A Propensity-Score Matched ACS-NSQIP Database Analysis of Primary Anastomosis With or Without Diversion for Acute Perforated Diverticulitis.

BACKGROUND: Resection with primary anastomosis (RPA) has emerged as an accepted alternative to Hartmann's procedure for acute perforated diverticulitis with peritonitis, yet the need for routine diversion remains unclear. We compared short-term outcomes of RPA with and without diversion in this setting. METHODS: We conducted a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database (2014-2021), including patients who underwent RPA for perforated diverticulitis. Patients who had or did not have a diverting stoma were propensity score-matched for baseline characteristics. The primary outcomes were anastomotic leak and 30-day mortality, and secondary outcomes included postoperative complications, readmission, length of stay, and operative time. A subgroup analysis in patients with preoperative sepsis was conducted. RESULTS: Among 1228 eligible patients, 387 patients were matched in each group. Omission of diversion was not associated with an increased risk of anastomotic leak (5.5% vs 4.1%; OR 1.36; 95% CI, 0.60-3.10; p = 0.46) or 30-day mortality (3.4% vs 1.8%; OR 1.89; 95% CI, 0.75-4.78; p = 0.18). In a subgroup analysis of patients with preoperative sepsis, diversion was associated with a lower rate of clinically significant anastomotic leak (1.2% vs 5.9%, p = 0.039). Postoperative morbidity was similar between groups, with no significant differences in infectious, pulmonary, renal, cardiovascular, or thromboembolic complications. Diversion was associated with significantly higher 30-day readmission (23.3% vs 16.4%; OR 1.55; 95% CI, 1.01-2.37; p = 0.044), longer operative times (159 vs 131minutes, p<0.001), and prolonged hospital stay (9 vs 8 days, p<0.001). CONCLUSION: Based on evidence from observational data, RPA without a diverting stoma might not be associated with increased mortality or anastomotic leak in select patients with perforated diverticulitis. However, because several intraoperative factors that influence the decision to divert are not captured in NSQIP, residual confounding by indication remains possible, and these findings should be interpreted with caution.