Surgeon perspective on the treatment of acute diverticulitis: A survey-based analysis

BACKGROUND: Although primary anastomosis (with or without proximal diversion) offers improved morbidity and higher reversal rates compared with Hartmann procedure, little is known about real-world factors influencing surgical decision making in acute diverticulitis. METHODS: We conducted a mixed methods survey of surgeons treating diverticulitis, recruited through national colorectal and acute care/trauma surgical organizations. Surgeons were surveyed on their decision-making process, patient considerations, personal experience, and practice structure using a web-based survey. The primary outcome was percentage of primary anastomoses performed for diverticulitis in the past year. RESULTS: We recorded 439 survey responses; 233 (53%) were colorectal surgeons and 99 (23%) acute care surgeons. The median (interquartile range) number of primary anastomoses and Hartmann procedures performed for acute diverticulitis in the past year was 3.0 (1.0, 5.0) and 4.0 (2.0, 6.0), respectively, per surgeon. Roughly a third of surgeons reported performing primary anastomosis a majority (58.3%-100%) of the time. High anticipated surgical difficulty and hemodynamic instability were considered the most important situational and patient factors when deciding to perform a Hartmann procedure over a primary anastomosis. On multivariable analysis, acute care surgical specialty (odds ratio 0.41, 95% confidence interval 0.26-0.65; P < .001) was associated with a lower percentage of primary anastomoses performed. CONCLUSIONS: In this national survey, only one-third of surgeons performed primary anastomosis most of the time for diverticulitis. Patient acuity, high anticipated surgical difficulty, and the presence of proper operative assistance are some of the most important factors surgeons consider when deciding between a Hartmann procedure and primary anastomosis.