title: Outcomes and cost of diverted versus undiverted restorative proctocolectomy.
abstract: BACKGROUND
  Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy.
  
  
  METHODS
  This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected.
  
  
  RESULTS
  There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients.
  
  
  CONCLUSIONS
  Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY, 10029, USA, as013j@gmail.com.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stey
authors.forename: Robert H
authors.initials: RH
authors.lastname: Brook
authors.forename: Emmett
authors.initials: E
authors.lastname: Keeler
authors.forename: Michael T
authors.initials: MT
authors.lastname: Harris
authors.forename: Tomas
authors.initials: T
authors.lastname: Heimann
authors.forename: Randolph M
authors.initials: RM
authors.lastname: Steinhagen
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000009:adverse effects; D057868:Anastomotic Leak / Q000209:etiology; D015331:Cohort Studies; D003251:Constriction, Pathologic / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D046449:Hernia, Abdominal / Q000209:etiology; D006801:Humans; D007081:Ileostomy / Q000009:adverse effects* / Q000191:economics*; D007412:Intestinal Fistula / Q000209:etiology; D007415:Intestinal Obstruction / Q000209:etiology; D007421:Intestine, Small; D007902:Length of Stay; D008297:Male; D061646:Operative Time; D016737:Proctocolectomy, Restorative / Q000009:adverse effects* / Q000191:economics* / Q000379:methods; D012189:Retrospective Studies