Laparoscopic Surgery for Diverticulitis Halves Complications

Laparoscopic surgery to treat diverticulitis is associated with half as many complications as open surgery, according to a study of nearly 7,000 surgeries performed over a 3-year period, reported Dr. Andrew Russ and colleagues.

Investigators at the University of Wisconsin, Madison, led by Dr. Gregory D. Kennedy, examined records from the American College of Surgeons' National Surgical Quality Improvement Program, a database of information on surgeries performed in participating U.S. hospitals (Gastroenterology 2010 June [doi:10.1053/j.gastro.2010.02.048]).

The research team identified records from all patients who had undergone any of 11 coded surgical procedures for diverticular disease from 2005 to 2008. Patients who had emergency surgeries were omitted Of the 6,970 patients remaining, 3,468 underwent an open resection procedure and 3,502 underwent a laparoscopic procedure.

The incidence of complications—including infections, pneumonia, deep vein thrombosis or pulmonary embolism, and postoperative sepsis or septic shock—was markedly lower in the laparoscopic group, with overall complications in the month after surgery reduced by nearly half, from 21.7% in the open group to 11.0% in the laparoscopic group. Hospital stays were reduced by more than a third, from an average of 7.8 days in the open group to 4.8 days for the laparoscopic patients.

However, the patients undergoing laparoscopic surgeries also happened to be younger (mean age 55.6 vs. 59.2 years for open surgery) and had fewer comorbidities, and this “is the crux of the difficulty with this paper,” Dr. Kennedy said in an interview. The nonrandomization of the study was another limitation, he said, as was the fact that most of the surgeries were performed in academic hospitals with high-volume colorectal surgery centers.

Also, poor wound condition was evident in more than 20% of the open surgeries. Although they investigators did not include any emergency surgeries (defined as those initiated within 12 hours of hospital admission), the fact that one-fifth of wounds in the open surgery group were classed as “dirty” or “infected,” compared with only 5.1% in the laparoscopic group, suggests that many of the open surgeries “could be considered on some level urgent,” Dr. Kennedy said.

But when the investigators used statistical models to correct for complication risks, such as wound condition, American Society of Anesthesiologists physical status classification, bond recent surgeries, theynonund that the risk of developing complications was roughly 50% lower after a laparoscopic procedure, compared with an open procedure.

“What we saw was that laparoscopy at least correlated with an improved outcome,” Dr. Kennedy said. “It is at least contributing to a 50% reduction” in complications.

He and his colleagues noted that, despite a growing body of research suggesting laparoscopy to be the safer option, it remains far from surgeons' first choice for diverticulitis. Currently, in the United States, Dr. Kennedy said, the availability of the procedure “depends largely on the market; if you're in Chicago and go for a colon surgery, nearly every surgeon will offer it. In other states, and in many rural areas, people are not performing or even offering laparoscopy.”

One reason for the hesitation, the investigators speculated, could be that laparoscopic surgeries for diverticular disease had been previously associated with high rates of conversion to open surgeries. But currently, they wrote, conversion rates are between 20% and 26%, “not dissimilar to current large series reports on conversion rates for neoplastic disease.”

Another reason, they said, could be the longer operating times associated with laparoscopic surgery.

The study was funded by the University of Wisconsin. Neither Dr. Kennedy nor any of his coauthors cited competing interests.