Background: Evidence increasingly supports sigmoidectomy with primary anastomosis (SPA) and diverting loop ileostomy over Hartmann's procedure for perforated diverticulitis in stable patients. Prompt diverting loop ileostomy reversal (DLIR) is often preferred by patients; however, optimal timing after index surgery remains unclear. The objective of this study is to examine the association of DLIR timing with clinical outcomes and costs.
Methods: Retrospective analysis was performed using National Readmissions Database (2010-2020) of all adults who underwent emergent sigmoidectomy with primary anastomosis (SPA) and diverting loop ileostomy for perforated diverticulitis with subsequent elective diverting loop ileostomy reversal (DLIR). Timing of DLIR in days after discharge from index admission was categorized as early (<25 percentile), middle (25-75 percentile), or late (>75 percentile). Multivariable regression was used to evaluate association of DLIR timing with postoperative complications, length of stay, and inpatient costs controlling for relevant patient and hospital characteristics including complications during index admission.
Results: A total of 5,757 patients were analyzed: 24% early DLIR (<61 days), 51.5% middle (61-115 days), and 24.5% late (>115 days). Late reversal patients had a higher proportion of public insurance, comorbidities, and incidence of complications after index SPA. After adjusting for patient and hospital characteristics, including complication after index SPA, odds of complication following DLIR was higher for middle (adjusted odds ratio, 1.85; 95% CI, 1.25-2.74) and late (adjusted odds ratio, 3.61; 95% confidence interval, 2.40-5.42) groups compared with the early reversal. Length of stay and cost of DLIR admission were also increased in middle and late groups.
Conclusion: Early DLIR after SPA for perforated diverticulitis is safe and associated with fewer postoperative complications, shorter length of stay, and lower costs compared with late reversal. Consideration should be given to early DLIR (6-8 weeks) after index SPA for appropriate patients.
Level Of Evidence: Well-designed Retrospective Cohort Study; Level IV.
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