performed using SAS software (version 9.4; SAS Institute Inc).

    Results
    Timing of Reversal and Patient Characteristics

    In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. In total, we identified 1660 patients (prognostic cohort) who underwent reversal within 365 days and had uncomplicated postoperative courses (ie, no readmissions between the index surgery and reversal) (among those with data available, 860 men [51.8%] and 773 [46.6%] women; median age, 61 years [interquartile range, 51-70 years]). The median reversal time was 129 days (interquartile range, 99-182 days), although the most common period (mode) for reversal was 90 to 100 days (Figure). Univariate analysis showed that individuals less likely to undergo early reversal (compared with middle and late reversal) were older (age >76 years, 48 of 561 [8.6%] vs 78 of 582 [13.4%] vs 72 of 501 [14.4%]), were nonwhite (84 of 561 [15.0%] vs 117 of 582 [20.1%] vs 112 of 501 [22.4%]), had more comorbidities (11 of 561 [2.0%] vs <10 vs 19 of 501 [3.8%]), and were underinsured (private insurance, 308 of 561 [54.9%] vs 273 of 582 [46.9%] vs 172 of 501 [34.3%]) (Table 1). Quiz Ref IDOn multivariable analysis, patient characteristics independently 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) (Table 2).

    Timing of Reversal and Outcomes

    On univariate analysis, the need for blood transfusion (36 of 561 [6.4%] vs 49 of 501 [9.8%]; P = .04), major complications (67 of 561 [11.9%] vs 86 of 501 [17.2%]; P = .02), 90-day readmissions (87 of 561 [15.5%] vs 121 of 501 [24.2%]; P < .01), and prolonged LOS (93 of 561 [16.6%] vs 136 of 501 [27.1%]; P < .01) were more common in the late compared with the early reversal groups (Table 3). After adjusting for patient age and comorbidities, there was no significant difference in hospital 90-day mortality, transfusion, ileus, and major complications (Table 4). Quiz Ref IDHowever, prolonged LOS (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 reversal groups (Table 4).

    Sensitivity Analyses

    We compared patients with reversals earlier than 90 days (249 patients) directly with those with later reversal. This comparison (eTable 1 in the Supplement) showed no difference in hospital 90-day mortality, transfusion, ileus, major complications, and prolonged LOS but did show that reversal before 90 days was associated with significantly reduced chance of 90-day readmission (OR, 0.57; 95% CI, 0.36-0.83; P = .005) compared with later reversal.

    In addition, we compared patients with reversals earlier than 60 days (44 patients) directly with those with later reversal. Observed complication rates were lower in the patients undergoing reversal within 60 days compared with later reversal, although this was not a significant difference (eTable 2 in the Supplement). We found no significant differences in hospital 90-day mortality, transfusion, ileus, major complications, prolonged LOS, and 90-day readmissions between these groups.

    Discussion

    After undergoing colostomy for diverticulitis, early reversal is a priority for many patients; however, little is known about the association of reversal timing and outcomes. This study of 1660 selected patients with uncomplicated postdischarge courses demonstrates that mortality and complications were similar between reversal times within 1 year, but that earlier reversal was associated with decreased LOS and fewer readmissions. Quiz Ref IDThese data suggest that colostomy reversal as early as 45 to 110 days is safe for selected patients with an uncomplicated course. Previous studies looking at this question have had contradictory results, likely owing to small groups studied at select institutions and difficulty in following up patients after the index surgery.5 For example, Roe et al7 retrospectively divided 69 patients between those who underwent reversal before and after 4 months and recommended early reversal after finding complications in 24% of early reversals and 35% of late reversals. Pearce et al6 analyzed 80 patients and concluded that reversal was safer after 6 months, finding 3 deaths and 4 septic complications in patients before 6 months and none after 6 months. Fleming and Gillen8 investigated 110 patients and recommended reversal before 9 months, showing similar complications between those undergoing reversal before and after this time frame. Comparatively, our study was able to link a much larger number of patients who underwent colostomy for diverticulitis to their colostomy reversals using the HCUP State Inpatient Databases and track patients across numerous institutions and multiple years.

    Subgroup analyses of patients undergoing reversal before 90 days and before 60 days show similar complication rates to those of later reversal groups and suggest that selected patients with an uncomplicated course may not need to wait an arbitrary 3 months for reversal. Although these results are encouraging, fewer patients underwent reversal before 90 days (n = 249) and 60 days (n = 44), so one cannot rely on these data to prove noninferiority; more study is needed to confirm these results.

    This study also demonstrates that it is exceedingly rare for a colostomy to be reversed sooner than 45 days after diverticulitis (<1%). The distribution of timing to colostomy reversal in this study was similar to that of other studies evaluating stoma closure, even including temporary ileostomies and cancer resections.13-16 Interestingly, small studies in diverting ileostomies have suggested that patients may undergo reversal as early as 8 days after the index surgery and that earlier reversal may be associated with cost savings.17,18 Contrarily, reversal of an end colostomy after diverticulitis is more morbid than reversal of a diverting ileostomy,5,19 and this study confirms that very few surgeons attempt closure earlier than 45 days. However, this study demonstrates that although colostomy reversal seems to be safe for patients with an uncomplicated course less than 90 days after the index operation, most patients will wait longer than 130 days to have their colostomy reversed. Future study should be focused on the barriers that prevent timely colostomy reversal in these suitable candidates with an uncomplicated course.

    This study also suggests that additional factors determine whether a patient obtains an early colostomy reversal, which may not be medical. Interestingly, among this group of patients with an uncomplicated course, Charlson comorbidity index was not independently associated with timing of reversal, but age was strongly significant. This finding is consistent with that of a previous study20 but contradicts other studies that found comorbidity as a significant reason why end colostomies were not reversed.21,22 However, the present study only analyzed patients who did, in fact, undergo reversal within 1 year. Therefore, this group was selected by a surgeon to be suitable candidates for reversal. Because it is unlikely that a patient’s comorbidities would change within 1 year and make them a more suitable candidate after an arbitrary number of months, it is not surprising that Charlson comorbidity index was not independently associated with timing of reversal in this study.

    As an unexpected finding, insurance status had the most robust independent association with early reversal, and race also had an independent association. Previous studies have also variably identified socioeconomic disparities in the rates and timing of stoma closure.20,21 Zafar et al11 found lower rates of stoma reversal among black compared with white patients but did not track individual patients and instead compared national formation rates to closure rates. Alternatively, Gunnells et al12 did not find a racial disparity in a single-institutional study within 1 year but did find a strong insurance-based disparity. The findings of the present study are likely more representative of socioeconomic disparities, given the size of the sample and the ability to track patients across institutions within a state.

    Finally, this study demonstrated a low overall rate of colostomy reversal within 1 year after diverticulitis (28.3%). Previous studies have demonstrated rates of reversal of end colostomy from 35% to 69%,8,13,15,20,22 but most studies included mixed groups of patients, who may have undergone diversion for diverticulitis, cancer, and other indications. The proportion of patients undergoing reversal in the present study is likely a conservative estimate, because deceased patients were not excluded from this proportion, and patients who moved across states would not be captured. Previous studies have shown that a dominant cause of nonreversal is death, and these patients were excluded in many previous analyses.10,15 Individuals who died between the index operation and 1 year were not excluded from this analysis because patient’s deaths are not reliably linked to this database unless the patient dies during an inpatient stay. This method likely lead to a low estimate in this study compared with other analyses.

    Limitations

    This study includes several limitations inherent to retrospective review of administrative databases. For example, we are unable to ascertain the surgical complexity of the index Hartmann procedure, Hinchey classification of diverticulitis, or surgical variables associated with the closure such as operative time. Also, surgeon bias may be at play in determining when to reverse a colostomy, and surgeons who perform later reversals may also be the same conservative surgeons who keep patients hospitalized longer and cause increased LOS. In addition, we can only study what surgeons are already doing. An interesting follow-up question to this study is what outcomes are like in individuals who undergo reversal earlier than 45 days after the index surgery and whether a sampling of adhesion severity or case complexity is associated with success of early reversal. However, these data cannot answer this question because very few surgeons are attempting this.

    Conclusions

    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 index procedure.

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    Article Information

    Accepted for Publication: September 1, 2018.

    Corresponding Author: Kevin Y. Pei, MD, Department of Surgery, Yale School of Medicine, 330 Cedar St, Room 310, Boardman Building, New Haven, CT 06519 (kevin.pei@yale.edu).

    Published Online: November 21, 2018. doi:10.1001/jamasurg.2018.4359

    Author Contributions: Drs Resio and Pei had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Resio, Pei.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Resio, Jean, Chiu.

    Administrative, technical, or material support: Jean.

    Supervision: Pei.

    Conflict of Interest Disclosures: None reported.

    Meeting Presentation: This paper was presented at the 2018 Association of Veterans Affairs Surgeons Annual Meeting; May 7, 2018; Miami, Florida.

    References
    1.
    Etzioni  DA, Mack  TM, Beart  RW  Jr, Kaiser  AM.  Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.  Ann Surg. 2009;249(2):210-217. doi:10.1097/SLA.0b013e3181952888PubMedGoogle ScholarCrossref
    2.
    Boermeester  MA, Humes  DJ, Velmahos  GC, Søreide  K.  Contemporary review of risk-stratified management in acute uncomplicated and complicated diverticulitis.  World J Surg. 2016;40(10):2537-2545. doi:10.1007/s00268-016-3560-8PubMedGoogle ScholarCrossref
    3.
    Stocchi  L.  Current indications and role of surgery in the management of sigmoid diverticulitis.  World J Gastroenterol. 2010;16(7):804-817.PubMedGoogle Scholar
    4.
    Cirocchi  R, Trastulli  S, Desiderio  J,  et al.  Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis.  Int J Colorectal Dis. 2013;28(4):447-457. doi:10.1007/s00384-012-1622-4PubMedGoogle ScholarCrossref
    5.
    Horesh  N, Rudnicki  Y, Dreznik  Y,  et al.  Reversal of Hartmann’s procedure: still a complicated operation.  Tech Coloproctol. 2018;22(2):81-87. doi:10.1007/s10151-017-1735-4PubMedGoogle Scholar
    6.
    Pearce  NW, Scott  SD, Karran  SJ.  Timing and method of reversal of Hartmann’s procedure.  Br J Surg. 1992;79(8):839-841. doi:10.1002/bjs.1800790844PubMedGoogle ScholarCrossref
    7.
    Roe  AM, Prabhu  S, Ali  A, Brown  C, Brodribb  AJ.  Reversal of Hartmann’s procedure: timing and operative technique.  Br J Surg. 1991;78(10):1167-1170. doi:10.1002/bjs.1800781006PubMedGoogle ScholarCrossref
    8.
    Fleming  FJ, Gillen  P.  Reversal of Hartmann’s procedure following acute diverticulitis: is timing everything?  Int J Colorectal Dis. 2009;24(10):1219-1225. doi:10.1007/s00384-009-0747-6PubMedGoogle ScholarCrossref
    9.
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