PALM BEACH, FLA.– Using laparoscopic surgery for colectomy with primary anastomosis in patients with complicated diverticulitis linked with significantly fewer major complications compared with open surgical management in a review of more than 10,000 patients from a nationwide database.
However, the inherent biases at play when surgeons decide whether to manage a diverticulitis patient by a laparoscopic or open approach make it difficult to draw definitive conclusions from the findings, Dr. Edward E. Cornwell III said at the annual meeting of the Southern Surgical Association.
Dr. Edward E. Cornwell, III
"If a surgeon did an operation laparoscopically, that by itself is an indicator of how sick the patient was. The surgeon selects an open operation for sicker patients, and laparoscopy for the less sick patients," he said in an interview. "Have we accounted for that difference [in the analysis]? That’s an open question," said Dr. Cornwell, professor and chairman of surgery at Howard University in Washington.
"Patients whom the surgeon deem well enough physiologically to sustain colectomy with primary anastomosis deserve strong consideration for the laparoscopic approach because those patients had the greatest difference in complications" compared with open surgery, he said.
The data Dr. Cornwell and his associates reviewed also showed a marked skewing in how surgeons used laparoscopy. Among the 10,085 patients included in the analysis, 7,562 (75%) underwent colectomy with primary anastomosis, and in this subgroup, 5,105 patients (68%) had their surgery done laparoscopically, while the remaining 2,457 (32%) were done with open surgery. In contrast, the 2,523 other patients in the series underwent a colectomy with colostomy, and within this subgroup, 2,286 patients (91%) had open surgery, with only 237 (9%) having laparoscopic surgery.
The overwhelming use of open surgery for the colostomy patients makes sense as it is a more complex operation, Dr. Cornwell said.
He and his associates used data collected during 2005-2009 at 237 U.S. hospitals by the National Surgical Quality Improvement Program of the American College of Surgeons on patients who underwent surgical management of complicated diverticulitis. The average age of the patients was 58 years, and overall 30-day mortality was 2%, while the overall postoperative complication rate during the 30 days following surgery was 23%.
Among the patients who underwent a primary anastomosis, the incidence of major complications during 30 days of follow-up was 13% in the open surgery patients and 6% in the laparoscopy patients, a statistically significant difference. Major complications included surgical site infections, dehiscence, transfusion, respiratory failure, sepsis, myocardial infarction, pulmonary embolism, stroke, renal failure or need for rehospitalization.
In a multivariate analysis that controlled for demographic parameters, body mass index, comorbidities, and functional status, patients who underwent laparoscopy had about half the number of total complications and major complications compared with patients who underwent open surgery – statistically significant differences. The laparoscopically-treated patients also had roughly half the rate of several individual major complications – wound infections, respiratory complications, and sepsis – compared with the open surgery patients, all statistically significant differences.
Thirty-day mortality was about 50% lower with laparoscopy compared with open surgery among patients who underwent a primary anastomosis, but this difference fell short of statistical significance.
The advantage of laparoscopy over open surgery was not nearly so clear among patients who underwent colectomy with colostomy. The data showed no significant difference between laparoscopy and open surgery in the rate of all major complications, although the number of major complications with laparoscopy was about 20% lower. The only individual complications significantly reduced in the laparoscopy group were wound infections, reduced by about 40% in the adjusted analysis, and respiratory complications, cut by about 50% by laparoscopy. The two surgical subgroups showed virtually no difference in 30-day mortality among patients who underwent a colectomy.
The results suggest that because of the broad reduction of major complications with laparoscopy, this approach "should be considered when primary anastomosis is deemed appropriate," Dr. Cornwell concluded.
Dr. Cornwell said that he had no disclosures.