Impact of Operative Delay on Sepsis and Mortality in Patients with Acute Diverticulitis

Abstract

Background: Ideal operative timing for non-emergent, acute diverticulitis (AD) remains unclear. Medical management is initially attempted to convert a high risk urgent surgery to a less morbid elective surgery, or to avoid surgery altogether. A large proportion of patients will fail medical treatment and require colectomy.Objectives: To evaluate the effect of operative delay on sepsis and mortality in patients with AD.Methods: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent colectomy with a primary diagnosis of diverticulitis between 2005 and 2014 were included. Multiple patient variables were analyzed to see their combined effect on death and sepsis. Patients undergoing surgical intervention on hospital day 0,emergent cases and those with preoperative sepsis were excluded. The impact of operative delay on mortality and sepsis was evaluated using day from admission as the predictor of the primary outcomes. Secondary outcomes included urinary tract infection (UTI), pneumonia (PNA), need for blood transfusion, septic shock, return to the operating room, length of stay (LOS), readmission,wound dehiscence, and surgical site infections (SSI). Frequency of patient variables was recorded and a multiple variable logistic regression analysis was performed to control for possible confounders. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for primary and secondary outcomes.Results: 32,399 patients underwent colectomy forADonhospital day 1 - 20. Adjusted for other factors, days to operation was found to be a significant predictor for death (OR = 1.038, 95% CI 1.020 - 1.057; P < 0.0001) and sepsis (OR = 1.051, 95% CI, 1.035 - 1.067; P < 0.0001).Each day in which surgical intervention was delayed was associated with a 3.8% increased risk of mortality and 5.1% increased risk of sepsis. Delay of surgery was also associated with an increased risk of blood transfusion, return to the operating room and increased LOS.Conclusions: Delaying operation for patients with AD has a significant impact on sepsis and mortality. While non-operative approaches may be attempted, with each additional day operative therapy is delayed there is a significant increase in the risk of morbidity and mortality. This data suggests that surgeons should pursue operative therapy earlier in the hospital course to improve patient outcomes.

Keywords

• acute diverticulitis
• operative timing
• medical management
• surgical management