Evaluation of the risk of a nonrestorative resection for the treatment of diverticular disease: the Cleveland Clinic diverticular disease propensity score.
OBJECTIVE
The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures.


METHODS
Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure.


RESULTS
Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independent predictors in favor for Hartmann's resection were body mass index > or = 30 kg/m2 (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08 vs. 13.32), and Hinchey stage > II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent.


CONCLUSIONS
Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score.
Aydin
H Nail
HN
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Tekkis
Paris P
PP
Remzi
Feza H
FH
Constantinides
Vasilis
V
Fazio
Victor W
VW
D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D015992:Body Mass Index; D012809:Colon, Sigmoid / Q000601:surgery; D003125:Colostomy / Q000009:adverse effects / Q000379:methods*; D004239:Diverticulitis, Colonic / Q000401:mortality / Q000601:surgery*; D004630:Emergencies; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D010538:Peritonitis / Q000150:complications; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods*