Emergency Colorectal Resection Research Articles

Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit.

Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (>16years) who underwent emergency (unplanned, within 24h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5). From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P=0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P=0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.

Appropriate selection is essential for achieving satisfactory outcomes in laparoscopic colonic resections in emergency settings

Dear Editor: Laparoscopic colectomy is increasingly accepted as the standard of care in the elective setting for both benign and malignant colorectal diseases. The most recent National Bowel Cancer Audit reported an uptake of just over 40 %. The use of laparoscopy in colorectal resection for cancer has been recommended by the National Institute for Healthcare and Clinical Excellence (NICE), provided it is performed by appropriately trained surgeons. Many randomised prospective studies have demonstrated the short-term benefits of laparoscopic over open colectomy for elective surgery. These include short recovery periods, early regaining of bowel function and short hospital stay, with comparable morbidity, mortality and recurrence rates [1–3]. The role of laparoscopy for emergency colorectal resection and its potential benefits remain controversial. The available studies in the literature compare the outcomes of emergency laparoscopic procedures with emergency open procedures. To the best of our knowledge, there have been no publications comparing outcomes of emergency with elective laparoscopic colectomy. We conducted a study is to examine the use of minimally invasive laparoscopic techniques in carefully selected emergency colorectal procedures and to assess its safety and feasibility when compared with elective surgery, and to assess the outcome when compared with emergency open colectomy. This is a retrospective study of a prospectively collected database. Research ethics committee approval was waived. A literature search was performed to assess the current evidence in laparoscopic emergency colectomy. The entire Ovid database was searched with the keywords Blaparoscopic^, Bcolectomy^ and Bemergency , and these were combined with the set operator BAND^. The search was completed on 19 June 2015. Thirty-one results were found and screened. Papers that were case series, case-control, cohort or randomised controlled trials of the use of emergency laparoscopic colectomy in adults were included. Fourteen papers did not meet the inclusion criteria and 9 were duplicates. All patients who underwent emergency laparoscopic colectomy, performed by one surgeon in a single district general hospital, between 2008 and 2014 were identified. Emergency open colectomy data was collected retrospectively by searching the theatre electronic coding system for the terms Bcolectomy^ and/or BHartmann’s^. The selection criteria for emergency laparoscopic surgery were a stable patient, being fit for laparoscopic procedure and the availability of experienced surgical and nursing staff. Patients with marked small-bowel dilatation or severe sepsis were excluded. Patients who underwent laparoscopic appendicectomy and laparoscopic stoma were excluded from the database. Emergency colectomy included both lifethreatening cases, booked on the emergency list as soon as possible, and urgent surgery which was defined as needed to occur before discharge of the patient. Data collected included age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, admission date, operation date, operation type, ICU admission, re-operation, morbidity and mortality. Statistical analysis was performed using Fisher’s exact test for categorical data and Student t test for numerical data. A total of 347 laparoscopic colectomies were performed between 2002 and 2014, of which 321 were elective. Twenty-six emergency procedures were performed after * N. Naguib nadernaguib71@yahoo.com

PTH-301 Emergency versus elective malignant colorectal resections: a single centre experience

Introduction Colorectal Cancer (CRC) is the 3 rd most common and 2 nd most lethal malignancy in men and women in the UK. CRC presents as a surgical emergency in Method This is a retrospective study carried out since January 2008 at Macclesfield District General Hospital. Patient factors, histopathology and surgical outcomes were evaluated for all emergency malignant colorectal resections. A cohort of elective malignant colorectal resections carried out since 2008 were recruited as controls. Results See Table 1 Conclusion Colorectal malignancy is more predominant in males, however emergency presentation was less predictable. Prolonged operative time in elective cases is attributed to use of laparoscopy. Emergency colorectal patients were generally ill patients (ASA 3) with sepsis. The greater LB specimen reflects more diseased (less viable LB due to obstruction) LB resection in the emergency cases. Consequently the survival was poorer in emergency colorectal resections. This study supports the bowel screening initiatives to detect early colorectal cancers. Disclosure of interest None Declared.

PWE-401 Nurse-led audit of post-operative morbidity following colorectal resection: making the most of existing resources

Introduction: Colorectal and stoma care nurses have been auditing their specialist services for years, but have contributed less frequently to colorectal surgical service-wide audit measuring clinical outcomes relating to surgical as well as nursing care. Nurse-led follow-up provides the ideal platform to measure key indicators of quality care and identify areas for both service improvement and future research activity. Method: A nurse-led follow-up clinic at 30 days following patient discharge was used to audit 142 consecutive patients undergoing elective (n= 98) or emergency (n=44) colorectal resection over a three month period. Audit data were recorded at two time-points, discharge from hospital and at clinic, with audit templates developed using validated tools designed to measure general post-operative morbidity (Grocott et al, 2007; Dindo et al, 2004) and modified to include a focus on colorectal surgery-specific complications. Audit templates were tested during two clinics prior to full data collection to ensure they included all required variables. Results: A wide range of anticipated and unanticipated findings were identified relating to both inpatient and early post- discharge morbidity. Findings were presented to the whole colorectal team, including upper GI and colorectal surgeons and their teams, specialist nurses, theatre-based and ward-based nursing staff. Areas of clinical practice identified by the audit as requiring improvement were identified and discussed, with immediate changes to surgical practice agreed by the whole team. Nurse-led follow-up for all colorectal patients was established as a potential goal for future service improvement. Conclusion: This nurse-led audit enabled the whole colorectal team to scrutinise their clinical practice by comprehensively examining patient outcomes at two time-points following colorectal resection. Nurse-led follow-up using an auditable documentation template facilitates the recognition and reporting of a wide range of post-operative complications and provides valuable support for patients, particularly those who do not have routine access to specialist nursing services.

PTU-271 Hidden morbidity following colorectal resection: postoperative evaluation

Introduction The implementation and evaluation of Enhanced Recovery after Surgery programmes over the past 15 years has ensured the accurate reporting of inpatient morbidity post colorectal resection. However, there is a paucity of audit or research examining post-operative morbidity in the early discharge period. Method 142 consecutive patients undergoing elective (n = 98) or emergency (n = 44) colorectal resection over a three-month period were invited to attend a nurse-led outpatient clinic at 30 days post-discharge. Audit data were collected at two time-points, discharge from hospital and at clinic. Audit templates were developed using the Postoperative Morbidity Survey, 1 Clavien-Dindo classification criteria 2 and modified to include additional colorectal surgery-specific outcomes. Results were recorded and analysed using SPSS. Results Unanticipated findings relating to post-discharge morbidity identified through the audit included: 35% (n = 32) of infection-free inpatients developed surgical site infections following discharge. 34% (n = 47) of all patients had significant urinary symptoms when seen in clinic. Dietary implications at 30 days post-discharge included an appetite of half or less than usual intake in 27% of patients (n = 37) and moderate to major changes in dietary intake compared to their pre-operative diet in 30% (n = 42). 27% (n = 38) of patients had an ileostomy; of those without an ileostomy, 20% (n = 21) had four or more daily bowel movements, with 22% (n = 23) describing their stool consistency as watery, loose or unsettled. 45% (n = 46) of those without an ileostomy reported one or more problematic bowel symptom related to their surgical experience at 30 days post-discharge. Conclusion These audit findings suggest that individuals undergoing colorectal resection experience significant levels of post-discharge morbidity, extending the burden on them and the services required to support them for longer than may have been previously anticipated. Nurse-led follow-up using auditable documentation templates facilitates the recognition and reporting of complications following discharge and provides valuable support for patients. Disclosure of interest None Declared. References Grocott MPW, et al . The Postoperative Morbidity Survey was validated and used to describe morbidity after pelvic surgery. J Clin Epidemiol 2007;60:919–928 Dindo D, et al . Classification of Surgical Complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery

BackgroundSurgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery.MethodsAll adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality.ResultsA total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (rs = 0·957, P < 0·001 versus 180-day mortality; rs = 0·860, P < 0·001 versus 365-day mortality).ConclusionExtending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.

Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly

Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients. This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients' characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors. Two-hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups. The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.

The majority of colorectal resections require an open approach, even in units with a special interest in laparoscopic surgery

Proponents suggest that laparoscopic colorectal resection might be achievable in up to 90% of cases, while keeping conversion rates below 10%. This unselected prospective case series reports on the proportion of patients having a completed laparoscopic colorectal resection in two units where laparoscopic colorectal practice is well established and readily available. All patients undergoing elective and emergency colorectal resection during a 6-month period were identified. The underlying pathology and the surgical approach (laparoscopic or open) were recorded. The contraindications to laparoscopic resection were also documented. The need and rationale for conversion to an open approach were recorded. In total, 205 consecutive patients (160 elective and 45 emergency procedures) underwent colorectal resection for malignancy [117 (57%) patients] and benign pathology [88 (43%) patients]. Laparoscopic resection was attempted in 127/205 (62%) patients and 31/127 (24%) of these were converted to open surgery. The main reasons for not attempting laparoscopic resection were locally advanced disease and emergency surgery. The commonest reasons for conversion were advanced disease and to allow completion of rectal dissection and/or cross-stapling of the rectum. Despite a special interest in laparoscopic colorectal surgery of the two colorectal units who provided the data for this study, fewer than half (96/205; 47%) of the patients in this consecutive unselected series who were undergoing major colorectal resection had the procedure completed laparoscopically.

Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics

Objective To describe national reoperation rates after elective and emergency colorectal resection and to assess the feasibility of using reoperation as a quality indicator derived from routinely collected data in...

Impact of Surgical Specialization on Emergency Colorectal Surgery Outcomes

To evaluate the impact of surgeon specialization on emergency colorectal resection in terms of mortality, morbidity, and type of operation performed. Observational study from January 1, 1993, through December 31, 2006. Bellvitge University Hospital, Barcelona, Spain. A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS). Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables. Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence. Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Comparison of Hospital Performance in Nonemergency Versus Emergency Colorectal Operations at 142 Hospitals

Quality improvement efforts have demonstrated considerable hospital-to-hospital variation in surgical outcomes. However, information about the quality of emergency surgical care is lacking. The objective of this study was to assess whether hospitals have comparable outcomes for emergency and nonemergency operations. Patients undergoing colorectal resections were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2005 to 2007 dataset. Logistic regression models for 30-day morbidity and mortality after emergency and nonemergency colorectal resections were constructed. Hospital risk-adjusted outcomes as measured by observed to expected (O/E) ratios, outlier status, and rank-order differences were compared. Of 25,710 nonemergency colorectal resections performed at 142 ACS NSQIP hospitals, 6,138 (23.9%) patients experienced at least 1 complication, and 492 (1.9%) patients died. There were 5,083 emergency colorectal resections; 2,442 (48%) patients experienced at least 1 complication, and 780 (15.3%) patients died. Outcomes for nonemergency versus emergency operations were weakly correlated for morbidity and mortality (Pearson correlation coefficient: 0.28 versus 0.13). Median differences in hospital rankings based on O/E ratios between nonemergency and emergency performance were 30.5 ranks (interquartile range [IQR] 13 to 59) for morbidity and 34 ranks (interquartile ratio 17 to 61) for mortality. Hospitals with favorable outcomes after nonemergency colorectal resections do not necessarily have similar outcomes for emergency operations. Hospitals should specifically examine their performance on emergency surgical procedures to identify quality improvement opportunities and focus quality improvement efforts appropriately.

Emergency colorectal resections in Asian octogenarians: Factors impacting surgical outcome

The population in developing countries is aging and the number of octogenarians is expected to increase in the future at an alarmingly fast rate. This paper evaluates the surgical outcomes of emergency colorectal resections among Asian octogenarians. We conducted a retrospective review of all octogenarians and older, who had an emergency colorectal resection performed between February 1996 to December 2001. Fifty-eight emergency colorectal resections were performed in patients with a median age of 83 years. The indications for surgery were colorectal cancer (74%) and complicated diverticular disease (12%). The most common presentation was an intestinal obstruction (72%). Fifty-one (88%) of the patients had comorbidities. Forty-five percent of patients had an American Society of Anesthesiologists (ASA) score of I and II, while 55% had a score of III and IV. Consultants performed 53% of the procedures. The mean surgical time was 156 min. Hartmann's procedure was the most common procedure performed (43%). There were 16 (28%) mortalities. The postoperative morbidity was 81%. The only factor impacting outcome was a high ASA score of III and IV. The median length of stay was 17.5 (range 3-108) days. The mortality and morbidity of emergency colorectal resections among Asian octogenarians are high and can be predicted by their ASA status.