Where Are We Now? An Update on Colectomies for Diverticulitis in the Wake of the COVID-19 Pandemic

Abstract

Background

The COVID-19 pandemic strained hospital systems and post-pandemic data on colectomy trends for diverticulitis are limited. We aimed to describe trends in colonic resections in patients with diverticulitis before, during, and after the pandemic.

Methods

This retrospective cohort study queried the American College of Surgeons NSQIP database, analyzing patients who underwent a colectomy for diverticulitis during quarters 2-4 (April 1-December 31) in 2018 (“pre-COVID”), 2020 (“during COVID”), and 2022 (“post-COVID”). The primary study outcome was emergency case rates during the 3 time periods. Secondary outcomes included trends in patient comorbidities, severity of presenting illness, 30-day postoperative complications, and disposition status.

Results

A total of 21,642 patients were studied (7163 pre-COVID, 6254 during COVID, and 8225 post-COVID). Emergency cases of diverticulitis increased to 21% during the COVID period but remained at 17% and 18% during the pre-COVID and post-COVID periods, respectively (P < 0.001). Similarly, end colostomy creation rates rose to 20% during COVID and returned to baseline levels (18%) after the pandemic (P < 0.001). Hospital length of stay and 30-day mortality increased during the COVID period and remained slightly elevated post-COVID.

Conclusions

The COVID-19 pandemic was associated with a temporary increase in emergency colectomies and end colostomy creations for diverticulitis, with operative urgency returning to pre-pandemic levels in the post-COVID period. Short-term postoperative outcomes also shifted modestly during and after the pandemic. These findings offer a national perspective on trends in the surgical management of diverticulitis during and after the pandemic and may help guide surgical practice during future health care disruptions.

Graphical Abstract

Keywords

COVID pandemic diverticulitis colorectal general surgery

Key Takeaways

• Emergency colectomy and end colostomy creation rates for diverticulitis increased during the COVID-19 pandemic but returned to near pre-pandemic levels in the post-pandemic period.

• Several short-term postoperative outcomes differed during and after the pandemic, including modest changes in length of stay, mortality, and readmissions related to the index surgery.

• These findings offer a national perspective on trends in the surgical management of diverticulitis during and after the pandemic and may help guide surgical practice during future health care disruptions.

Introduction

The World Health Organization officially declared COVID-19 a global pandemic in March 2020. By August 2020, COVID-19 had become the third leading cause of death in the United States, with daily fatalities exceeding 1000 and nationwide cases surpassing 5 million. As of July 2025, COVID-19-related deaths have exceeded 7 million worldwide and 1.2 million in the United States.¹

Not surprisingly, the COVID-19 pandemic placed a substantial strain on health care institutions across the United States.² There was considerable concern among health care professionals that these constraints would result in significant delays in care and worse outcomes for patients with various disease conditions. Nationwide, non-emergency surgeries were canceled, leading to immediate and long-term impacts on access to surgical care and worse patient outcomes.^3,4

During the acute phase of the pandemic, several studies reported a decrease in hospitalizations and surgical volume among patients with diverticulitis, accompanied by a significant increase in the severity of presenting illness and rates of emergency surgeries compared with pre-pandemic levels.^5,6,7,8,9 Furthermore, patients requiring emergency surgeries during the pandemic were more likely to have significant comorbidities at baseline, suggesting that limited access to timely care may have led to more severe presentations.⁶

Previous studies have demonstrated an increase in both emergency operations and the severity of presenting illness related to diverticulitis during the pandemic; however, less is known about trends following the pandemic. This study aimed to describe nationwide trends in colectomies in patients with diverticulitis before, during, and after the pandemic, using the NSQIP database. We hypothesized that compared to the pandemic period, post-pandemic years would demonstrate a return to pre-pandemic distributions of emergency vs elective colectomy and postoperative outcomes among patients undergoing surgery for diverticulitis.

Methods

Study Design

We performed a retrospective cohort study utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Adult patients who underwent a colectomy for diverticulitis during quarters 2-4 (April 1 to December 31) of 3 representative calendar years, namely, 2018 (“pre-COVID”), 2020 (“during COVID”), and 2022 (“post-COVID”), were included. These specific months and years were selected to reflect surgical practice patterns for colectomies performed for diverticulitis before, during, and after the peak impact of the COVID-19 pandemic on hospital systems in the United States.

Setting

The ACS NSQIP is a nationally validated database that includes de-identified, prospectively collected clinical data from participating hospitals across the United States. Hospitals contributing to NSQIP include academic, community, and private institutions, allowing for a nationally representative sample of surgical patients.

Participants

Eligible participants were adults (age ≥18 years) who underwent colectomy for diverticulitis. Patients were identified in the ACS NSQIP database using relevant Current Procedural Terminology (CPT) codes (Appendix A). Patients were included if their primary indication for surgery was diverticulitis, as defined in NSQIP’s Targeted Colectomy Participant Use Data File user guide.

Exposure Variable

The primary exposure was the year of surgery, categorized as pre-COVID (quarters 2-4, 2018, control year), during COVID (quarters 2-4, 2020), or post-COVID (quarters 2-4, 2022, control year). Control years, 2018 and 2022, were chosen based on a prior publication to account for any COVID impact on health institutions in late 2019 or early 2021.⁶

Outcomes

The primary outcome was emergency case status rates across the 3 time periods, as defined by NSQIP’s emergency case designation. Secondary outcomes included patient comorbidities, severity of presenting illness, reason for emergency surgery, surgical approach, end colostomy creation rates, 30-day postoperative complications, and disposition status across the 3 time periods. Additional patient- and procedure-level variables included the patient’s age, sex, race, body mass index (BMI), and American Society of Anesthesiologists (ASA) class. Thirty-day complications included superficial and organ space surgical site infections (SSIs), wound disruption or dehiscence, postoperative pneumonia, unplanned intubation, pulmonary embolism, failure to wean from ventilator >48 hours, urinary tract infections, stroke, myocardial infarction, sepsis, septic shock, reoperation, readmission, or mortality.

Statistical Analysis

Continuous variables are shown as mean with standard deviation and were compared using one-way analysis of variance (ANOVA). Categorical variables are shown as proportions and were compared using Chi-square tests. A multivariable adjusted logistic regression analysis examining between-period differences in emergency case status was carried out using backward selection, beginning with all variables with P < 0.20 in the univariate association, and retaining all variables with P < 0.05 in the final model. No patients were excluded due to missing data. Variables with >10% missingness (race and ethnicity) were retained by coding missing values as separate categories. Since all other variables had <10% missingness, no formal imputation was performed. All statistics were performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA).

IRB Exemption

Since this study analyzed only de-identified, publicly available data, it was deemed exempt from Institutional Review Board approval.

Results

Study Population Characteristics

We queried the NSQIP database for patients who underwent a colectomy in 2018, 2020, and 2022 (n = 128,780). A total of 21,642 patients who underwent colonic resection for diverticulitis during quarters 2-4 (April 1 to December 31) of these years met our inclusion criteria. The pre-COVID era (2018) included 7163 patients, the COVID era (2020) included 6254 patients, and the post-COVID era (2022) included 8225 patients (Table 1). During the COVID era, compared with the pre-COVID era, there was a relative decrease in operative volume for diverticulitis of 12.7%. In the post-COVID era, compared with the COVID era, there was a relative increase in operative volume for diverticulitis of 31.5%.

Table 1.

Study Population Characteristics by Time Period

N (%) or mean (SD)	Pre-COVID (2018)N = 7163	During COVID (2020)N = 6254	Post-COVID (2022)N = 8225	P-value
Age, years	60.0 (13.3)	60.0 (13.2)	60.0 (13.3)	0.99
Male sex	3177 (44.0)	2812 (45.0)	3664 (45.0)	0.77
Race				<0.001
American Indian/Native Hawaiian/Pacific Islander	41 (0.6)	49 (0.8)	63 (0.8)
Asian	69 (1.0)	64 (1.0)	101 (1.2)
Black or African American	518 (7.2)	475 (7.6)	557 (6.8)
Multiracial/unknown/other	825 (12.0)	1011 (16.0)	1296 (16.0)
White	5710 (80.0)	4655 (74.0)	6208 (75.0)
Hispanic ethnicity	530 (7.4)	486 (7.8)	825 (10)	<0.001
BMI, mean (SD)	29.7 (7.0)	29.7 (7.3)	29.7 (7.2)	0.77
Functional status prior to hospitalization				0.94
Independent	7018 (98.0)	6131 (98.0)	8017 (98.0)
Partially dependent	110 (1.5)	98 (1.6)	137 (1.7)
Totally dependent	17 (0.2)	14 (0.2)	22 (0.3)
ASA				<0.001
1- no disturbance	129 (1.8)	67 (1.1)	75 (0.9)
2- mild disturbance	3340 (47.0)	2619 (42.0)	3498 (43.0)
3- severe disturbance	3165 (44.0)	2983 (48.0)	3919 (48.0)
4- life-threatening	499 (7.0)	537 (8.6)	665 (8.1)
5- moribund	30 (0.4)	41 (0.7)	54 (0.7)
Comorbidities
Current smoker	1408 (20.0)	1299 (21.0)	1552 (19.0)	0.017
Diabetes	824 (12.0)	709 (11.0)	943 (11.0)	0.95
Ventilator dependent	24 (0.3)	36 (0.6)	35 (0.4)	0.11
COPD	370 (5.2)	318 (5.1)	391 (4.8)	0.46
Ascites	25 (0.4)	24 (0.4)	124 (1.5)	<0.001
CHF	66 (0.9)	72 (1.2)	325 (4.0)	<0.001
Hypertension requiring medication	3296 (46.0)	2930 (47.0)	3775 (46.0)	0.48
Acute renal failure	29 (0.4)	41 (0.7)	142 (1.7)	<0.001
Dialysis	67 (0.9)	63 (1.0)	71 (0.9)	0.67
Disseminated cancer	86 (1.2)	97 (1.6)	85 (1.0)	0.019
Steroid use	512 (7.2)	467 (7.5)	599 (7.3)	0.78
Bleeding disorder	269 (3.8)	275 (4.4)	376 (4.6)	0.035
Systemic sepsis preop				<0.001
None	5978 (83.0)	4992 (80.0)	6571 (80.0)
SIRS	181 (2.5)	199 (3.2)	233 (2.8)
Sepsis	869 (12.0)	901 (14.0)	1170 (14.0)
Septic shock	135 (1.9)	162 (2.6)	251 (3.1)
Emergency case	1244 (17.0)	1315 (21.0)	1464 (18.0)	<0.001
Rates of emergency colectomy among emergency cases				0.30
Bleeding	22 (1.8)	15 (1.1)	20 (1.4)
Obstruction	121 (9.7)	133 (10)	124 (8.5)
Other	55 (4.4)	71 (5.4)	70 (4.8)
Perforation	1023 (82.0)	1083 (82.0)	1230 (84.0)
Toxic colitis	12 (1.0)	8 (0.6)	15 (1.0)
Unknown	11 (0.9)	5 (0.4)	5 (0.3)

Abbreviations: standard deviation (SD), American Society of Anesthesiologists (ASA) Physical Status Classification System, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and systemic inflammatory response syndrome (SIRS).

Patient Demographics

Across the 3 time periods, there were no significant differences in the rates of colon resection for diverticulitis by age (60 years) or sex (44-45% male). There was a significant difference among the various races that underwent a colonic resection across the 3 time periods (P < 0.001) (Table 1). Colon resections for black individuals slightly increased (7.2% to 7.6%) from pre-COVID to COVID, which then receded below pre-pandemic levels (6.8%). The proportion of colonic resections among white individuals decreased from 80% pre-COVID to 74% during COVID, before slightly increasing to 75% in the post-COVID period. Across the 3 time periods, the proportion of colonic resections for Hispanic individuals persistently increased (from 7.4% to 10%).

Patient Comorbidities

During the COVID era, there was a greater proportion of patients with significant comorbidities who underwent a colonic resection for diverticulitis (Table 1). A greater proportion of ASA class 4 patients underwent colonic resection for diverticulitis during the COVID era. Current smokers and patients with disseminated cancer were also more likely to undergo resection during the pandemic, whereas acute renal failure, ascites, bleeding disorders, and CHF were more common in the post-COVID period.

Emergency Case Status

Despite a decrease in operative volume during the COVID pandemic, the proportion of emergency colonic resections for diverticulitis increased significantly compared to the pre- and post-COVID periods (Table 1). Multivariable logistic regression demonstrated higher odds of emergency colectomy for diverticulitis during the COVID period compared with pre-COVID (aOR: 1.14, 95% CI: 1.03-1.26) and lower odds in the post-COVID period (aOR: 0.87, 95% CI: 0.80-0.96), after controlling for demographic, comorbidity, and perioperative factors (Table 2).

Table 2.

Likelihood of Undergoing an Emergency Case by Time Period

	Crude estimate (OR)	Multivariable adjusted estimate^a (aOR)
Pre-COVID	Ref.	Ref.
COVID	1.27 (95% CI: 1.16-1.38)	1.14 (95% CI: 1.03-1.26)
Post-COVID	1.03 (95% CI: 0.95-1.12)	0.87 (95% CI: 0.80-0.96)

Abbreviations: odds ratio (OR), adjusted odds ratio (aOR).

^aAdjusted for age, sex, race, Hispanic ethnicity, ASA class, current smoking, ventilator dependence, ascites, hypertension requiring medication, acute renal failure, disseminated cancer, steroid use, and bleeding disorder.

Perioperative Factors

Preoperatively, a greater proportion of patients presented with sepsis during and after the COVID pandemic compared to before. The proportion of patients diagnosed with septic shock preoperatively increased during the COVID period and continued to rise in the post-COVID period.

Intraoperative Factors

During the COVID period, there was a greater proportion of end colostomy creations (ie, Hartmann’s procedures) compared to before and after the COVID period (Table 3). Overall, operative approaches for all colonic resections varied significantly before, during, and after the COVID period. The proportion of open colonic resections increased from the pre-COVID to the COVID period and then decreased in the post-COVID period. Across all 3 time periods, there was a steady relative increase in robotic approaches for colonic resections from 16% to 25%.

Table 3.

Operative Approach and Stoma Rates Among Colonic Resections by Time Period

N (%)	Pre-COVID (2018)N = 7163	During COVID (2020)N = 6254	Post-COVID (2022)N = 8225	P-value
Operative approach				<0.001
Laparoscopic	3813 (53.0)	3008 (48.0)	3654 (44.0)
Open	2196 (31.0)	2065 (33.0)	2455 (30.0)
Other	35 (0.5)	31 (0.5)	26 (0.3)
Robotic	1119 (16.0)	1150 (18.0)	2088 (25.0)
Unexpected conversion	609 (8.5)	515 (8.2)	673 (8.2)	0.75
End colostomy creation (Hartmann’s procedure)	1258 (18.0)	1254 (20.0)	1479 (18.0)	<0.001

Postoperative Complications

Compared to the pre-COVID period, 30-day mortality and hospital length of stay were modestly higher during and after the COVID period (Table 4). Patients treated during the COVID period experienced slightly increased rates of organ space surgical site infection (SSI), prolonged postoperative nil per os (NPO) status or nasogastric tube (NGT) use, and failure to wean from the ventilator for more than 48 hours. Despite the increased proportion of emergency cases during the pandemic, no significant differences were observed in 30-day reoperation rates or several postoperative complications, including superficial SSI, wound disruption, wound dehiscence, unplanned intubation, pulmonary embolism, urinary tract infection, stroke/CVA requiring therapy, cardiac arrest requiring CPR, anastomotic leak requiring treatment or conservative management, or days to readmission across the 3 time periods. In the post-COVID period, there was a slight increase in the number of days from hospital admission to operation, as well as higher rates of postoperative pneumonia, sepsis, and septic shock.

Table 4.

30-Day Postoperative Complications and Disposition Status by Time Period

N (%) or mean (SD)	Pre-COVID (2018)N = 7163	During COVID (2020)N = 6254	Post-COVID (2022)N = 8225	P-value
Total hospital length of stay (days)	6.8 (6.1)	7.1 (6.4)	7.0 (6.5)	0.011
Days from hospital admission to operation, mean (SD)	1.1 (3.1)	1.2 (3.1)	1.2 (3.6)	0.011
Death	118 (1.7)	139 (2.2)	178 (2.2)	0.027
Superficial surgical site infection (SSI)	256 (3.6)	244 (3.9)	326 (4.0)	0.42
Wound disruption	42 (0.6)	42 (0.7)	65 (0.8)	0.31
Organ/space surgical site infection	510 (7.1)	587 (9.4)	728 (8.9)	<0.001
Wound dehiscence	85 (1.2)	83 (1.3)	96 (1.2)	0.65
Postoperative pneumonia	136 (1.9)	196 (3.1)	252 (3.1)	<0.001
Unplanned intubation	100 (1.4)	92 (1.5)	111 (1.4)	0.83
Pulmonary embolism	43 (0.6)	39 (0.6)	73 (0.9)	0.06
Failure to wean from ventilator >48 h	160 (2.2)	196 (3.1)	227 (2.8)	0.005
Urinary tract infection	126 (1.8)	122 (2.0)	153 (1.9)	0.71
Stroke/CVA requiring therapy	16 (0.2)	8 (0.1)	21 (0.3)	0.23
Cardiac arrest requiring CPR	32 (0.5)	40 (0.6)	45 (0.6)	0.31
Myocardial infarction	37 (0.5)	53 (0.9)	70 (0.9)	0.027
Sepsis	561 (7.8)	551 (8.8)	809 (9.8)	<0.001
Septic shock	258 (3.6)	317 (5.1)	433 (5.3)	<0.001
Anastomotic leak
Leak, no treatment intervention documented	16 (0.2)	13 (0.2)	18 (0.2)	0.98
Leak, treated with interventional means	42 (0.6)	53 (0.9)	52 (0.6)	0.15
Leak, treated with non-interventional/non-operative means	47 (0.7)	37 (0.6)	34 (0.4)	0.11
Leak, treated with reoperation	96 (1.3)	91 (1.5)	127 (1.6)	0.55
Prolonged postoperative NPO or NGT use	976 (14.0)	972 (16.0)	1238 (15.0)	0.004
Reoperation	306 (4.3)	309 (4.9)	389 (4.7)	0.16
Reoperation related to index surgery	282 (3.9)	282 (4.5)	332 (4.0)	0.20
Days to readmission, mean (SD)	15.5 (7.4)	15.3 (7.0)	15.7 (7.6)	0.71
Unplanned readmission	613 (8.6)	531 (8.5)	652 (7.9)	0.24
Readmission related to index surgery	562 (7.9)	476 (7.6)	539 (6.6)	0.018
Discharge destination				<0.001
Home	6360 (89.0)	5610 (91.0)	7342 (91.0)
Acute care hospital	33 (0.5)	31 (0.5)	40 (0.5)
Other facility	655 (9.2)	392 (6.4)	533 (6.6)
Expired during hospital stay	95 (1.3)	106 (1.7)	135 (1.7)
AMA	5 (0.1)	7 (0.1)	16 (0.2)

Abbreviations: surgical site infection (SSI), cerebrovascular accident (CVA), cardiopulmonary resuscitation (CPR), nil per os (NPO), nasogastric tube (NGT), and against medical advice (AMA).

Discussion

This study demonstrates that following the COVID-19 pandemic, although there was an overall increase in the total number of colectomies performed for diverticulitis, the proportion of emergency cases has returned to pre-pandemic levels. In many other pathologies, the literature has shown that the COVID pandemic caused interruptions in clinical care, leading to delays in treatment and altered health care-seeking behavior, resulting in increased severity at presentation and worse outcomes for both acute and chronic conditions.^10,11 However, the long-term implications of these delays remain an active area of investigation.

Previous studies have reported similar patterns in emergency colonic resection rates for diverticulitis when comparing pre-COVID pandemic and COVID pandemic periods^5,6,7,8,9,12; however, these trends do not appear to be consistent across other disease pathologies. One study demonstrated that patients with inflammatory bowel disease were less likely to undergo an emergency operation in 2020 than in 2019.¹³ These differences likely reflect underlying pathophysiological differences in disease course and the thresholds at which operative intervention is pursued. The increased rates of emergency colectomies and end colostomy creations during the COVID pandemic may be attributed to several factors. Studies have suggested that the rise in emergency cases during the pandemic may reflect increased use of conservative management and delays in care, as patients avoided seeking medical attention or were unable to undergo elective resections, potentially allowing disease progression.^{6,8,9,14,15,16} Our multivariable logistic regression model supports these findings and suggests that, after adjusting for demographic and perioperative factors, the increase in emergency vs elective colonic resections during the COVID period was temporary, with case mix returning toward pre-pandemic levels post-COVID.

Another plausible explanation for the higher rates of emergency colonic resection and end colostomy creation during the pandemic may be the direct effects of coronavirus infection on disease severity. Unfortunately, the diagnosis of COVID-19 at the time of colonic resection was not available for all 3 time periods in the NSQIP database. Recent studies have demonstrated a possible link between acute diverticulitis and COVID-19 infection.^6,17,18 These studies suggest that the COVID-induced chronic inflammatory state may cause inflammation-mediated tissue damage, leading to increased intestinal edema and promoting bacterial overgrowth, which could result in acute diverticulitis and intestinal perforation. However, we did not detect a significant difference in indications, including perforation, for emergency colectomy cases in patients with diverticulitis before, during, and after the COVID pandemic.

Similar to other studies, our findings demonstrated that more patients underwent an open operative approach, including procedures involving end colostomy creation, during the COVID-19 pandemic, likely reflecting a transient rise in emergency cases.¹⁴ This increase in the proportion of open operative approaches and end colostomy creations was observed only during the pandemic. Laparoscopic cases steadily decreased, while robotic approaches significantly increased throughout the study period. These findings highlight a broader evolution in the management of diverticulitis, including the adoption of minimally invasive techniques and more individualized surgical decision-making.¹⁹ Another plausible explanation for the transient increase in open procedures and end colostomy rates during the COVID period was reduced access to colorectal surgeons. While this cannot be discerned through NSQIP, subspecialty-trained colorectal surgeons may be more likely to employ minimally invasive techniques and perform primary anastomosis, in keeping with the American Society of Colon and Rectal Surgeons clinical practice guidelines on diverticulitis.²⁰ Finally, another plausible explanation for the transient rise in open procedures is that early in the pandemic, there was concern regarding potential SARS-CoV-2 transmission via aerosolization during laparoscopic insufflation, leading many surgeons to favor open approaches during this period.^21,22

Postoperative outcomes varied modestly across the study periods. During the COVID period, higher rates of organ space infections and prolonged ventilator dependence were observed, whereas the post-COVID era showed slight increases in pneumonia, sepsis, and septic shock. Despite a transient rise in emergency cases, reoperation rates did not differ significantly across the study periods. We also observed a modest increase in 30-day mortality between the pre-COVID and COVID periods, which aligns with findings from prior studies.^8,14 Our analysis extends these observations by including data from the post-COVID era. Although emergency colectomy rates returned toward pre-pandemic levels, 30-day mortality and hospital length of stay remained modestly elevated following the pandemic. These patterns may reflect the persistent increase in illness severity among patients undergoing colectomy during and after the pandemic. While this study cannot assess outpatient access to care or delays in presentation, we only observed slight increases in the time from hospital admission to surgery across the time periods. These findings provide additional context for the patterns of postoperative outcomes among patients undergoing colectomy for diverticulitis before, during, and after the COVID-19 pandemic.

In our study, we observed a continued trend of patients being discharged home rather than to post-acute care facilities, a pattern that emerged during the COVID period and persisted thereafter. This finding aligns with a prior NSQIP analysis demonstrating decreased discharges to post-hospitalization facilities despite increased emergency colonic resections during the pandemic.²³ Our findings expand on this work by providing additional context for discharge practices during and after the COVID period.

Study Strengths and Limitations

Strengths of this study include the use of the NSQIP database, which enabled us to evaluate trends in colonic resections for diverticulitis across the pre-COVID, COVID, and post-COVID periods. Additionally, the month-matched analysis, including only quarters 2-4, aligns the study periods with the onset of the pandemic and accounts for the known seasonality of diverticulitis, strengthening the validity of the analysis. To our knowledge, this is the first study to characterize post-pandemic trends in the surgical management of diverticulitis at a national level. Specifically, we document that emergency colonic resections for diverticulitis returned to pre-pandemic levels following temporary disruptions caused by the pandemic, with only modest differences observed in select postoperative outcomes.

This study has several limitations that should be considered when interpreting our findings. First, it is retrospective and relies on data from the NSQIP database, which may not capture all relevant clinical variables, including COVID-19 infection status, disease recurrence, or details of outpatient management. Next, unmeasured confounding factors may have influenced the designation of emergency status, such as hospital triage policies, surgeon preferences, or regional case surges during the pandemic. Finally, NSQIP does not capture outpatient access, non-operative management, or the direct effects of lockdown policies, so we were unable to assess whether system-level improvements or timely clinical evaluation influenced the management of diverticulitis across the 3 time periods.

To our knowledge, this is the first nationwide study to report post-pandemic trends in colon resections for diverticulitis and to demonstrate a return to pre-pandemic levels of emergency cases. Our findings show that although the proportion of emergency cases and the rates of end colostomy creation increased during the COVID period, operative urgency returned to pre-pandemic levels in the post-COVID era, while several short-term postoperative outcomes differed modestly across the study periods. These results provide national-level context for patterns in the surgical management of diverticulitis before, during, and after the pandemic and may help guide surgical practice during future health care disruptions.

Footnotes

Acknowledgments

American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

ORCID iDs

Benjamin Gallant

Andrew Hu

Author Contributions

Dr. Gallant and Dr. Aulet were responsible for conceptualization, investigation, methodology, resources, writing—original draft, writing—review and editing, and validation. Ms. Crawford conducted the formal analysis and assisted with writing—review and editing. Dr. Peponis, Dr. Sturrock, Dr. Alavi, and Dr. Maykel contributed to investigation, methodology, and writing—review and editing. Dr. Hu, Dr. Oldewurtel, and Mr. Hwang contributed to methodology and writing—review and editing. All authors provided substantial contributions.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1-TR001453. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Meeting Presentation

E-poster presentation at the American Society of Colon and Rectal Surgeons meeting (ASCRS), May 10-13, 2025, San Diego, CA.

IRB Approval

Since this study analyzed only de-identified, publicly available data, it was deemed exempt from approval by the University of Massachusetts Chan Medical School Institutional Review Board.

Appendix

The following CPT procedure codes were included: 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, and 44210.

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