Emergency Colon Surgery Research Articles

Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know

Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know

Surgical outcomes and prognostic factors associated with emergency left colonic surgery.

Mortality from emergency left-sided colorectal surgery can be substantial due to acuteness of the presentation and the urgent need to operate in the setting of a limited preparation in a morbid patient. Determine the 30-day postoperative outcomes and identify risk factors for complications and mortality following emergency colorectal operations. Retrospective SETTINGS: Three tertiary hospitals in three countries. Factors that were studied included age, sex, ASA score, type and extent of the operation, and presence/absence of malignancy. Unadjusted 30-day patient outcomes examined were complications and mortality. Differences in proportions were assessed using the Pearson chi-square test while logistic regression analyses were carried out to evaluate the correlation between risk factors and outcomes. 30-day postoperative morbidity and mortality SAMPLE SIZE: 104 patients. Among 104 patients, 70 (67.3%) were men, and 34 (32.7%) were women. The mean (SD) age was 57.2 (17.1) years. The most common indication for emergency colonic surgery was malignant obstruction in 33 (31.7%) patients. The postoperative complication rate was 24% (25/104), and the mortality rate was 12.5% (13/104) within 30 days of the operation. The ASA status (P=.02), presence of malignancy (P=.02), and the presence of complications (P=.004) were significantly related to mortality in the multivariable logistic regression analysis. The 30-day mortality of emergency colorectal operations is greatly influenced by the presence of malignancy in the colon and physiological status at the time of the procedure. The retrospective design and small sample size. None.

ПРИМЕНЕНИЕ ПРОГРАММЫ УСКОРЕННОГО ВОССТАНОВЛЕНИЯ У ПАЦИЕНТОВ ПОСЛЕ ВМЕШАТЕЛЬСТВ НА ОБОДОЧНОЙ И ПРЯМОЙ КИШКЕ

The study aims to improve the outcomes of surgical treatment for patients with colon and rectum pathology by using an enhanced recovery program. A retrospective, single-center, non-randomized analysis of the treatment results of 122 patients who underwent elective and emergency colon and rectal surgery was carried out. Patients were divided into two groups: the main group, which included 66 (54.1 %) patients who underwent enhanced recovery program-based surgery in 2020–2021, and the control group, which included 56 (45.9 %) patients who underwent conventional surgery in 2012–2015. The main criteria for comparing the performance were the post-surgery recovery time of the intestines’ functional activity, particularly the time of the peristalsis appearance, the gases output, and the first stool, the number and type of complications, as well as the duration of in-patient treatment. Clinical practice demonstrated significant improvements when using the enhanced recovery protocol for patients after colon and rectal surgeries: accelerated recovery of the intestines’ motor-evacuation function, reduction of the number and severity of post-surgical complications from 30.4 % to 9.1 %, resulting in a faster in-patient recovery from 16.3 ± 9.4 to 9.4 ± 4.2 days.

Kırılganlık İndeksinin Tıkayıcı ve Perfore Kolon Kanseri İçin Yapılan Acil Kolektomi Sonuçları Üzerine Etkisi

This study aimed to analyze the predictive impact of frailty index and patterns of outcomes in patients with obstructing and perforated colon cancer who had emergency surgery. The nighty-nine patients who underwent right and left hemicolectomy were retrospectively evaluated within emergency conditions such as obstruction or perforation of tumor between February 2017 and October 2020. The 5-mFI (modified frailty index) score was measured by multiplying each number of frailty features (1 point per each existence; 0 - 5 points) and categorized into three groups (mFI=0, mFI=1, and mFI ≥ 2). The average age of the patient population was 65.21±13.84 years old. The male patients were 60 (60%). Albumin level was seen lower in patients who had higher mFI (3.86±0.63vs. 3.51±0.76 vs. 3.51±0.65, p=0.045). The predictive outcomes regarding the mFI potentially showed increased Clavien Dindo classification (CDC) [OR: 1.49, 95%CI: 0.82-2.75, p=0.2], morbidity [OR: 2.43, 95%CI: 0.50-13.98, p=0.3], and leakage [OR: 2.02, 95%CI: 0.63-6.65, p=0.2]. The morbidity (16, 24.6% vs. 16, 47.1%), p=0.041) and mortality (10, 15.4% vs. 9, 26.5%, p=0.289) were more likely seen for right sided tumors. Stoma formation was seen more likely for left sided tumors (29, 60% vs. 8, 23.5%, p=0.001). The 5-mFI score might be assumed as a preoperative prognostic tool for emergency colon surgery considering morbidity, mortality, prolonged hospitalization, and reoperation. Although morbidity and mortality in right-sided tumors and stoma formation are higher in left-sided tumors, 5-mFI score can be evaluated in patients regardless of colon cancer location.

Differences in the management of patients requiring an emergency resection for colonic cancer in two European populations.

BackgroundPatients with colonic cancer who require emergency colonic cancer surgery often experience poorer outcomes compared with their elective counterparts. In this setting, several treatments approaches are available. In 2009, Danish guidelines recommended treatment with stent for obstruction in left-sided tumours as a bridge to surgery, if expertise is accessible. The aim of this study was to compare the use of elective and emergency resections for colonic cancer and postoperative mortality in two similar demographic populations.MethodsAll patients who underwent a major resection for colonic cancer, between 2005 and 2016 in Denmark and Yorkshire (UK) were identified. The proportion undergoing emergency surgery, the proportion receiving a stent procedure before their resection, and 30-day postoperative mortality were compared between the populations. Logistic regression was used to determine changes in the proportion of those undergoing emergency surgery and 30-day postoperative mortality.ResultsOut of 45 397 patients treated during the study interval, 41 880 were selected. Emergency surgery decreased in Denmark from 16.6 per cent in 2005–07 to 12.9 per cent in 2014–16, but increased in Yorkshire (13.5 per cent to 16.8 per cent). Danish patients with left-sided tumours were less likely to undergo emergency surgery (risk ratio 0.90, 95 per cent c.i. 0.82 to 0.99) and an increase in stent use coincided with a statistically significant decrease in emergency surgery in these patients. Thirty-day postoperative mortality in all resections (elective and emergency) decreased in both populations, but a larger decrease was observed in Denmark (7.7 per cent to 3.0 per cent in Denmark and 7.1 per cent to 3.3 per cent in Yorkshire).ConclusionPatients in Denmark experienced a reduction in the use of emergency resection and increase in stenting procedures, following the policy implemented in some departments of converting potential emergency resections into elective resections.

Patient outcomes and prognostic factors associated with colonic perforation surgery: a retrospective study.

BackgroundDespite advances in surgery and intensive perioperative care, fecal peritonitis secondary to colonic perforation is associated with high rates of morbidity and mortality. This study was performed to review the outcomes of patients who underwent colonic perforation surgery and to evaluate the prognostic factors associated with mortality. MethodsA retrospective analysis was performed on 224 consecutive patients who underwent emergency colonic perforation surgery between January 2008 and May 2019. We divided the patients into survivor and non-survivor groups and compared their surgical outcomes.ResultsThe most common cause of colon perforation was malignancy in 54 patients (24.1%), followed by iatrogenic perforation in 41 (18.3%), stercoral perforation in 39 (17.4%), and diverticulitis in 37 (16.5%). The sigmoid colon (n=124, 55.4%) was the most common location of perforation, followed by the ascending colon, rectum, and cecum. Forty-five patients (20.1%) died within 1 month after surgery. Comparing the 179 survivors with the 45 non-survivors, the patient characteristics associated with mortality were advanced age, low systolic blood pressure, tachycardia, organ failure, high C-reactive protein, high creatinine, prolonged prothrombin time, and high lactate level. The presence of free or feculent fluid, diffuse peritonitis, and right-sided perforation were associated with mortality. In multivariate analysis, advanced age, organ failure, right-sided perforation, and diffuse peritonitis independently predicted mortality within 1 month after surgery.ConclusionAge and organ failure were prognostic factors for mortality associated with colon perforation. Furthermore, right-sided perforation and diffuse peritonitis demonstrated a significant association with patient mortality.

1411 Amoebic Colitis: Inaccurate Diagnosis; Inappropriate Surgery

Abstract Global prevalence of symptomatic Amoebiasis (pathogen Entamoeba histolytica) is approximately 50 million cases per year, with an annual mortality of up to 100,000. Despite this, a diagnosis of amoebiasis is rarely considered in the UK. Transmission is via the faeco-oral route, person-to-person contact or oral-anal sexual contact. The majority of cases diagnosed in the UK are in international travellers or immigrants. Symptoms of amoebiasis can closely mirror those of Inflammatory Bowel Disease (IBD) resulting in diagnostic uncertainty. A misdiagnosis could result in treatment with corticosteroids, immunosuppressant or biological agents when standard treatment for amoebiasis is actually Metronidazole. In exceptional circumstances, a misdiagnosis of IBD may lead to a patient requiring colectomy and formation of end ileostomy due to an apparent failure of medical management. Emergency colonic surgery is associated with a risk of complications such as wound infections and collections, together with the psychological consequences of major illness and surgery. We report on two patients who have undergone emergency subtotal colectomy and end ileostomy in whom a diagnosis of amoebic colitis was made on histology. Both British Asian patients were under 55 years of age, had a travel history to India and presented with diarrhoea. The diagnosis of amoebiasis must be considered in the differential diagnosis for all returning travellers and immigrants who present with GI symptoms, consistent with IBD. A correct diagnosis allows appropriate, simple, curative treatment and avoids unnecessary surgery with its attendant morbidity. Polymerase chain reaction is the gold standard diagnostic test and is currently significantly under-utilised.

Impact of the COVID-19 pandemic lockdown on the utilization of acute surgical care in the State of Salzburg, Austria: retrospective, multicenter analysis

BackgroundSome medical disciplines have reported a strong decrease of emergencies during the coronavirus disease 2019 (COVID-19) pandemic; however, the effect of the lockdown on general surgery emergencies remains unclear.MethodsThis study is a retrospective, multicenter analysis of general surgery emergency operations performed during the period from 1 March to 15th 2020 lockdown and in the same time period of 2019 in three medical centers providing emergency surgical care to the area Salzburg-North, Austria.ResultsIn total 165 emergency surgeries were performed in the study period of 2020 compared to 287 in 2019. This is a significant decrease of 122 (42.5%) emergency surgeries during the COVID-19 lockdown (p = 0.005). The length of hospital stay was reduced to 3 days in 2020 compared to 4 in 2019. Appendectomy remained the most performed emergency surgery for both periods; however the number of surgeries was reduced to less than a half, with 72 cases in 2019 and 33 cases in 2020 (p = 0.118). Emergency colon surgery observed the strongest decrease of 75% from 17 cases in 2019 to 4 in 2020. In addition, the emergency abdominal wall hernia, cholecystectomies for acute cholecystitis, small surgeries and proctological emergencies recorded drops of 70%, 39%, 33% and 47% respectively. The strongest reduction in frequencies of emergency surgeries was reported from the designated COVID center in the examined region.ConclusionsEmergency general surgery is an essential service that continues to run under all circumstances. Our data show that COVID-19-related restrictions have resulted in a significant decrease in the utilization of acute surgical care.

Does Wound Management Technique Impact Surgical Site Infection in Open Emergency Colon Procedures?

Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures. We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission. A total of 118 patients were included in the study, with a mean age of 62.8years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques. We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

Feasibility and effects of enhanced recovery vs. conventional care after emergency colon surgery for patients with left colon perforation

The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.

Consultant versus trainee led surgery and impact on outcome following an emergency colonic resection.

Emergency colonic surgery carries a high mortality rate. In the UK, strategies to improve outcomes in emergency general surgery recommend a consultant surgeon to be physically present during all operations involving a patient with a predicted mortality > 5%. To test the assertion of the consultant surgeon's presence in theatre as a determinate of improved outcome, we assessed patients following an emergency colonic resection and the effect of operator seniority. A retrospective analysis was undertaken for all patients undergoing an emergency colonic resection during a 4-year period between 2013 and 2017. Patient's pre-operative risk was assessed using P-POSSUM score and ASA grade. Outcomes assessed were post-operative morbidity (recorded using Clavien-Dindo classification), 30day/inpatient mortality and length of stay (LOS). Outcomes were then compared between consultant and trainee led cases using univariate logistic regression techniques with results presented in terms of odds ratios (95% confidence intervals). A p value of 0.05 is used to determine statistical significance. A total of 130 patients were identified over the 4-year study period. 65% had their operation performed by a consultant and 35% by a trainee. Pre-operative P-POSSUM scores were the same between the groups (9.4% [5.0-25.2] vs 9.4% [4.9-28.6] p 0.75). There was no significant difference in post-operative complication rates between consultant and trainee led cases for minor (OR 1.58 [0.76-3.20] p 0.27) or major complications (OR 1.08 [0.50-2.31] p 0.84). Overall post-operative mortality was 14% with a trend for higher mortality rates in consultant led cases (15% vs 9%) albeit not statistically significant (p 0.57). Despite similar complication rates, trainee led operations were associated with slightly longer LOS at 19 (IQR 12-38) vs 15 (IQR 9-23) days (p 0.56). Emergency colonic surgery remains associated with a high level of morbidity and mortality. However, consultant presence at the operating table does not appear to be the sole determinant of outcome following an emergency colonic resection.

Big colon surgery, little incisions: Minimally invasive techniques in emergent colon surgery.

Big colon surgery, little incisions: Minimally invasive techniques in emergent colon surgery.

Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery.

Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery. This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis. A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin. Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.

Weekend Effect in Emergency Colon and Rectal Cancer Surgery: A Prospective Study Using Data From the Dutch ColoRectal Audit.

Background: It is unclear whether emergency weekend colon and rectal cancer surgery are associated with worse outcomes (ie, weekend effect) because previous studies mostly used administrative data, which may insufficiently adjust for case-mix. Materials and Methods: Prospectively collected data from the 2012-2015 Dutch ColoRectal Audit (n=5,224) was used to examine differences in 30-day mortality and severe complication and failure-to-rescue rates for emergency weekend (Saturday and Sunday) versus Monday surgery, stratified for colon and rectal cancer. Analyses were adjusted for age, sex, body mass index, Charlson comorbidity index, American Society of Anesthesiologists classification score, tumor stage, presence of metastasis, preoperative complication, additional resection for metastasis or locally advanced tumor, location primary colon tumor, type of rectal surgery (lower anterior resection or abdominal perineal resection), and type of neoadjuvant therapy (short-course radiotherapy or chemoradiotherapy). Results: A total of 5,052 patients undergoing colon cancer surgery and 172 undergoing rectal cancer surgery were included. Patients undergoing colon or rectal cancer surgery during weekends had significantly more preoperative tumor complications compared with those undergoing surgery on a weekday. Additionally, differences in year of surgery and location of primary tumor were found for colon cancer surgery. Emergency colon cancer surgery during the weekend was associated with increased 30-day mortality (odds ratio [OR], 1.66; 95% CI, 1.10-2.50) and severe complications (OR, 1.29; 95% CI, 1.03-1.63) compared with surgery on Monday. Estimates for emergency weekend rectal cancer surgery were similar but not statistically significant, likely explained by small numbers. Conclusions: Weekend emergency colon cancer surgery was associated with higher mortality and severe complication rates. More research is needed to understand which factors explain and contribute to these differences.

Outcomes and complications of self-expanding metal stent placement for malignant colonic obstruction in a single-center study.

IntroductionApproximately 20% of cases of colorectal cancer are accompanied by acute colonic obstruction. While emergency colonic surgery is associated with high mortality and morbidity rates, placement of a self-expanding metal stent (SEMS) has been suggested as an alternative method. The SEMS placement can serve as either a definitive treatment in palliative cases or a bridge to surgery.AimTo summarize the experience of our center in the treatment of malignant colonic obstruction using SEMS placement.Material and methodsA retrospective review was conducted of all patients who underwent a SEMS placement for colorectal stricture in the study period. The procedures were performed under fluoroscopic guidance with colonoscopic assistance, and uncovered stents were used in all patients.ResultsThe study population consisted of 28 patients treated with SEMS placement due to malignant colonic obstruction. The majority of procedures were performed with palliative intent. The overall technical success rate was 96.5%, and clinical success was achieved in all of the successfully placed SEMSs. One fatal complication due to colonic perforation occurred. In the bridge-to-surgery group, all patients experienced tumor resection with no stoma creation.ConclusionsThe SEMS placement is an optimal treatment in the vast majority of acute colonic obstruction cases. Due to the possibility of potentially fatal complications, SEMS procedures should be performed by proficient endoscopists.

Comparison of surgical incision complete closure versus leaving skin open in wound class IV in emergent colon surgery

IntroductionOur aim was to compare the effect of techniques of wound closure in the emergent colon surgery with wound class IV. MethodsUsing 2014 the colectomy targeted ACS-NSQIP dataset; we identified patients undergoing emergent colectomy with wound class IV. Comparison of surgical incision complete closure versus leaving the skin open and multivariate logistic regression analyses was performed. ResultsOf 1792 patients undergoing emergent colectomy with wound class IV, the complete closure cohort had 1376 patients and the incision skin open cohort had 416 patients. The incidence of deep SSI was 2.3% in the complete closure cohort vs. 1.2% in the incision skin open, p = 0.15, and intra-abdominal abscess rate was 11.8% in the complete closure cohort vs. 12.3% in the incision skin open, p = 0.78. The dehiscence rate, readmission rate, and reoperation rates were not statistically significant between two cohorts. A multivariate model for dehiscence did not yield significant association between the complete closure cohort and incision skin open cohort. ConclusionsSurgical incision complete wound closure in the emergent colon surgery with wound class III/IV is safe and effective.

30-Day, 90-day and 1-year mortality after emergency colonic surgery.

Emergency surgery is an independent risk factor in colonic surgery resulting in high 30-day mortality. The primary aim of this study was to report 30-day, 90-day and 1-year mortality rates after emergency colonic surgery, and to report factors associated with 30-day, 90-day and 1-year mortality. Second, the aim was to report 30-day postoperative complications and their relation to in-hospital mortality. All patients undergoing acute colonic surgery in the period from May 2009 to April 2013 at Copenhagen University Hospital Herlev, Denmark, were identified. Perioperative data was collected from medical journals. 30-day, 90-day and 1-year mortality was 21, 30 and 41%, respectively. Age >70years, Performance status ≥3 and resection with stoma were independent factors associated with 30-day mortality. Age >70years, Performance status ≥3, resection with stoma and malignant disease were independent risk factors associated with 90-day mortality. Age >70years, Performance status ≥3, resection with stoma and malignant disease were independent factors associated with 1-year mortality. Overall, 30-day complication rate was 63%, with cardiopulmonary complications leading to most postoperative deaths. Mortality and complication rates after emergency colonic surgery are high and associated with patient related risk factors that cannot be modified, but also treatment related outcomes that are modifiable. An increased focus on medical and other preventive measures should be explored in the future.

Comparison of Surgical Incision Complete Closure vs Leaving Skin Open in Wound Class III and IV in Emergent Colon Surgery: Analysis Using the Targeted Colectomy American College of Surgeons NSQIP Database

Comparison of Surgical Incision Complete Closure vs Leaving Skin Open in Wound Class III and IV in Emergent Colon Surgery: Analysis Using the Targeted Colectomy American College of Surgeons NSQIP Database

Intraoperative Fires during Emergent Colon Surgery

Intraoperative Fires during Emergent Colon Surgery

Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period

Purpose: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. Materials and Methods: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. Results: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). Conclusions: Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.