Emergency Colectomy Research Articles

Previous infliximab therapy and postoperative complications after proctocolectomy with ileum pouch anal anastomosis

Background and aimsIt is unclear whether infliximab treatment induces increased complication rates after surgery for ulcerative colitis. Aim was to compare complication rates after pouch surgery in refractory ulcerative colitis patients with versus without previous infliximab therapy. MethodsWe performed a retrospective study evaluating all patients who underwent an ileoanal J-pouch for refractory ulcerative colitis over a four-year period. Postoperative complications, infliximab use and time between last infliximab administration and restorative surgery were assessed. 1-stage procedures (proctocolectomy with pouch, with or without temporary diversion) and 2-stage procedures (emergency colectomy and subsequent completion proctectomy with pouch, with or without temporary diversion) were analyzed separately. ResultsSeventy-two patients were included; 33 underwent 1-stage procedure and 39 had 2-stage surgery. In the 1-stage group, 21 patients (64%) had previous infliximab therapy (median time between last infusion and surgery: 7.1 months (IQR 2.6-8.3)). Infliximab-treated patients had higher incidence of pelvic sepsis (5/21 vs. 0/12; risk difference 24%; 95% CI: 6 to 42, p=0.067) and non-infectious complications (8/21 vs. 1/12; risk difference 30%; 95% CI: 4 to 56, p=0.065). In the 2-stage group, 17 (44%) had previous infliximab therapy (median time between last infusion and surgery: 11.8 months (IQR 7.3-15.5)). Total, infectious, non-infectious complication rates and pelvic sepsis rates were similar for infliximab and non-infliximab patients in the 2-stage group. ConclusionsThis small study suggests that infliximab use prior to 1-stage restorative proctocolectomy in patients with UC is associated with increased incidence of pelvic sepsis. A 2-stage procedure in these patients should be considered.

Feasibility of Emergency Laparoscopic Colectomy for Children with Acute Colonic Perforations and Fibropurulent Peritonitis

Several studies have demonstrated that laparoscopic surgery is safe and effective for urgent and emergent colectomy in adulthood. The aim of the present study was to evaluate the feasibility of laparoscopic colectomy for children in emergent settings. Between March 2008 and August 2011, 10 consecutive children with acute colonic perforations and fibropurulent peritonitis secondary to infectious colitis underwent emergency laparoscopic colectomy. Simultaneously, we reviewed and recorded the same data from another consecutive 10 patients who underwent standard laparotomy between November 2004 and February 2008. The two groups were compared with regard to operative time, length of hospital stay (LOS), and complications. The gender, age, body weight, serum C-reactive protein, number of involved bowel segments, operative time, and LOS were not significantly different (P = 0.36, 0.50, 0.33, 0.62, 0.81, 0.14 and 0.23, respectively). In the laparoscopy group, one patient required conversion to open surgery because of extensive bowel involvement, and another patient with solitary colonic perforation required reoperation for anastomostic leakage. However, patients who underwent laparotomy had a higher incidence of later complications, including wound infection, incisional hernia, and adhesion ileus (P = 0.03, 0.06, and 0.03, respectively) and thus required more additional unplanned operations (P = 0.05). Emergency laparoscopic surgery is technically feasible in most children with acute colonic perforations and fibropurulent peritonitis. However, extensive intestinal involvement with multiple perforations should be an indication for converting to open surgery.

Infliximab in Crohn's Disease-associated Toxic Megacolon

Refractory medical treatment of Crohn disease-associated toxic megacolon usually requires surgery, which carries substantial morbidity and mortality. We report a case of a woman with steroid and antibiotic-refractory fulminant Crohn colitis and ileitis, complicated by a toxic megacolon, who was successfully treated with infliximab. Infliximab induced rapid clinical response and remission, thereby avoiding emergency (ileo) colectomy. This is the first report of treatment of Crohn disease-associated toxic megacolon with infliximab.

282 Alemtuzumab Minimizes Airway Ischemic Reperfusion Injury (aIRI), Which Is Associated with Graft Damage and Deaths Post-Lung Transplant (LT)

There were no differences in CMV among R pts, nor in chest wall (4% vs 6%) or other infections (30% vs 35%, including mediastinitis, empyema, pneumonia, bacteremia, C. diff and invasive fungal infection). At 3, 6 and 12 mos post-LT, mean cumulative ACR grade A1 for Bmab pts (0.7, 1.3 and 1.4) was higher than Amab (0.2, 1.9 and 2.3), (p 0.02, 0.003 and 0.02, respectively). Moreover, Bmab pts were more likely to develop ACR grade A1 within 3 mos of LT (33% vs 17%; p 0.04); 5% of Bmab pts required ATG or Amab within 3 mos of LT. Colon ischemia requiring emergent colectomy was higher among BaAb pts (1.5% vs 11%; p 0.02); outbreak investigation implicated higher MMF doses in Bmab pts as causative (median 3g vs 2 g/d; p 0.0001). There was no difference in wound dehiscense or healing between groups, nor in survival. Conclusions: There was a trade-off with Amab regimens: significantly less ACR and fewer colonic emergencies, but increased CMV infection in D /RLT. Impact on chronic rejection requires more follow-up. Bmab may be preferable in CMV D /RLT, and Amab in others.

Factors that predict clinical outcome after colectomy for fulminant <i>Clostridium difficile</i> colitis

Background: Historically, the incidence of C. difficile-associated colitis has increased significantly over the last decade. Of these patients, approximately 10% - 20% will ultimately require colectomy due to fulminant disease and progression to toxic colitis. Despite operative intervention, the mortality for this population remains high (35% - 80%). This study evaluates for preoperative risk factors for mortality. Methods: Retrospective medical record review of 47 patients who underwent emergent colectomy for fulminant C. ddifficile colitis over a five-year period at three teaching hospitals in New York City. Results: Forty-seven patients with Clostridium difficile colitis underwent colectomy from January 2003 to December 2008. The mean age was 66 years with 31 (67%) male and 16 (34%) female. The 30-day mortality was 34% (16/47 patients). Thirty-eight (81%) underwent subtotal colectomy, six (13%) Hartmann resection, two (4%) right hemicolectomy, and one (2%) underwent left colectomy. Univariate analysis showed that age (71.6 vs. 67.5 years; p = 0.402), white blood cell count (35,500 vs. 27,700/mm3; p = 0.271), and use of vaso-pressors in the pre-operative period *p = 0.440) were not statistically predictive of postoperative mortality. Conversely, preoperative serum lactate level (4.3 vs. 2.1 mmol/L p + 0.009) was statistically greater in the postoperative mortality group. Conclusion: In the setting of fulminant C. difficile colitis, serum lactate levels can help predict postoperative outcome following emergent colectomy and should be closely followed to facilitate the decision to proceed with surgery.

Efficacy of Infliximab Rescue Therapy in Hospitalized Patients with Steroid-Refractory Ulcerative Colitis: Single Center Experience

Background/Aims: In hospitalized patients with acute steroid-refractory UC, infliximab has been demonstrated to be one of the medical rescue therapies to avoid colectomy. We report the result of a retrospective observational study to find the efficacy and safety of infliximab as a rescue therapy in our hospital. Methods: Between January 2007 and January 2010, 9 hospitalized patients with steroid-refractory UC were selected to receive three infusions of infliximab (5 mg/kg), at weeks 0, 2, and 6. Efficacy of treatment was evaluated at 8 weeks after the first infliximab infusion and at the end of follow-up period. Adverse events related to infliximab rescue therapy were also collected. Results: Seven patients (77.8%) had completed 3 infusions of infliximab and achieved clinical response at 8 weeks after the first infliximab infusion. Clinical remission rate and the rate of mucosal healing at 8 weeks were 57.1% (4/7) and 71.4% (5/7), respectively. They were followed up for median time of 24.9 months (19.5-53.6 months). One patient underwent emergency colectomy at weeks 2, due to colon perforation, while another patient had discontinued infliximab treatment at weeks 4, because of Clostridium difficile-associated colitis. Finally, colectomy was avoided in 77.8% (7/9) of cases. There was no mortality. Conclusions: Rescue therapy with infliximab has sustained clinical benefit in 88.9% of our hospitalized patients with acute steroid-refractory UC. Future prospective and long-term follow-up trials with a large number of patients are needed to confirm the efficacy and safety of the treatment. (Intest Res 2012;10:152-160) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Less adhesiolysis and hernia repair during completion proctocolectomy after laparoscopic emergency colectomy for ulcerative colitis

BackgroundThe aim of this study was to determine whether the need for adhesiolysis during completion proctectomy (CP) with ileopouch anal anastomosis (IPAA) is influenced by the surgical approach of the initial emergency colectomy for ulcerative colitis and the hospital setting.MethodsOne hundred consecutive patients who underwent CP with IPAA in our center between January 1999 and April 2010 were included. Emergency colectomy had been performed laparoscopically in 30 of 52 patients at the Academic Medical Center Amsterdam and in 6 of 48 patients at referring hospitals. Case files of these patients were retrospectively reviewed.ResultsSignificantly more extensive adhesiolysis was performed after open compared to laparoscopic colectomy (47 vs. 6%, P < 0.001). In univariate analysis, emergency colectomy at a referring hospital was also predictive for adhesiolysis (P = 0.003), but the open approach for the initial colectomy was the only independent predictive factor for the need for adhesiolysis (P < 0.001) in a multivariable ordinal logistic regression analysis. Operating time of CP was significantly longer when limited [18 (95% CI = 0–36) min] or extensive [55 (35–75) min] adhesiolysis had to be performed. The interval to CP was longer after open colectomy and after colectomy performed at a referring hospital. Significantly more incisional hernia corrections during CP were performed after open emergency colectomy (14 vs. 0%, P = 0.024). Overall morbidity and postoperative hospital stay of CP were not related to the surgical approach or the hospital setting of the emergency colectomy.ConclusionLaparoscopic as opposed to open emergency colectomy is associated with less adhesiolysis, fewer incisional hernias, and a shorter interval to completion proctectomy.

Clostridium difficile Infection in Ulcerative Colitis: Increased Risk of Colectomy and Postoperative Infectious Complications

Purpose: Ulcerative colitis (UC) patients diagnosed with Clostridium difficile (C. difficile) in hospital have worse outcomes; however, the majority of studies have only evaluated the influence of in-hospital diagnosis of C. difficile. The aims of this study were to determine whether: 1) UC patients diagnosed with C. difficile infections in-hospital and up to 90 days prior to admission were more likely to have an emergent colectomy; and 2) whether C. difficile increased the risk of postoperative complications following colectomy. Methods: Population-based surveillance was conducted in the Calgary Health Zone between January 1, 2000 and December 31, 2009 to identify all adults (≥ 18 years) admitted to hospital for an UC flare (n=481). In addition, the Calgary Laboratory Services (CLS) laboratory provided all C. difficile toxin tests ordered within 90 days of hospital admission (n=123). UC patients admitted to hospital for flare who responded to medical management (n=295) and were discharged from hospital were compared to UC patients who failed medical management and required an in-hospital emergent colectomy (n=186). Secondly, the records of patients undergoing emergency colectomy were reviewed to assess for the occurrence of various postoperative complications stratified as any complication and infectious. Multivariate logistic regression analysis was performed to examine the association between C. difficile infection and: 1) emergent colectomy versus medically responsive UC flare; and 2) postoperative complications (any and infectious). Results: Patients diagnosed with C. difficile 90 days before or during hospitalization (n=18) were at higher risk for having a colectomy when compared to patients who were C. difficile negative (OR= 2.87; 95% CI: 1.03-8.03) after adjusting for age, sex, corticosteroid use in hospital and disease extent. UC patients who underwent emergent colectomy and were diagnosed with C. difficile prior to surgery were not at a statistically higher risk of developing postoperative complications in general (OR=3.48; 95% CI: 0.93-13). However, preoperative C. difficile infection increased the risk of specified infectious complications (OR=4.56; 95% CI: 1.07-18.34) in the postoperative period. Conclusion: UC patients were significantly less likely to be medically responsive and hence, required a colectomy when they were diagnosed with a C. difficile infections in-hospital or within 90 days of admission. Moreover, UC patients who had concomitant C. difficile, preoperatively were at a higher risk of infectious complications following colectomy.

Alternative specimen extraction techniques after laparoscopic emergency colectomy in inflammatory bowel disease

BackgroundOmitting the extraction site incision potentially further decreases the abdominal wall trauma in laparoscopic surgery. The purpose of this study was to report the results of alternative specimen extraction techniques after laparoscopic emergency colectomy in patients with inflammatory bowel disease (IBD).MethodsTen consecutive patients with IBD underwent (sub)acute emergency colectomy for refractory disease from October 2009 until December 2010. The specimen was retrieved via the stoma site in three and transrectally in seven patients. Patient data were prospectively collected. In case of later completion proctectomy and pouch procedure, adhesions were systematically scored.ResultsThe extraction techniques were all feasible. Median operative time was 219 (interquartile range (IQR), 197–232) min. The pain scores and morphine requirement in patients decreased quickly after surgery. No infectious complications occurred. In five patients, a completion proctectomy was performed at a median time of 7 (IQR, 3.8–9.3) months after colectomy. All patients showed absence of any adhesions in the pelvis. In two patients, limited adhesions of the cut side of the mesentery were present.ConclusionsSpecimen extraction via the rectum or stoma site is a safe, alternative way to extract the specimen after laparoscopic colectomy. No infectious complications were observed postoperatively and no pelvic adhesions were found during completion proctectomy.

Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance

The number of reported cases of Clostridium difficile (CD) infections has increased markedly worldwide. CD causes a spectrum of clinical syndromes, ranging from mild diarrhea to a very severe illness in the form of pseudomembranous colitis (PMC), toxic megacolon, leading to colonic perforation, peritonitis, and even death. In today's practice, toxic megacolon is more often caused by pseudomembranous colitis than ulcerative colitis. There is urgent need to establish clear guidelines about how and when to refer patients with fulminant CD colitis to surgeons. Furthermore, there is no strict protocol for the timing of surgical intervention. The aim of this review is to review the available evidence about the criteria for referral to surgeons and timing for surgery. Medline search was carried out for articles published on fulminant CD colitis with emergency colectomy from 1966 to 2010. There were no prospective randomized trails. All retrospective cohort and case control studies were included. We excluded case reports, letters, and studies with less than five patients. Our search showed that patients with confirmed or suspected CD who failed to respond to maximum medical therapy and develop three of the following should be referral for surgical assessment: abdominal pain, abdominal distension, localized tenderness, pyrexia >38°C, and tachycardia >100 beats per minute. In addition to the above, if the patient is above 65 years old and develops four of the following, they should be considered for an emergency colectomy: WBC >16 × 109/l, lactate >2.2 mmol/l, albumin <30 g/l, blood pressure <90 mm Hg, CT/endoscopy evidence of severe colitis in spite of maximum anti-clostridial therapy. Colectomy still carries a high mortality rate; however, timely surgical intervention in fulminant CD colitis (FCDC) prevents many deaths in selected cases. In the absence of published prospective multicenter trial, we suggest that our criteria may enhance early diagnosis and consideration of early referral for surgery. Ultimately, this may reduce the significant morbidity and mortality associated with FCDC.

Stoma pouch noise: meeting patient needs

British Journal of NursingVol. 20, No. 15 CommentStoma pouch noise: meeting patient needsRebecca DavenportRebecca DavenportSearch for more papers by this authorRebecca DavenportPublished Online:16 Aug 2013https://doi.org/10.12968/bjon.2011.20.15.908AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetailsCited byPsychosocial health following stoma formation: a literature reviewFiona Brown20 April 2017 | Gastrointestinal Nursing, Vol. 15, No. 3Analysing the role of support wear, clothing and accessories in maintaining ostomates' quality of lifeDebbie Johnson, Linda Readding, Claire Ryan21 September 2015 | Gastrointestinal Nursing, Vol. 13, No. 7Journal ScanOsman K, Ahmed MH, Hamad MA (2011) Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance. Scand J Gastroenterol46(10): 1222–7Nikki Welyczko16 August 2013 | Gastrointestinal Nursing, Vol. 9, No. 9Journal ScanDavenport R (2011) Stoma Pouch noise: meeting patients needs. Br J Nurs20(15): 908Nikki Welyczko16 August 2013 | Gastrointestinal Nursing, Vol. 9, No. 9 11 August 2011Volume 20Issue 15ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 16 August 2013 Published in print 11 August 2011 Information© MA Healthcare LimitedPDF download

Surgical Outcome of Community-Acquired Clostridium difficile Colitis Presenting as Toxic Megacolon: Case Report

Over the past decade, there has been an increase in both community-acquired and health-care-associated Clostridium difficile colitis secondary to broad-spectrum antibiotic exposure. Toxic megacolon is a rare complication of pseudomembranous colitis that often necessitates emergency colectomy. Review of the pertinent English-language literature. We present a case of community-acquired C. difficile colitis that made its initial presentation as fulminant toxic megacolon. Six months after a total colectomy, the patient has no complaints. Prompt total colectomy may improve survival in patients with toxic megacolon. The incidence of C. difficile-related toxic megacolon and post-operative outcomes of total colectomy should be investigated in a larger observational study.

Postoperative Complications and Mortality Following Colectomy for Ulcerative Colitis

Complications after colectomy for ulcerative colitis (UC) have not been well characterized in large, population-based studies. We characterized postoperative in-hospital complications, stratified them by severity, and assessed independent clinical predictors, including use of immunosuppressants. We performed population-based surveillance using administrative databases to identify all adults (≥18 y) who had an International Classification of Diseases-9th/10th revisions code for UC and a colectomy from 1996 to 2009. All medical charts were reviewed. The primary outcome was severe postoperative complications, including in-hospital mortality. Logistic regression was used to assess predictors of complications after colectomy and then restricted to patients undergoing emergent or elective surgeries. Of the 666 UC patients who underwent a colectomy, a postoperative complication occurred in 27.0% and the mortality rate was 1.5%. Independent predictors of postoperative complications were age (for patients >64 vs 18-34 y: odds ratio [OR], 1.95; 95% confidence interval [CI], 1.07-3.54), comorbidities (>2 vs none: OR, 1.89; 95% CI, 1.06-3.37), and admission status (emergent vs elective colectomy: OR, 1.62; 95% CI, 1.14-2.30). Significant risk factors for an emergent colectomy included time from admission to colectomy (>14 vs 3-14 d: OR, 3.32; 95% CI, 1.62-6.80) and a preoperative complication (≥1 vs 0: OR, 3.04; 95% CI, 1.33-6.91). A prescription of immunosuppressants before colectomies did not increase the risk for postoperative complications. Postoperative complications frequently occur after colectomy for UC, predominantly among elderly patients with multiple comorbidities. Patients who were admitted to the hospital under emergency conditions and did not respond to medical treatment had worse outcomes when surgery was performed 14 or more days after admission.

Colectomy Performance Improvement within NSQIP 2005–2008

All open and laparoscopic colectomies submitted to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were evaluated for trends and improvements in operative outcomes. 48,247 adults (≥18 y old) underwent colectomy in ACS NSQIP, as grouped by surgical approach (laparoscopic versus open), urgency (emergent versus elective), and operative year (2005 to 2008). Primary outcomes measured morbidity, mortality, perioperative, and postoperative complications. The proportion of laparoscopic colectomies performed increased annually (26.3% to 34.0%), while open colectomies decreased (73.7% to 66.0%; P < 0.0001). Most emergent colectomies were open procedures (93.5%) representing 24.3% of all open cases. The overall risk-adjusted morbidity and mortality for all colectomy procedures did not show a statistically significant change over time, however, morbidity and mortality increased among open colectomies (r = 0.03) and decreased among laparoscopic colectomies (r = -0.04; P < 0.0001). Postoperative complications reduced significantly including superficial surgical site infections (9.17% to 8.20%, P < 0.004), pneumonia (4.60% to 3.97%, P < 0.0001), and sepsis (4.72%, 2005; 6.81%, 2006; 5.62%, 2007; 5.09%, 2008; P < 0.0002). Perioperative improvements included operative time (169.2 to 160.0 min), PRBC transfusions (0.27 to 0.25 units) and length of stay (10.5 to 6.61 d; P < 0.0001). It appears that laparoscopic colectomies are growing in popularity over open colectomies, but the need for emergent open procedures remains unchanged. Across all colectomies, however, key postoperative and perioperative complications have improved over time. Participation in ACS NSQIP demonstrates quality improvement and may encourage greater enrollment.

Are Targeted Preoperative Risk Prediction Tools More Powerful? A Test of Models for Emergency Colon Surgery in the Very Elderly

Whether preoperative risk prediction improves with the use of more patient- and procedure-targeted models is unclear. We created a customized preoperative mortality risk prediction score for patients 80 years or older needing an emergency colectomy and compare it with existing, more generic risk assessment methods. A targeted mortality prediction model was created using 2007 to 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and was validated using 2005 to 2006 data. We constructed a scoring system from the significant predictors identified. The model fit of our targeted score was compared with the American Society of Anesthesiologist's (ASA) score, the Surgical Risk Scale, and the ACS Colorectal Surgery Risk Calculator. Analyses identified 1,358 and 372 emergency colectomies in the training and validation samples, respectively. Our targeted risk prediction score had a goodness-of-fit p value greater than 0.05 (indicating a good fit) and a c-statistic of 0.77, which represents a significantly better fit compared with the ASA score, the Surgical Risk Scale, and the ACS Colorectal Surgery Risk Calculator c-statistics (0.66, 0.66, and 0.71, respectively). When using the scores to predict mortality with 80% specificity, our targeted risk prediction score was 25% more likely to predict correctly than the ACS Colorectal Surgery Risk Calculator and 33% more likely to predict correctly compared with the ASA score and Surgical Risk Scale. Our study presents a validated preoperative mortality score for very elderly patients needing an emergency colectomy. The greater discriminating power of this targeted score indicates that preoperative risk assessment may need to be customized to specific procedures and patient circumstances.

Laparoscopic Emergency Colectomy for Ulcerative Colitis is Associated With Fewer Adhesions Compared to Open

Laparoscopic Emergency Colectomy for Ulcerative Colitis is Associated With Fewer Adhesions Compared to Open

In-Hospital and 6-Month Mortality Rates After Open Elective vs Open Emergent Colectomy in Patients Older Than 80 Years

There are few reports of long-term outcomes in elderly patients after open colectomy. This study aimed to determine the in-hospital and 6-month outcomes and identify the variables associated with mortality after colectomy in patients ≥ 80 years of age. The charts of patients ≥ 80 years of age, who underwent open colectomy, were analyzed. Data included indications for operation, underlying diagnoses, preoperative functional status, type of procedure, length of procedure, length of stay, ASA grade, complications, and in-hospital and 6-month mortality rates. Univariate and multivariate logistic regression analyses were conducted to ascertain risk factors for mortality. P values of < .05 were considered significant. The main outcome measures were in-hospital and 6-month mortality. One hundred sixty-two patients ≥ 80 years of age underwent colectomy: 99 patients emergently; 63, electively. Postoperative acute renal failure (3% vs 19%, P = .0032) and in-hospital deaths were significantly higher (4.7% vs 28%, P = .0002) among the patients undergoing emergent colectomies. The mortality rate among emergent cases rose from 28% in-hospital to 52% at 6 months. Mortality among the elective cases increased similarly from 4.7% to 28.5%. Admission from a nursing facility was associated with higher in-hospital mortality (47.6% vs 14.9%, P = .0005). Discharge to a skilled nursing facility was associated with a higher 6-month mortality rate compared with discharge to home (40% vs 17%). Length of procedure, postoperative complications, perioperative blood transfusion, and emergent indications for operation independently predicted in-hospital mortality. Postoperative complications and emergent diagnosis independently predicted 6-month mortality. The 6-month mortality rate varied according to the underlying diagnosis as follows: fulminant Clostridium difficile colitis (86%); ischemic colitis (60%); gastrointestinal bleeding (37%), and volvulus (40%). This study was limited by its retrospective nature. Emergent open colectomy in elderly patients is associated with a high morbidity and mortality rate. The mortality rate rises by >20% in both elective and emergent cases at discharge to 6 months. Length of procedure, postoperative complications, and colectomy for emergent indications predicted mortality.

A woman with severe lupus nephritis and difficult to control diabetes mellitus

A woman with severe lupus nephritis and difficult to control diabetes mellitus

Surgical treatment of chronic inflammatory bowel disease in children

Surgery for chronic inflammatory bowel disease (IBD) is increasingly often necessary in children. This study aimed at assessing the results of these operations in order to facilitate adequate preoperative counseling. We reviewed patients treated from 1992 to 2009. The operations, complications and functional outcome were recorded. For those with preserved rectal defecation, continence (Koivusalo score) and quality of life (standardized questionnaire) were assessed in the long term. Eighty five of 192 patients had Crohn disease (CD), 107 of 192 had ulcerative colitis (UC), and 3 of 192 had indeterminate colitis (IC). 12 of 85 CD patients (15%) aged 14 (12-19) years required 13 resections, 1 stricturoplasty, 1 transplantation and 6 other operations including 3 permanent enterostomies for anorectal involvement. Removal of the involved bowel led to significant improvement of nutritional status, growth and quality of life. The transplanted patient had a striking recovery but eventually died 1 year later of unrelated complications. 29 of 107 UC patients (26%) aged 11 (2-15) years required 87 operations. Nine had emergency colectomy for toxic megacolon (3, one death) or severe hemorrhage (6). 28 had restorative proctocolectomy and ileoanostomy (RPCIA) without (16) or with (12) J-pouch under protective ileostomy. Complications were frequent (40%). Permanent ileostomy was required in five children (17%). Twelve months postoperatively, RPCIA patients had 6.5 (2-13) stools/day; all were continent during daytime, and 25% have nocturnal leaks. Mean Koivusalo score (5-12) was 8.8 ± 2. Quality of life was good in all. All attended normal school and 7 the university, 4 work and 60% of those older than 18 years have sexual partners. Three of 107 children treated as UC with RPCIA had ultimately IC (3%) and were permanently diverted. The nature of IBD involves frustrating surgery. However, it may change life for CD patients and provide a reasonably good quality of life for UC after the first year. Pediatric surgeons should be able to provide adequate preoperative counseling to patients and families.

Impact of Narcotic Use on the Requirement for Colectomy in Inpatients With Ulcerative Colitis

The effect of narcotic use in the disease course of ulcerative colitis has not been studied. The aim of the study was to evaluate the impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis. All eligible patients with ulcerative colitis admitted to gastroenterology service for disease flare-ups between 2002 and 2008 were included. Excluded were patients with ulcerative colitis admitted to the colorectal surgery service for emergent or elective colectomy and patients with Crohn's disease. Demographic, clinical, and laboratory data were reviewed. The definition of narcotics use was oral or intravenous administration of the agents during hospital admission or at hospital transfer. Multivariable analysis was performed. A total of 223 patients were included. One hundred six patients were males. The mean age was 38.7 +/- 18.1 years. Forty-four patients (19.7%) were on oral or intravenous narcotics during the hospitalization. Sixty-seven patients (30%) had colectomy during the hospitalization and the colectomy rate was similar between narcotic user and nonnarcotic users (29.5% vs 30.2%, P = .9). In multivariable analysis, only the serum albumin level remained in the model as an independent risk factor associated with colectomy (OR = 0.4; 95% CI, 0.2-0.9; P = .03). Narcotic use was not an independent risk factor for colectomy in this study (P = .5). Narcotics were commonly prescribed to patients with ulcerative colitis who were admitted to the gastroenterology service. However, narcotic use appeared not to have a significant negative impact on the colectomy rate in inpatients with ulcerative colitis. In contrast, the low albumin level at flare was associated with an increased risk for colectomy.