Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis.
OBJECTIVE
Hartman's procedure (HP) or primary anastomosis (PA) are the two surgical techniques used in patients undergoing emergency colectomy for perforated diverticulitis. There are no objective criteria to guide the surgeon's choice of procedure. This study assesses whether classification and scoring systems can be used in the decision-making process.


METHODS
One hundred eleven patients undergoing emergency laparotomy for perforated diverticulitis were analyzed. Logistic regression and interaction models were used to determine the predictive value in the two settings.


RESULTS
Sixty five patients underwent HP and 46 patients underwent PA. Patients with HP had significantly higher scores, median age, and were more often on immunosuppressive medication. Mortality and surgical morbidity did not differ between the groups. The clinical anastomotic leak rate was 28.3% in the PA group. In the univariate logistic regression for in-hospital death, all scores showed a significant influence. The multivariate logistic regression analysis showed that only Charlson comorbidity index (CCI) and American Society of Anesthesiologists score had a significant influence on mortality. Each score was analyzed for its predictive value regarding mortality and morbidity with respect to type of operative procedure. Only CCI revealed a trend towards statistical significance. The risk of death increases with increasing CCI when PA is performed compared to HP.


CONCLUSIONS
None of the tested scores can be used to help the surgeon decide whether a PA or HP is appropriate in a specific patient. Comorbidity, represented as CCI in this study, might be more important than the locoregional situation.
Pasternak
Itai
I
Department of Surgery, Triemli Hospital, 8063 Zurich, Switzerland.
Dietrich
Michael
M
Woodman
Richard
R
Metzger
Urs
U
Wattchow
David A
DA
Zingg
Urs
U
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002965:Classification; D003657:Decision Making; D003661:Decision Support Techniques; D004239:Diverticulitis, Colonic / Q000401:mortality / Q000601:surgery*; D004630:Emergencies; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000401:mortality / Q000601:surgery*; D007813:Laparotomy / Q000379:methods* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index