Toward lowering morbidity, mortality, and stoma formation in emergency colorectal surgery: the role of specialization

Comparing return of bowel function after right versus extended right hemicolectomy: a retrospective analysis

BACKGROUND

Prolonged postoperative ileus (PPOI) is associated with higher morbidity and extended inpatient stay. Although evidence suggests that PPOI is more common following right-sided resections, it is uncertain if return to bowel function is similar following extended right (ERH) versus right hemicolectomy (RH).

METHODS

The recovery of patients undergoing ERH and RH in a regional hospital in New Zealand was retrospectively compared, from 2012 to 2021. Rates of PPOI, return of bowel function and postoperative complications were compared. Other factors potentially relating to PPOI were analysed.

RESULTS

293 patients were included (42 who underwent ERH, and 251 RH). PPOI was more common following ERH than RH (43% vs. 25%, P = 0.02). When accounting for the operative approach, rate of PPOI was not significantly different (42% open ERH vs. 36% open RH; P = 0.56). Excluding PPOI, return of bowel function did not differ between groups. Patient undergoing ERH versus RH had significantly higher length of stay (1 day) and Hb drop (2.5 g/L) postoperatively.

CONCLUSION

Higher rates of PPOI have been demonstrated in ERH versus RH however when controlling for approach, there was not a significant difference. Further interrogation into rates of PPOI (particularly after laparoscopic surgery) are warranted to tailor locoregional ERAS protocols.

Postoperative outcomes and identification of risk factors for complications after emergency intestinal stoma surgery - a multicentre retrospective study

AIM

Approximately 4000 patients in the UK have an emergency intestinal stoma formed each year. Stoma-related complications (SRCs) are heterogeneous but have previously been subcategorized into early or late SRCs, with early SRCs generally occurring within 30 days postoperatively. Early SRCs include skin excoriation, stoma necrosis and high output, while late SRCs include parastomal hernia, retraction and prolapse. There is a paucity of research on specific risk factors within the emergency cohort for development of SRCs. This paper aims to describe the incidence of SRCs after emergency intestinal surgery and to identify potential risk factors for SRCs within this cohort.

METHOD

Consecutive patients undergoing emergency formation of an intestinal stoma (colostomy, ileostomy or jejunostomy) were identified prospectively from across three acute hospital sites over a 3-year period from the ELLSA (Emergency Laparotomy and Laparoscopic Scottish Audit) database. All patients were followed up for a minimum of 1 year. A multivariate logistic regression model was used to identify risk factors for early and late SRCs.

RESULTS

A total of 455 patients were included (median follow-up 19 months, median age 64 years, male:female 0.52, 56.7% ileostomies). Early SRCs were experienced by 54.1% of patients, while 51% experienced late SRCs. A total of 219 patients (48.1%) had their stoma sited preoperatively. Risk factors for early SRCs included end ileostomy formation [OR 3.51 (2.24-5.49), p < 0.001], while preoperative stoma siting was found to be protective [OR 0.53 (0.35-0.83), p = 0.005]. Patient obesity [OR 3.11 (1.92-5.03), p < 0.001] and reoperation for complications following elective surgery [OR 4.18 (2.01-8.69), p < 0.001] were risk factors for late SRCs.

CONCLUSION

Stoma-related complications after emergency surgery are common. Preoperative stoma siting is the only truly modifiable risk factor to reduce SRCs, and further research should be aimed at methods of improving the frequency and accuracy of this in the emergency setting.

Machine learning-based prediction of postoperative mortality in emergency colorectal surgery: A retrospective, multicenter cohort study using Tokushukai medical database

Background

Although prognostic factors associated with mortality in patients with emergency colorectal surgery have been identified, an accurate mortality risk assessment is still necessary to determine the range of therapeutic resources in accordance with the severity of patients. We established machine-learning models to predict in-hospital mortality for patients who had emergency colorectal surgery using clinical data at admission and attempted to identify prognostic factors associated with in-hospital mortality.

Methods

This retrospective cohort study included adult patients undergoing emergency colorectal surgery in 42 hospitals between 2012 and 2020. We employed logistic regression and three supervised machine-learning models: random forests, gradient-boosting decision trees (GBDT), and multilayer perceptron (MLP). The area under the receiver operating characteristics curve (AUROC) was calculated for each model. The Shapley additive explanations (SHAP) values are also calculated to identify the significant variables in GBDT.

Results

There were 8792 patients who underwent emergency colorectal surgery. As a result, the AUROC values of 0.742, 0.782, 0.814, and 0.768 were obtained for logistic regression, random forests, GBDT, and MLP. According to SHAP values, age, colorectal cancer, use of laparoscopy, and some laboratory variables, including serum lactate dehydrogenase serum albumin, and blood urea nitrogen, were significantly associated with in-hospital mortality.

Conclusion

We successfully generated a machine-learning prediction model, including GBDT, with the best prediction performance and exploited the potential for use in evaluating in-hospital mortality risk for patients who undergo emergency colorectal surgery.

Weekend effect in emergency laparotomy: a propensity score-matched analysis

BACKGROUND

The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients.

METHODS

A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics.

RESULTS

Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464).

CONCLUSIONS

These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

Surgical approaches to colonic and rectal anastomosis: systematic review and meta-analysis

PURPOSE

Postoperative complications after a colonic and rectal surgery are of significant concern to the surgical community. Although there are different techniques to perform anastomosis (i.e., handsewn, stapled, or compression), there is still no consensus on which technique provides the least number of postoperative problems. The objective of this study is to compare the different anastomotic techniques regarding the occurrence or duration of postoperative outcomes such as anastomotic dehiscence, mortality, reoperation, bleeding and stricture (as primary outcomes), and wound infection, intra-abdominal abscess, duration of surgery, and hospital stay (as secondary outcomes).

METHODS

Clinical trials published between January 1, 2010, and December 31, 2021, reporting anastomotic complications with any of the anastomotic technique were identified using the MEDLINE database. Only articles that clearly defined the anastomotic technique used, and report at least two of the outcomes defined were included.

RESULTS

This meta-analysis included 16 studies whose differences were related to the need of reoperation (p < 0.01) and the duration of surgery (p = 0.02), while for the anastomotic dehiscence, mortality, bleeding, stricture, wound infection, intra-abdominal abscess, and hospital stay, no significant differences were found. Compression anastomosis reported the lowest reoperation rate (3.64%) and the handsewn anastomosis the highest (9.49%). Despite this, more time to perform the surgery was required in compression anastomosis (183.47 min), with the handsewn being the fastest technique (139.92 min).

CONCLUSIONS

The evidence found was not sufficient to demonstrate which technique is most suitable to perform colonic and rectal anastomosis, since the postoperative complications were similar between the handsewn, stapled, or compression techniques.

Peristomal Necrosis Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Case Report

BACKGROUND

Peristomal necrosis is a rare but challenging condition requiring multidisciplinary management involving surgical debridement and intensive WOC nurse management.

CASE

Mr T was a 56-year-old man who underwent cytoreductive surgery with intraperitoneal chemotherapy for a high-grade appendiceal neoplasm. As part of the procedure, an Abcarian stoma (end-ileostomy with a distal lumen from the transverse colon brought out flush with skin beside the proximal stoma) was created. Postoperatively there was leakage of effluent under the subcutaneous skin resulting in full-thickness necrosis of the peristomal area requiring surgical debridement. Consequently, a large peristomal skin defect occurred, resulting in difficulty achieving a good seal of the ostomy pouching system. To overcome these challenges, a multidisciplinary approach with WOC nurses, colorectal surgeons, and plastic surgeons was implemented. Initially, the defect was managed with a negative pressure wound therapy system, followed by a primary closure of the peristomal skin by the plastic surgeons. Mr T was discharged to home 58 days after his initial surgery; by that time, the peristomal skin was healed and he was able to manage ostomy pouching changes independently. Eight months later his ileostomy was successfully reversed.

CONCLUSIONS

Large peristomal defects are challenging but can be managed successfully via a multidisciplinary approach including WOC nurses, colorectal surgeons, and plastic surgeons.

The impact of surgical subspecialization on patient outcomes following emergency colorectal resections in the north of England: a retrospective cohort study

AIM

Emergency colorectal surgery is associated with significant morbidity and mortality. Most general surgeons have a subspecialty, which forms the focus of their elective work, allowing development of specialist skill sets. The aim of this study was to assess the impact of consultant subspecialization on patient outcomes following emergency colorectal resections.

METHODS

Data were requested for all emergency admissions under a general surgeon between 1 January 2002 and 31 December 2016 within the north of England. These were acquired from individual Trusts following Caldicott approval. Data included demographics, diagnoses and any procedures undertaken. Patients were assigned to cohorts based on the subspecialist interest of the consultant they were under the care of. The primary outcome of interest was 30-day postoperative mortality. Categorical data were compared with the chi-squared test, and continuous data with the t test or ANOVA. A logistic regression model determined factors associated with 30-day in-hospital mortality.

RESULTS

Overall, 7648 emergency colorectal resections were performed with a 30-day postoperative mortality of 13.8%. This was significantly lower if the responsible consultant was a colorectal surgeon compared with other general surgery subspecialties (11.8% vs. 15.2%, P < 0.001). This was significant on univariate analysis (OR 0.75, P < 0.001); however, following multivariable adjustment, this was not statistically significant (P = 0.380). The colorectal specialists had a higher laparoscopy rate than their colleagues-9.8% versus 6.8% (P < 0.001). Stoma rates were also lower (46.9% vs. 51.0%, P = 0.001) and anastomosis rates higher (55.9% vs. 49.3%, P < 0.001) amongst colorectal surgeons.

CONCLUSION

These findings add to the growing body of evidence that patient outcomes may be improved by involving subspecialists in colorectal emergencies.

Comparison of primary anastomosis and staged surgery in emergency treatment of complicated Crohn's disease

OBJECTIVES

Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies.

METHODS

Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs.

RESULTS

Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra-abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log-rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m² ) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group.

CONCLUSION

SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.

Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors

Purpose

The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis.

Methods

Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression.

Results

Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044).

Conclusions

In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.

Does declared surgeon specialist interest influence the outcome of emergency laparotomy?

INTRODUCTION

In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes.

METHODS

Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes.

RESULTS

Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay.

CONCLUSION

Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.

Volume and in-hospital mortality after emergency abdominal surgery: a national population-based study

​OBJECTIVES: Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level. ​DESIGN: This is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland. ​SETTING: 24 public hospitals providing EAS services. ​PARTICIPANTS AND INTERVENTIONS: Patients undergoing EAS as identified by primary procedure codes during the period 2014-2018. ​MAIN OUTCOME MEASURES: The main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250-449) and high (450+) volume and surgical teams with low (<30), medium (30-59) and high (60+) volume during the study period were also estimated. ​RESULTS: The study included 10 344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals. ​CONCLUSION: Patients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.

Ostomy-Related Complications

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

Emergent Colon Resections: Does Surgeon Specialization Influence Outcomes?

BACKGROUND

Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described.

OBJECTIVE

The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy.

DESIGN

This was a retrospective cohort study.

SETTINGS

Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included.

PATIENTS

Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon.

MAIN OUTCOME MEASURES

Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients.

RESULTS

A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001).

LIMITATIONS

This study was limited by its retrospective design, with potential selection bias attributed to referral patterns.

CONCLUSIONS

After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Intestinal Stomas-Postoperative Stoma Care and Peristomal Skin Complications

Intestinal stomas are necessary for several colon and rectal conditions and represent a major change in the new ostomate's daily life. Though dehydration is the most frequent etiology requiring readmission, irritant contact dermatitis and a host of other peristomal skin conditions are more common complications for ostomates. Wound, ostomy, and continence nurses are invaluable resources to both ostomy patients and providers. A few simple interventions can prevent or resolve most common peristomal complications. Good stoma care is possible in a resource-poor environment.

[Enteroenterostomy in surgical treatment of malignant colonic obstruction]

AIM

To consider surgical tactics and to study the immediate results of primary enteroenterostomy in surgical treatment of malignant colonic obstruction.

MATERIAL AND METHODS

Radical surgery was performed in 170 (63.9%) out of 266 patients with malignant obstructive colonic obstruction. Colonic resection followed by anastomosis was performed in 68 patients. Conventional hemicolectomy (9 patients) and various original techniques of Y-shaped ileotransversanastomoses (27 patients) were used for right-sided tumor process. In case of left-sided tumor we used intraoperative colonic irrigation with enterosorption (20 operations), Y-shaped anastomoses (9 operations) and subtotal colectomy (3 operations).

RESULTS

There was significantly increased mortality in patients with sub- and decompensated stages of malignant colonic obstruction. Postoperative mortality after radical surgery was 10.6%, after palliative interventions - 21.9%. There was similar postoperative mortality after various types of radical interventions with/without enteroenterostomy (8.8% and 11.8%, respectively).

CONCLUSION

In favorable clinical situation radical surgery with tumor removal at the first emergency stage should be preferred for malignant colonic obstruction. At the specialized hospital segmental colonic resection with primary anastomosis is possible after comprehensive assessment of surgical risk, intraoperative colonic irrigation is obligatory for left-sided tumor. This approach increases surgical effectiveness and provides early rehabilitation.

Outcomes in Colorectal Surgeon-Driven Management of Obstructing Colorectal Cancers

BACKGROUND

Emergency surgery for obstructing colorectal cancer is associated with high mortality and morbidity rates.

OBJECTIVE

The purpose of this study was to assess outcomes of emergency surgery for obstructing colorectal cancer in a single hospital, where care was primarily provided by colorectal surgeons.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at the Toyonaka Municipal Hospital.

PATIENTS

The study included 208 consecutive patients who underwent emergency surgery for obstructing colorectal cancer between 1998 and 2013.

MAIN OUTCOME MEASURES

Surgical outcomes, including mortality and morbidity, were evaluated.

RESULTS

The obstructing cancers involved the right colon, left colon, and rectum in 78, 97, and 33 of the included patients. Many patients had poor performance indicators, such as age ≥75 years (42%), ASA score of III or more (38%), stage IV colorectal cancer (39%), obstructive colitis (12%), and perforation or penetration (9.6%). Colorectal surgeons performed the operations in all but 5 of the patients. Primary resection and anastomosis were accomplished in 96%, 70%, and 27% of cases involving the right colon, left colon, and rectum. Intraoperative colonic irrigation (n = 32), manual colonic decompression (n = 11), and subtotal or total colorectal resection (n = 34) were performed before left-sided anastomoses. Anastomotic leak was reported in only 2 patients. The in-hospital mortality and morbidity rates were 1.3% and 34.0%.

LIMITATIONS

This study was a retrospective analysis of data from a single hospital.

CONCLUSIONS

Surgical outcome analysis for obstructing colorectal cancers managed by specialized colorectal surgeons demonstrates low mortality and morbidity rates. Therefore, we concluded that our management of this condition is safe and feasible.

Outcomes and Risk Factors Affecting Mortality in Patients Who Underwent Colorectal Emergency Surgery

Purpose

Emergency colorectal surgery has a high risk of mortality and morbidity because of incomplete bowel preparation, bacterial proliferation, and contamination. In this study, we investigated the outcomes and the risk factors affecting mortality in patients who had undergone emergency surgery for the treatment of various colorectal diseases.

Methods

This study is a retrospective analysis of prospectively collected data to survey the clinical results for patients who had undergone emergency colorectal surgery from January 2014 to December 2014. We analyzed various clinicopathologic factors, which were divided into 3 categories: preoperative, intraoperative, and postoperative.

Results

A total of 50 patients had undergone emergency colorectal surgery during the time period covered by this study. Among them, 10 patients (20%) died during the postoperative period. A simple linear regression analysis showed that the risk factors for mortality were old age, preoperative hypotension, and a high American Society of Anesthesiologist (ASA) score. Moreover, a multiple linear regression analysis showed a high ASA score and preoperative hypotension to be independent risk factors.

Conclusion

In this study, emergency colorectal surgery showed a relatively high mortality rate. Furthermore, the independent risk factors for mortality were preoperative hypotension and high ASA score; thus, patients with these characteristics need to be evaluated more carefully and receive better care if the mortality rate is to be reduced.

Emergency right colectomy: which strategy when primary anastomosis is not feasible?

Background

Primary anastomosis is considered the standard strategy after right emergency colectomy. The present study aimed to evaluate alternative treatment strategies when primary anastomosis is not possible to prevent definitive ostomy.

Methods

This retrospective study included all consecutive patients who underwent right emergency colectomy between July 2006 and June 2013. Demographics, surgical data, and postoperative outcomes were entered in an anonymized database. Comparative analysis was performed between patients with primary anastomosis (PA group) and those where alternative strategies were employed (no-PA group). Outcomes were 30 days complications rate and rate of bowel continuity restoration.

Results

One hundred forty-eight patients (57 % male) with a median age of 65 years (15–96) were included. One hundred and sixteen patients underwent PA (78 %) and 32 were in the no-PA group (22 %). No-PA group patients had more comorbidities (Carlson comorbidity index >3: 98 % vs. 54, p < 0.001). Major complications rate (Dindo-Clavien III to IV) was 24 % in PA group, 88 % in no-PA group (p < 0.001). The 30-day mortality rate was 6 % (n = 7) in PA group versus 25 % (n = 8) in no-PA group (p = 0.004). Fourteen patients in the no-PA group had a split stoma and 18 had a two-staged procedure. Five patients had continuity restoration after initial split stoma (36 %) compared to 10 after a two-staged procedure (55 %; p = 0.265). Anastomotic leak occurred in 10 patients of the PA group (9 %) versus 0 in the no-PA group, where 15 out of 32 patients (47 %) had continuity restoration.

Conclusion

Eighty percent of patients requiring emergency right colectomy were anastomosed primarily. For the remaining a two-staged procedure might facilitate bowel continuity restoration in the long-term.

Day and night surgery: is there any influence in the patient postoperative period of urgent colorectal intervention?

BACKGROUND

Medical activity performed outside regular work hours may increase risk for patients and professionals. There is few data with respect to urgent colorectal surgery. The aim of this work was to evaluate the impact of daytime versus nighttime surgery on postoperative period of patients with acute colorectal disease.

METHODS

A retrospective study was conducted in a sample of patients with acute colorectal disease who underwent urgent surgery at the General Surgery Unit of Braga Hospital, between January 2005 and March 2013. Patients were stratified by operative time of day into a daytime group (surgery between 8:00 and 20:59) and the nighttime group (21:00-7:59) and compared for clinical and surgical parameters. A questionnaire was distributed to surgeons, covering aspects related to the practice of urgent colorectal surgery and fatigue.

RESULTS

A total of 330 patients were included, with 214 (64.8%) in the daytime group and 116 (35.2%) in the nighttime group. Colorectal cancer was the most frequent pathology. Waiting time (p < 0.001) and total length of hospital stay (p = 0.008) were significantly longer in the daytime group. There were no significant differences with respect to early or late complications. However, 100% of surgeons reported that they are less proficient during nighttime.

CONCLUSIONS

Among patients with acute colorectal disease subjected to urgent surgery, there was no significant association between nighttime surgery and the presence of postoperative medical and surgical morbidities. Patients who were subjected to daytime surgery had longer length of stay at the hospital.

Treatment of perforated colon carcinomas-outcomes of radical surgery

PURPOSE

When patients present with a perforation of a colon cancer (CC), this situation increases the challenge to treat them properly. The question arises how to deal with these patients adequately, more restrictively or the same way as with elective cases.

METHODS

Between January 1995 and December 2009, 52 patients with perforated CC and 1206 nonperforated CC were documented in the Erlangen Registry of Colorectal Carcinomas (ERCRC). All these patients underwent radical resection of the primary including systematic lymph node dissection with CME. The median follow-up period was 68 months.

RESULTS

The median age of the patients in the perforated CC group was significantly higher than in the nonperforated CC group (p = 0.010). Significantly, more patients with perforated CC were classified in ASA categories 3 and 4 (p = 0.014). Hartmann procedures were performed significantly more frequently with perforation than with the nonperforated ones (p < 0.001). If an anastomosis was performed, the leakage rate of primary anastomoses did not differ (p = 1.0). Cancer-related survival was significantly lower with perforated cancer (difference 12.8 percentage points) and by 9.6 percentage points for observed survival, if postoperative mortality was excluded.

CONCLUSIONS

Perforated CC patients should be treated basically following the same oncologic demands, which are CME for colonic cancer including multivisceral resections, if needed. This strategy can only be performed if high-quality surgery is available, permanently.

Diverticulitis Outcomes are Equivalent between Level 1 Trauma Centers and Community Hospitals in New Jersey

Traditionally, general surgeons provide emergency general surgery (EGS) coverage by assigned call. The acute care surgery (ACS) model is new and remains confined mostly to academic centers. Some argue that in busy trauma centers, on-call trauma surgeons may be unable to also care for EGS patients. In New Jersey, all three Level 1 Trauma Centers (L1TC) have provided ACS services for many years. Analyzing NJ state inpatient data, we sought to determine whether outcomes in one common surgical illness, diverticulitis, have been different between L1TC and nontrauma centers (NTC) over a 10-year period. The NJ Medical Database was queried for patients aged 18 to 90 hospitalized from 2001 to 2010 for acute diverticulitis. Demographics, comorbidities, operative rates, and mortality were compiled and analyzed comparing L1TC to NTC. For additional comparison between L1TC and NTC, 1:1 propensity score matching with replacement was accomplished. χ2, t test, and Cochran-Armitage trend test were used. From 2001 to 2010, 88794 patients were treated in NJ for diverticulitis. 2621 patients (2.95%) were treated at L1TCs. Operative rates were similar between hospital types. Patients treated at L1TCs were more often younger (63.1 ± 0.3 vs 64.7 ± 0.1; P < 0.001), nonwhite (43.1% vs 23.1%; P < 0.0001), and uninsured (11.0% vs 5.5%; P < 0.0001). After propensity matching, neither operative mortality (9.7% vs 7.9% P = 0.45), nor nonoperative mortality (1.2% vs 1.3% P = 0.60) were different between groups. Mortality and operative rates for patients with acute diverticulitis are equivalent between LT1C and NTC in NJ. Trauma centers in NJ more commonly provide care to minority and uninsured patients.

Emergency surgery for perforated diverticulitis in the immunosuppressed patient

AIM

Immunosuppression is believed to worsen outcomes for patients who require surgery for perforated diverticulitis. The aim of this study was to compare surgical outcomes between immunocompromised and immunocompetent patients undergoing surgery for complicated diverticulitis.

METHOD

All patients who underwent emergency surgery for complicated diverticulitis between 2004 and 2012 in a single unit were studied. Patients were classified as immunosuppressed (group I) or immunocompetent (group II). Operation type and postoperative morbidity and mortality were compared between groups. The impact of operating surgeons' specialization and the Peritonitis Severity Score (PSS) were also evaluated to determine their impact on the restoration of gastrointestinal (GI) continuity.

RESULTS

One-hundred and sixteen patients (mean age: 63.7 years), 41.4% women, were included. Fifty-three (45.7%) patients were immunosuppressed (group I): 42 underwent Hartmann's procedure (HP) (79.2%), nine (17.0%) underwent resection and primary anastomosis (RPA) with ileostomy (IL) and two (3.8%) underwent RPA without IL. In group II, 15 HP (23.8%), nine RPA with IL (14.3%) and 39 RPA without IL (61.9%) were performed. Postoperative morbidity and mortality were 79.2% and 26.4%, respectively, in group I and 63.5% and 6.3%, respectively, in group II. The overall mean PSS was 9.5, with a mean PSS of 11.1 in group I and of 8.1 in group II. The decision to perform a primary anastomosis differed significantly between colorectal surgeons and general surgeons in the patients with a PSS of 9-10-11.

CONCLUSION

In immunocompromised patients, RPA with IL can be a safe surgical option, whereas HP should be reserved for patients with a PSS of > 11. Colorectal surgical specialization is associated with higher rates of restoration of GI continuity in patients with perforated diverticulitis, especially in patients with an intermediate PSS score. Evaluation of each patient's PSS facilitates decision making in surgery for perforated diverticulitis.

Status and literature review of self-expandable metallic stents for malignant colorectal obstruction

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.

Current UK practice in emergency laparotomy

INTRODUCTION

Emergency laparotomy is a common procedure, with 30,000-50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality.

METHODS

Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded.

RESULTS

Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. 'True' emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation.

CONCLUSIONS

This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

Current UK practice in emergency laparotomy

Introduction

Emergency laparotomy is a common procedure, with 30,000–50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality.

Methods

Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded.

Results

Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. ‘True’ emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation.

Conclusions

This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas

AIM

The aim of the study was to compare outcomes for emergency management of diverticulitis before and after the creation of a regional subspecialist colorectal unit.

METHOD

We retrieved data on all emergency admissions for diverticulitis from the regional surgical audit database and compared results before (January 1998 to August 2002) and after (August 2002 to December 2008) establishment of the subspecialist colorectal surgery unit in August 2002. Additional data were retrieved from electronic patient records. The primary outcome measures were mortality and rate of primary anastomosis following resection.

RESULTS

There were 879 patients before and 1280 patients after subspecialization. Nonoperative management was undertaken in approximately 80% of cases. Total mortality fell from 3.3 to 1.5% (P = 0.008), attributable to reduced operative mortality (9.6 to 4.2%; P = 0.019). The primary anastomosis rate for all left colon resections increased from 50.3 to 77.9%; P < 0.0001. Stoma formation of any type fell from 46.6 to 27.7%; P < 0001).

CONCLUSION

Emergency management of diverticulitis by subspecialist colorectal surgeons is associated with low overall and operative mortality whilst safely achieving high rates of primary anastomosis.

Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

There is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction. Primary resection and anastomosis offers the advantages of a definite procedure without need for further surgery. Its main disadvantages are related to the increased technical challenge and to the potential higher risk of anastomotic leakage that occurs in the emergency setting. Primary resection with end colostomy (Hartmann’s procedure) is considered the safer option. Tan et al compared in a systematic review and meta-analysis the use of self-expanding metallic stents (SEMS) as a bridge to surgery vs emergency surgery in the management of acute malignant left-sided large bowel obstruction. The authors concluded that the technical and clinical success rates for stenting were lower than expected. SEMS was associated with a high incidence of clinical and silent perforation. Stenting instead of loop colostomy can be recommended only if the appropriate expertise is available in the hospital. The goal of stenting, a decrease of the stoma rate, may be advocated only if the complication rates of stenting are lower than those of stoma creation in the emergency situation. Until now, this was not demonstrated in a prospective randomized trial.

Emergency laparoscopic-assisted right hemicolectomy: can we achieve outcomes similar to elective operation?

The aim of this study was to compare short-term clinical outcomes of elective and emergency laparoscopic-assisted right hemicolectomy. Between January 2005 and December 2009, 181 patients had laparoscopic-assisted right hemicolectomy performed at our institute (148 elective and 33 emergency cases). The demographic data, operative details, and short-term outcomes were collected. There were 104 men and 77 women. The median age was 69 years (range, 22-88 years). The demographic data of the 2 groups were similar except the patients were younger in the emergency surgery group (60 vs. 69 years; P=.02). The operating time of the emergency group was significantly longer then the elective group (165 vs. 150 minutes; P<.001) but the intraoperative blood loss was similar. The postoperative complication and recovery were similar between the 2 groups. In selected clinical settings, emergency laparoscopic-assisted right hemicolectomy can be safely performed without worsening the clinical outcomes.

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

The revised ACPGBI model is a simple and accurate predictor of operative mortality after potentially curative resection of colorectal cancer

BACKGROUND

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer.

METHODS

A total of 423 patients who underwent potentially curative resection of colorectal cancer at a single institution (1997-2007) were included. Data used in the construction of the ACPGBI model was collected prospectively. The models were compared by examining observed to expected (O:E) ratios, the Hosmer-Lemeshow (H-L) goodness-of-fit test, and area under the receiver operator characteristic curve (AUC) analysis.

RESULTS

The 30-day mortality rate was 4%. The performance of the models was as follows: revised ACPGBI model (O:E ratio = 1.05, AUC = 0.73, H-L = 11.02), original ACPGBI model (O:E ratio = 0.58, AUC = 0.76, H-L = 14.23), P-POSSUM (O:E ratio = 0.87, AUC = 0.79, H-L = 10.63), and CR-POSSUM (O:E ratio = 0.63, AUC = 0.84, H-L = 15.84). In subgroup analysis, the revised ACPGBI model performed well in both elective cases (O:E ratio = 1.06) and emergency cases (O:E ratio = 0.91).

CONCLUSIONS

The revised ACPGBI model is simple to construct and accurately predicts operative mortality after potentially curative resection of colorectal cancer.

Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis?

PURPOSE

Hartmann's procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience.

METHODS

From January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP.

RESULTS

A total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation.

CONCLUSIONS

RPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Long-term survival after perforated diverticulitis

AIM

Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis.

METHOD

All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population.

RESULTS

Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07).

CONCLUSION

Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.

Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

BACKGROUND

Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.

METHODS

The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.

RESULTS

Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).

CONCLUSIONS

Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

Background

Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.

Methods

The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.

Results

Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).

Conclusions

Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Logistics and outcome in urgent and emergency colorectal surgery

AIM

Infrastructure-related factors are seldom described in detail in studies on outcome after surgical procedures. We studied patient, procedure, physician and infrastructure characteristics and their effect on outcome at a Norwegian University hospital.

METHOD

All patients admitted between 1st January 2002 and 30th June 2003 who underwent urgent or emergency colorectal surgery were extracted from the hospital databases and retrospectively analysed.

RESULTS

There were 196 patients. The overall complication rate was 39%. Forty-six (24%) patients died during admission after surgery. Those who died were less likely to be operated by a subspecialized colorectal surgeon (17%vs 30%, P = 0.001). The anaesthesiologist was a resident in most of the cases (> 75%) for both those who survived and those who died. Surgery performed out-of-office hours was common in both groups, although the patients who died were more likely to be operated upon at night (28%vs 18%, P = 0.001). The time interval standard from admission to surgery was met in only 84 (43%) patients. Forty-nine (49/196, 25%) procedures were delayed beyond the time requested by the surgeon by more than 120 min (mean 363 min).

CONCLUSION

The outcome after emergency colorectal surgery was consistent with the literature but the infrastructure was not optimal. Improvements may be achieved by a focus on decreasing waiting times, abandoning of out-of-office emergency surgery and increasing the involvement of senior staff.

Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis

OBJECTIVE

Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model.

METHOD

Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score.

RESULTS

Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients.

CONCLUSION

The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery

BACKGROUND

The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery.

MATERIALS AND METHODS

All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database.

RESULTS

The median age of patients was 73 (range 17-98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm(3) (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score > or =3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003).

CONCLUSIONS

The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.

The effect of surgical subspecialization on outcomes in peptic ulcer disease complicated by perforation and bleeding

BACKGROUND

Emergency surgical services in Edinburgh were restructured in July 2002 to deliver subspecialist management of colorectal and upper-gastrointestinal emergencies on separate sites. The effect of emergency subspecialization on outcome from perforated and bleeding peptic ulceration was assessed.

METHODS

All patients admitted with complicated peptic ulceration (January 2000-February 2005) were identified from a prospectively compiled database.

RESULTS

Perforation: 148 patients were admitted with perforation before the service reorganization (period A - 31 months) of whom 126 (85.1%) underwent surgery; 135 patients were admitted in period B (31 months) of whom 114 (84.4%) were managed operatively. The in-hospital mortality was lower in period B (14/135, 10.4%) than period A (30/148, 20.3%; P = 0.023; relative risk (RR), 0.51; 95% confidence interval (CI), 0.28-0.91). There was a significantly higher rate of gastric resection in the second half of the study (period A 1/126 vs. period B 8/114; P = 0.015; RR, 8.84; 95% CI, 1.48-54.34). Length of hospital stay was similar for both groups. Bleeding: 51 patients underwent operative management of bleeding peptic ulceration in period A and 51 in period B. There were no differences in length of stay or mortality between these two groups.

CONCLUSION

Restructuring of surgical services with emergency subspecialization was associated with lower mortality for perforated peptic ulceration. Subspecialist experience, intraoperative decision-making, and improved postoperative care have all contributed to this improvement.

Emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma: a comparative study of short-term clinical outcomes

BACKGROUND

The aim of the present study was to compare the clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma.

METHODS

Between July 2003 and July 2006, 43 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 14 with the laparoscopic-assisted approach and 29 with the open approach. Clinical data were retrospectively recorded and compared between the two groups.

RESULTS

There were no significant differences between the two groups with respect to age, gender, co-morbidities, duration of obstructing symptoms, tumor length, and tumor staging. The laparoscopic-assisted group had longer operative time than the open group (187.5 min versus 145 min; p=0.034) but less blood loss (20 ml versus 100 ml; p=0.020). The median time to full ambulation was significantly shorter in the laparoscopic-assisted group (4 days versus 6 days; p=0.016), but the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (55.2% versus 28.6%), but the difference was not statistically significant.

CONCLUSIONS

Emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. In comparison with the open approach, the laparoscopic-assisted procedure is associated with less blood loss, earlier ambulation, and possibly lower morbidity rate.

Emergency management of malignant acute left-sided colonic obstruction

INTRODUCTION

The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress.

METHODS

A literature search was undertaken using PubMed and the Cochrane Library regarding the options in emergency management of left-sided colonic obstruction focusing on outcomes such as mortality, morbidity, long-term prognosis and cost effectiveness.

DISCUSSION

Colonic stenting is the best option either for palliation or as a bridge to surgery. It reduces morbidity and mortality rate and the need for colostomy formation. Stenting is likely to be cost effective, but data are variable depending on the individual healthcare system. Nevertheless, surgical management remains relevant as colonic stenting has a small rate of failure, and it is not always available. There are various surgical options. One-stage primary resection and anastomosis is the preferred choice for low-risk patients. Intra-operative colonic irrigation has no proven benefit. Subtotal colectomy is useful in cases of proximal bowel damage or synchronous tumours. Hartmann's procedure should be reserved for high-risk patients. Simple colostomy has no role other than for use in very ill patients who are not fit for any other procedure.