Prognostic factors for survival in colonic perforation

Factors associated with postoperative recurrence in perforated colorectal cancer: unraveling the high recurrence rate of perforated colorectal cancer

BACKGROUND

Perforated colorectal cancer exhibits a higher recurrence rate than non-perforated colorectal cancer; however, the reasons for this difference remain unclear. This study identifies factors affecting recurrence in patients with perforated colorectal cancer who underwent R0 surgery.

METHODS

This study included consecutive patients with Stage II or III perforated colorectal cancer who underwent radical surgery at a single center between 2007 and 2020. The comparison group included patients with non-perforated, non-obstructive, non-perforated colorectal cancer who underwent surgery during the same period. Clinicopathological background factors (age, sex, localization, surgical procedure, stoma, T stage, lymphatic invasion, venous invasion, differentiation, extent of lymph node dissection, number of dissected lymph nodes, lymph node metastasis, postoperative complications, and 30-day postoperative death) of perforated and non-perforated colorectal cancers were investigated. Factors influencing recurrence were examined in patients who were followed for more than 3 years after surgery, up to 5 years postoperatively.

RESULTS

This study included 89 perforated and 323 non-perforated cases. The median patient ages were 74 and 73 years in the perforated and non-perforated groups, respectively. In perforated cases, the proportion of T4 stage tumors was significantly higher (39% vs. 18% in non-perforated cases, with p < 0.001). Additionally, the number of lymph node dissections was significantly lower (10 vs. 17 in non-perforated cases, p < 0.001), and the rate of postoperative complications was higher (46% vs. 7% in the non-perforated cases, p < 0.001). Postoperatively, 55 perforated and 284 non-perforated cases were available for follow-up. Univariate analysis revealed that perforation, T4 stage, lymph node metastases, and postoperative complications were associated with significantly higher recurrence rates. Multivariate analysis identified T4 stage and lymph node metastases as independent risk factors.

CONCLUSIONS

The recurrence rate of perforated colorectal cancer was higher than that of non-perforated cases, primarily due to advanced disease stages, such as T4 or lymph node metastases. Perforation itself may not directly cause recurrence but reflects cancer progression. Further research is needed to clarify the mechanisms linking cancer progression, perforation, and recurrence.

Combination of radiomic and clinical characteristics to predict mortality in patients with colorectal perforation

PURPOSE

We aim to construct and verify a model combining radiomic and clinical data to predict early mortality in patients with colorectal perforation in a two-center study.

METHODS

Data from 147 patients at Xiaogan Central Hospital (2014-2024) and 52 patients at Southern Hospital of Southern Medical University (2021-2023) were collected for model training and validation. Univariate and multivariate analyses were performed to identify risk factors associated with mortality. Radiomic characteristics from CT scans were extracted via least absolute shrinkage and selection operator (LASSO) regression to construct an imaging score. A nomogram was developed by integrating the findings from the multivariate analysis. Predictive performance was evaluated via the area under the receiver operating characteristic curve (AUC), and clinical utility was assessed via decision curve analysis (DCA).

RESULTS

Univariate analysis highlighted age, ASA classification, shock index, rad-score, white blood cell (WBC) count, neutrophil (N) and lymphocyte (L) counts, sodium (Na+), creatinine (Cr), and procalcitonin (PCT) as significant prognostic indicators for mortality (p < 0.05). Multivariate analysis confirmed age, ASA classification, PCT, and rad-score as independent prognostic factors. The radiomic combined with clinical characteristics nomogram (RCCCN) includes four variables: the patient's age, ASA classification, PCT level, and rad-score. The RCCCN model demonstrated excellent predictive performance for mortality risk in the validation cohort (AUC: 0.92, 95% CI: 0.84-0.99) with good calibration.

CONCLUSION

A nomogram combining radiomic features and clinical characteristics effectively predicts mortality in patients with colorectal perforation, providing a valuable tool for clinical decision-making and patient management.

Gut microbes of the cecum versus the colon drive more severe lethality and multi-organ damage

Intestinal perforations lead to a high risk of sepsis-associated morbidity and multi-organ dysfunctions. A perforation allows intestinal contents (IC) to enter the peritoneal cavity, causing abdominal infections. Right- and left-sided perforations have different prognoses in humans, but the mechanisms associated with different cecum and colon perforations remain unclear. This study investigates how gut flora influences outcomes from perforations at different sites in mice. Using fecal-induced peritonitis mouse model, isolated IC from the cecum or colon was injected peritoneally at 2 mg/kg. Bacterial burden was quantified with quantitative PCR, and microbial communities were analyzed using 16S rRNA gene sequencing. Survival rates were monitored, and blood biochemical indices, histological changes, cytokines expression, immunological signaling and multiple-organ damage were assessed at 16 h post-injections. The results showed cecum IC developed more severe sepsis than colon IC, with shorter median survival time and greater multi-organ damage. Mice treated with cecum IC displayed elevated tissue damage markers in the liver, heart, and kidneys, contributing to worsened pathology. This was likely driven by systematic inflammatory cytokines production and lung inflammation. Mechanistically, cecum IC triggered stronger cGAS-STING and TBK1-NF-κB signaling, promoting systemic inflammation compared to the colon IC. Moreover, bacterial analysis demonstrated that cecum IC carry a higher bacterial burden than colon IC and exhibit a different microbial community. A detailed microbiome comparison revealed an increased abundance of potentially pathogenic bacteria in the cecum IC. These findings suggest that the site of intestinal perforation influences sepsis severity, with the cecum being associated with a higher bacterial burden and a relatively increased abundance of potentially pathogenic bacteria compared to the colon. Our findings first compared the lethality associated with the microbial composition of the cecum and colon, indicating the perforation site could help providers predict the severity of sepsis, thereby introducing a novel perspective to microbiology and sepsis research.

Risk Factors and Patterns of Recurrence in Stage III Perforated Colorectal Cancer: A Single-Center, Retrospective, Observational Study

BACKGROUND

Colorectal perforation generally results in a poor prognosis with a high mortality rate. Malignant colorectal perforation may result in cancer recurrence; however, the reason for higher recurrence rates in perforated than in nonperforated colorectal cancer is unclear. Therefore, we aimed to identify factors influencing stage III perforated colorectal cancer recurrence after a microscopically margin-negative resection (R0) surgery.

MATERIALS AND METHODS

This single-center, retrospective, observational study enrolled patients with stage III colorectal cancer who had undergone R0 surgery between 2007 and 2019. The clinicopathological characteristics and recurrence patterns of patients with perforated (n = 34) versus nonperforated tumors (n = 120) were compared.

RESULTS

The T4 disease proportion was significantly higher, and lymphatic invasion was more severe in the perforated group than in the nonperforated group. Significantly more dissected lymph nodes (n = 17) were observed in the nonperforated group than in the perforated group (n = 11). The rates of postoperative Clavien-Dindo III or higher complications and in-hospital mortality were significantly higher in the perforated group. Of the 23 and 96 patients who underwent long-term follow-up in the perforated and nonperforated groups, recurrence occurred in 14 (61%) and 34 patients (35%), respectively. The proportion of stage IIIC lesions was higher in the recurrence subset of the nonperforated group; however, clinicopathological characteristics did not differ significantly between the subsets of the perforated group.

CONCLUSIONS

The higher recurrence rate of stage III perforated colorectal cancer is likely due to higher T classification, lymphatic invasion, and increased lymph node metastases. Factors leading to perforation are likely related to advanced cancer stage.

Importance of high suspicion of intestinal perforation in blunt abdominal injury in patients with inflammatory bowel disease

Estimated to affect 3 million individuals in Europe alone, Crohn's disease is an inflammatory bowel disease causing transmural inflammation throughout the gastrointestinal tract. We describe the case of a patient with a known background of Crohn's disease who presented with abdominal pain following blunt abdominal trauma after a hit and run where initial diagnosis of perforation was missed on pan-computed tomography, however, diagnosis was made early due to high clinical suspicion of perforation. This suggests that current diagnostic imaging can be inaccurate, leading to delays where urgent surgery is otherwise indicated which is a cause for concern. Herein, we emphasize the importance of a high index of suspicion for perforation in patients with blunt abdominal trauma, especially where there is underlying bowel disease.

The role of radiology in diagnosing gastrointestinal tract perforation

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

Prognostic impact and survival outcomes of colon perforation in patients with metastatic colorectal cancer: a multicenter retrospective cohort study

BACKGROUND

Colon perforation caused by colorectal cancer (CRC) is a fatal condition requiring emergency intervention. For patients with metastatic lesions, surgeons face difficult decisions regarding whether to resect the primary and metastatic lesions. Moreover, there is currently no established treatment strategy for these patients. This study aimed to investigate the clinical practice and long-term outcomes of patients with metastatic CRC diagnosed with the onset of colon perforation.

METHODS

We performed a population-based multicenter cohort study. Consecutive patients diagnosed with stage IV CRC between 2008 and 2015 at all designated cancer hospitals in Fukushima Prefecture, Japan, were enrolled in this study. We evaluated the impact of colon perforation on the survival outcomes of patients with metastatic CRC. The main outcome was the adjusted hazard ratio (aHR) of perforation for overall survival (OS). Survival time and HRs were estimated using Kaplan‒Meier and Cox proportional regression analyses.

RESULTS

A total of 1258 patients were enrolled (perforation: n = 46; non-perforation: n = 1212). All but one of the patients with perforation underwent primary resection or colostomy and 25 cases were able to receive chemotherapy. The median OS for the perforation and non-perforation groups was 19.0 and 20.0 months, respectively (p = 0.96). Moreover, perforation was not an independent prognostic factor (aHR: 0.99; 95% confidence interval: 0.61-1.28).

CONCLUSIONS

In metastatic CRC, perforation is not necessarily a poor prognostic factor. Patients with perforation who undergo primary tumor resection or colostomy and prompt initiation of systemic chemotherapy might be expected to have a survival time similar to that of patients with non-perforated colon.

Inadvertent laparoscopic lavage of perforated colon cancer: a systematic review

BACKGROUND

Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis.

METHODS

The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate % and 95% confidence intervals.

RESULTS

Eleven studies (three randomized, two prospective, six retrospective) totaling 642 patients met inclusion criteria. Eight studies reported how patients were screened for cancer and the number of patients who completed follow-up. The pooled cancer rate was 3.4% (0.9%, 5.8%) with low heterogeneity (Isquare2 = 34.02%) in eight studies. Cancer rates were 8.2% (0%, 3%) (Isquare2 = 58.2%) and 1.7% (0%, 4.5%) (Isquare2 = 0%) in prospective and retrospective studies, respectively. Randomized trials reported a cancer rate of 7.2% (3.1%, 11.2%) with low among-study heterogeneity (Isquare2 = 0%) and a median delay to diagnosis of 2 (1.5-5) months.

CONCLUSIONS

This systematic review found that 7% of patients undergoing laparoscopic lavage for peritonitis had perforated colon cancer with a delay to diagnosis of up to 5 months.

Impact of Preoperative Stoma Site Marking on Morbidity and Mortality in Patients with Colorectal Perforation: A Nationwide Retrospective Cohort Study

BACKGROUND

Preoperative stoma site marking reduces the incidence of complications from elective surgery. However, the impact of stoma site marking in emergency patients with colorectal perforation remains unclear. This study aimed to assess the impact of stoma site marking on morbidity and mortality in patients with colorectal perforation who underwent emergency surgery.

METHODS

This retrospective cohort study used the Japanese Diagnosis Procedure Combination inpatient database from April 1, 2012, to March 31, 2020. We identified patients who underwent emergency surgery for colorectal perforation. We compared outcomes between those with and without stoma site marking using propensity score matching to adjust for confounding factors. The primary outcome was the overall complication rate, and the secondary outcomes were stoma-related, surgical, and medical complications and 30-day mortality.

RESULTS

We identified 21,153 patients (682 with stoma site marking and 20,471 without stoma site marking) and grouped them into 682 pairs using propensity score matching. The overall complication rates were 23.5% and 21.4% in the groups with and without stoma site marking, respectively (p = 0.40). Stoma site marking was not associated with a decrease in stoma-related, surgical, or medical complications. The 30-day mortality did not differ significantly between the groups with and without stoma site marking (7.9% vs. 8.4%, p = 0.843).

CONCLUSIONS

Preoperative stoma site marking was not associated with a reduction in morbidity and mortality in patients with colorectal perforation who underwent emergency surgery.

Risk factors for the recurrence of stage II perforated colorectal cancer: A retrospective observational study

BACKGROUND

Patients with perforated colorectal cancer (PCRC) experience higher recurrence rates than those with non-perforated tissue. We identified the promoting factors of stage II PCRC recurrence after R0 surgery.

METHOD

This retrospective observational study included patients treated for colorectal cancer at a single facility between 2007 and 2016, and compared the clinicopathological features of patients with perforating versus non-perforating stage II tumors who underwent R0 resection, while focusing on recurrences.

RESULTS

Thirty-two and 112 patients (predominantly men) with perforating and non-perforating tumors, respectively, were included. The perforated group had significantly higher proportions of T4 tumors than the non-perforated group (44% vs. 15%). The perforated group had significantly lower numbers of resected lymph nodes than the non-perforated group (6 vs. 17). Seven of 17 patients with follow-up data in the perforated group experienced recurrence (41%), versus 19 of 104 in the non-perforated group (18%). In the non-perforated group, male sex (89% vs. 60%, p = 0.030), T4 stage (32% vs. 9%, p = 0.029), and fewer resected lymph nodes (12.5 vs. 18.6, p = 0.003) were significantly associated with recurrence; however, no such influences on recurrence were observed in the perforated group. The recurrence sites in the perforated group were mostly local (6 patients, 86%). Conversely, recurrences in the non-perforated group were mostly distant; 8 of 19 patients (42%) had liver metastasis and 1 (5%) had lung metastasis.

CONCLUSION

Patients with stage II PCRC experienced higher recurrence rates regardless of clinicopathological features and had high local recurrence rates indicating possible local tumor cell dispersal owing to perforation.

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

Background

Despite 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.

Methods

A 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.

Results

The 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.

Conclusion

Age 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.

Correlation of gastrointestinal perforation location and amount of free air and ascites on CT imaging

PURPOSE

To analyze the amount of free abdominal gas and ascites on computed tomography (CT) images relative to the location of a perforation.

METHODS

We retrospectively included 172 consecutive patients (93:79 = m:f) with GIT perforation, who underwent abdominal surgery (ground truth for perforation location). The volume of free air and ascites were quantified on CT images by 4 radiologists and a semiautomated software. The relation of the perforation location (upper/lower GIT) and amount of free air and ascites was analyzed by the Mann-Whitney test. Furthermore, best volume cutoff for upper and lower GIT perforation, areas under the curve (AUC), and interreader volume agreement were assessed.

RESULTS

There was significantly more abdominal ascites with upper GIT perforation (333 ml, range 5 to 2000 ml) than with lower GIT perforation (100 ml, range 5 to 2000 ml, p = 0.022). The highest volume of free air was found with perforations of the stomach, descending colon and sigmoid colon. Significantly less free air was found with perforations of the small bowel and ascending colon compared to the aforementioned. An ascites volume > 333 ml was associated with an upper GIT perforation demonstrating an AUC of 0.63 ± 0.04.

CONCLUSION

Using a two-step process based on the volumes of free air and free fluid can help localizing the site of perforation to the upper, middle or lower GI tract.

Perioperative clinical parameters associated with short-term mortality after colorectal perforation

Purpose

Although early prediction of mortality is useful for the management of patients with colorectal perforations, no significant perioperative predictive factors have been identified. The purpose of this study was to identify useful prognostic factors for patients with colorectal perforation.

Methods

This single-center retrospective study included consecutive patients undergoing emergency surgery for colorectal perforation from January 2012 to December 2019. The primary outcome was combined 30 day and in-hospital mortality. Patient- and disease-related factors obtained perioperatively were evaluated for mortality prediction. A scoring system was developed to enhance clinical utility.

Results

Overall, 146 patients were included and 20 (14%) died after surgery. Multivariate logistic regression identified five predictive factors: age, hemodialysis, uncommon perforation etiology, plasma albumin level, and decreased platelet count. The area under the receiver operating curve for the scoring system using these parameters was 0.894 (95% CI 0.835–0.952). Patients at high-risk of mortality were classified by the proposed score with a sensitivity of 90.0% and negative predictive value of 98.0%.

Conclusion

This study identified five perioperative factors significantly associated with mortality of patients with colorectal perforation. Although these parameters predict mortality of patients with colorectal perforation using a score with high discrimination, further study is required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01719-8.

Successful colonoscopic removal of a foreign body that caused sigmoid colon perforation: a case report

Large bowel perforation is an acute abdominal emergency requiring rapid diagnosis for proper treatment. The high mortality rate associated with large bowel perforation underlines the importance of an accurate and timely diagnosis. Computed tomography is useful for diagnosis of ingested foreign bodies, and endoscopic repair using clips can be an effective treatment of colon perforations. We herein describe a 78-year-old man with sigmoid colon perforation caused by accidental swallowing of a jujube pit. The jujube pit had become stuck in the wall of the sigmoid colon and was successfully removed by colonoscopy, avoiding an aggressive surgery. As a result of developments in endoscopic techniques, endoscopic closure has become a feasible option for the management of intestinal perforation.

Failure to rescue patients after emergency laparotomy for large bowel perforation: analysis of the National Emergency Laparotomy Audit (NELA)

BACKGROUND

Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability.

METHODS

Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality.

RESULTS

Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770).

CONCLUSION

Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.

Facility of Origin Predicts Mortality After Colonic Perforation

INTRODUCTION

Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation.

MATERIALS AND METHODS

Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed.

RESULTS

4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death.

DISCUSSION

Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.

Prognostic Factors and Management for Left Colonic Perforation: Can Hartmann's Procedure Be Preventable?

PURPOSE

To identify factors significantly associated with the mortality of patients with left colonic perforation, and to compare the outcome of Hartmann's procedure (HP) and primary repair (PR) or primary anastomosis (PA) in patients with left colonic perforation without factors associated with mortality.

METHODS

This retrospective study included patients who underwent surgery for left colonic perforation from January 2009 to February 2018. Preoperative factors related to postoperative mortality, including vital signs, laboratory findings, and intraoperative findings, were analyzed by type of operation. The chi-square, Fisher exact, and Mann-Whitney U-tests were used to analyze the data.

RESULTS

Ninety-one patients were included (36 men, 55 women), and 15 (16.5%) died postoperatively. Prognostic factors were age, leukopenia, thrombocytopenia, bleeding tendency, acute kidney injury, hemodynamic instability, and the existence of feculent ascites. Leukopenia and longer operative time were independent risk factors for mortality. Seventy-nine patients did not have leukopenia and 30 of these patients who underwent PR without diversion were excluded from the subanalysis. HP was performed in 30 patients, and PR with diversion and PA with or without diversion were performed in 19. Compared to the other operative methods, HP had no advantage in reducing hospital mortality (P=0.458) and morbidity.

CONCLUSION

Leukopenia could be an objective prognostic factor for left colonic perforation. Although HP is the gold standard for septic left colonic perforation, it did not improve the hospital mortality of the patients without leukopenia. For such patients, PR or PA may be suggested as an alternative option for left colonic perforation.

Intraabdominal continuous negative pressure therapy for secondary peritonitis: an observational trial in a maximum care center

Background: Acute secondary peritonitis is afflicted with a high morbidity and mortality. Intensive care therapy, antibiotics and surgical procedures are mandatory. Continuous negative pressure therapy (cNPT) seems to be beneficial but it is unclear which patients will benefit most from this procedures.Methods: We performed a prospective observational trial including all patients that needed to undergo an exploratory laparotomy for the suspicion of acute secondary peritonitis and were treated with cNPT in one year.Results: Thirty nine patients fitted the criteria. Median hospitalization length was 40 days. The vacuum therapy treatment was applied for a median of 4 days. The subgroup analysis between patients, who received the cNPT-dressing for one time (Group A) and patients, in whom the cNPT was continued after first relaparotomy (Group B) showed no differences concerning patients' characteristics. The Mannheimer Peritonitis Index (MPI) during the first operation was significantly correlated with the number of dressing changes (Spearman's rho 0.518, p = .002).Conclusions: Fast acting in acute secondary peritonitis for elimination of the source, abdominal lavage, derivation of the exsudat and interdisciplinary treatment is the treatment of choice. The MPI could be beneficial for the decision process of using cNPT.

Low psoas muscle index is a poor prognostic factor for lower gastrointestinal perforation: a single-center retrospective cohort study

Background

Various body composition indices have been reported as prognostic factors for different cancers. However, whether body composition affects prognosis after lower gastrointestinal tract perforation requiring emergency surgery and multidisciplinary treatment has not been clarified. This study examined whether body composition evaluations that can be measured easily and quickly from computed tomography (CT) are useful for predicting prognosis.

Methods

Subjects comprised 64 patients diagnosed with perforation at final diagnosis after emergency surgery for a preoperative diagnosis of lower gastrointestinal tract perforation and penetration. They were divided into a survival group and a non-survival (in-hospital mortality) group and compared. Body composition indices (psoas muscle index (PMI); psoas muscle attenuation (PMA); subcutaneous adipose tissue index (SATI); visceral adipose tissue index (VATI); visceral-to-subcutaneous fat area ratio (VSR)) were measured from preoperative CT. Cross-sectional psoas muscle area at the level of the 3rd lumbar vertebra was quantified. Optimal cut-off values were calculated using receiver operating characteristic curve analysis. Poor prognostic factors were investigated from multivariate logistic regression analyses that included patient factors, perioperative factors, intraoperative factors, and body composition indices as explanatory variables.

Results

The cause of perforation was malignant disease in 12 cases (18.7%), and benign disease in 52 cases (81.2%). The most common cause was diverticulum of the large intestine. Emergency surgery for the 64 patients led to survival in 52 patients and death in 12 patients. On multivariate logistic regression analysis, independent predictors of poor prognosis were Sequential Organ Failure Assessment score (odds ratio 1.908; 95% confidence interval (CI) 1.235–3.681; P = 0.0020) and PMI (odds ratio 13.478; 95%CI 1.342–332.690; P = 0.0252). The cut-off PMI was 4.75 cm²/m² for males and 2.89 cm²/m² for females. Among survivors, duration of hospitalization was significantly longer in the low PMI group (29 days) than in the high PMI group (22 days, p = 0.0257).

Conclusions

PMI is easily determined from CT and allows rapid evaluation of prognosis following lower gastrointestinal perforation.

Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report

Patient: Male, 57

Final Diagnosis: Perforated diverticuli

Symptoms: Asymptomatic

Medication: —

Clinical Procedure: —

Specialty: Surgery

The Association between Absence of Abdominal Pain and Mortality in Lower Intestinal Perforation in Patients with Autoimmune Rheumatic Diseases

Objective

To determine mortality and predictive factors for lower intestinal perforation (LIP) among patients with autoimmune rheumatic diseases.

Methods

This retrospective, single-center, observational study analyzed mortality rates in 31 autoimmune rheumatic disease patients with LIP who were admitted to our hospital from January 2002 to June 2017. The primary outcome was the mortality rate during hospitalization.

Results

The median age at the time of LIP was 61 years, and the survival rate at discharge was 64.5%. Eleven patients died of sepsis during hospitalization. Cox univariable analysis for mortality during hospitalization showed that absence of abdominal pain (hazard ratio (HR) 5.61, 95% confidence interval (CI) 1.38–22.9), higher age (HR 1.06, 95% CI 1.01–1.11), chronic kidney disease (HR 6.89, 95% CI 1.85–25.7), systemic vasculitis (HR 3.95, 95% CI 1.14–13.6), higher blood urea nitrogen (HR 1.02, 95% CI 1.01–1.04), higher serum creatinine (HR 1.41, 95% CI 1.06–1.87), and LIP due to malignancy (HR 14.3, 95% CI 1.95–105.1) significantly increased mortality.

Conclusion

Abdominal pain was absent in 16% of LIP patients with autoimmune rheumatic diseases, and this absence was a poor prognostic factor in this cohort. Moreover, higher age, chronic kidney disease, systemic vasculitis, and LIP due to malignancy were associated with significantly increased mortality. Physicians should be aware of LIP in autoimmune disease patients with higher age, chronic kidney diseases, or systemic vasculitis even if patients reveal mild abdominal symptoms.

Colon cancer with perforation

Perforation of the colon is a rare complication for patients with colon cancer and usually requires emergent surgery. The characteristics of perforation differ based on the site of perforation, presenting as either perforation at the cancer site or perforation proximal to the cancer site. Peritonitis due to perforation tends to be more severe in cases of perforation proximal to the cancer site; however, the difference in the outcome between the two types remains unclear. Surgical treatment of colon cancer with perforation has changed over time. Recently, many reports have shown the safety and effectiveness of single-stage operation consisting of resection and primary anastomosis with intraoperative colonic lavage. Under certain conditions, laparoscopic surgery can be feasible and help minimize the invasion. However, emergent surgery for colon cancer with perforation is associated with a high rate of mortality and morbidity. The long-term prognosis seems to have no association with the existence of perforation. Oncologically curative resection may be warranted for perforated colon cancer. In this report, we perform a literature review and investigate the characteristics and surgical strategy for colon cancer with perforation.

Mortality risk factor analysis in colonic perforation: would retroperitoneal contamination increase mortality in colonic perforation?

Purpose

Colonic perforation is a lethal condition presenting high morbidity and mortality in spite of urgent surgical treatment. This study investigated the surgical outcome of patients with colonic perforation associated with retroperitoneal contamination.

Methods

Retrospective analysis was performed for 30 patients diagnosed with colonic perforation caused by either inflammation or ischemia who underwent urgent surgical treatment in our facility from January 2005 to December 2014. Patient characteristics were analyzed to find risk factors correlated with increased postoperative mortality. Using the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) audit system, the mortality and morbidity rates were estimated to verify the surgical outcomes. Patients with retroperitoneal contamination, defined by the presence of retroperitoneal air in the preoperative abdominopelvic CT, were compared to those without retroperitoneal contamination.

Results

Eight out of 30 patients (26.7%) with colonic perforation had died after urgent surgical treatment. Factors associated with mortality included age, American Society of Anesthesiologists (ASA) physical status classification, and the ischemic cause of colonic perforation. Three out of 6 patients (50%) who presented retroperitoneal contamination were deceased. Although the patients with retroperitoneal contamination did not show significant increase in the mortality rate, they showed significantly higher ASA physical status classification than those without retroperitoneal contamination. The mortality rate predicted from Portsmouth POSSUM was higher in the patients with retroperitoneal contamination.

Conclusion

Patients presenting colonic perforation along with retroperitoneal contamination demonstrated severe comorbidity. However, retroperitoneal contamination was not found to be correlated with the mortality rate.

Nontraumatic large bowel perforation: spectrum of etiologies and CT findings

Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.

Postoperative recurrence and risk factors of colorectal cancer perforation

PURPOSE

The common causes of colorectal perforation are benign. However, perforated colorectal cancer confers a risk of recurrence in the long term because of the malignant nature of the disease. In addition, the recurrence rate can also increase because of dissemination of cancer cells, reduced extent of lymph node dissection to prioritize saving life, and other reasons.

METHODS

We evaluated the clinical features and postoperative recurrence in patients with perforated colorectal cancer who developed general peritonitis and underwent emergency surgery during a 7-year period between April 2007 and March 2014.

RESULTS

During the study period, 44 patients had colorectal cancer perforation. The cancer sites were the ascending colon in 6 patients, transverse colon in 1, descending colon in 4, sigmoid colon in 15, and rectum in 18. The disease stage was stage II in 18 patients, stage III in 15, and stage IV in 7. Among 22 patients who could be followed up, 8 had postoperative recurrence. The recurrence rates were 18.2% for stage II cancer and 54.5% for stage III. Postoperative recurrence was more likely to occur in the patients positive for lymph node metastasis, those with poorly differentiated adenocarcinoma, those with T4 cancer, and those who did not receive postoperative adjuvant chemotherapy.

CONCLUSION

The recurrence rate was higher in the patients with perforated colorectal cancer than in those who underwent surgery for common colorectal cancer. The prognosis can be expected to improve by performing standard surgical procedures, to the maximum extent possible, followed by postoperative adjuvant chemotherapy.

Ostomy in Nontraumatic Conditions: Our Experience and Review of the Literature

A number of nontraumatic acute abdomen can result in peritonitis leading to sepsis. In emergent conditions, various procedures like segmentary colectomy and/or subtotal colectomy with anastomosis, Hartmann's procedure, transverse colectomy, and/or expandable metallic stent (SEMS) placement can be performed, considering the status of the patient and the facilitaties of the institution. In our study, we examined the cases diagnosed as acute abdomen without the history of trauma, which had lead to a procedure requiring colostomy. We retrospectively analysed 105 cases of nontraumatic acute abdomen, resulted in a procedure requiring colostomy. American Society of Anesthesiologists (ASA) scoring and Mannheim Peritonitis Index (MPI) were used in the evaluation of the risk of mortality and morbidity. There were colonic perforations of rectosigmoid tumor in 66 cases (62.8 %), sigmoid volvulus in 10 cases (9.5 %), colonic anastomotic leakage in 9 cases (8.5 %), intestinal adhesions in 8 cases (7.6 %), mesenteric ischemia in 5 cases (4.7 %), gynecological diseases in 3 cases (2.85 %), strangulated hernias in 3 (2.85 %), and Ogilvie syndrome in 1 case (0.95 %). Rate of morbidity was found to be 25.7 %, while mortality occurred in 2.8 % of the cases. Cases with mortality and morbidity had ASA scores above two and MPI scores above 23. Anastomotic leakage was the only reason of mortality. In nontraumatic occasions, the management and prognosis of cases with peritonitis, general status of the patients play major roles. The prognosis rates of morbidity and mortality can be highly predicted when ASA and MPI scores are evaluated together.

A comparison of the surgical mortality due to colorectal perforation at different hospitals with data from 10,090 cases in the Japanese National Clinical Database

Colorectal perforation has a high rate of mortality. We compared the incidence and fatality rates of colorectal perforation among different hospitals in Japan using data from the nationwide surgical database.Patients were registered in the National Clinical Database (NCD) between January 1st, 2011 and December 31st, 2013. Patients with colorectal perforation were identified from surgery records by examining if acute diffuse peritonitis (ADP) and diseases associated with a high probability of colorectal perforation were noted. The primary outcome measures included the 30-day postsurgery mortality and surgical mortality of colorectal perforation. We analyzed differences in the observed-to-expected mortality (O/E) ratio between the two groups of hospitals, that is, specialized and non-specialized, using the logistic regression analysis forward selection method.There were 10,090 cases of disease-induced colorectal perforation during the study period. The annual average postoperative fatality rate was 11.36%. There were 3884 patients in the specialized hospital group and 6206 in the non-specialized hospital group. The O/E ratio (0.9106) was significantly lower in the specialized hospital group than in the non-specialized hospital group (1.0704). The experience level of hospitals in treating cases of colorectal perforation negatively correlated with the O/E ratio.We conducted the first study investigating differences among hospitals with respect to their fatality rate of colorectal perforation on the basis of data from a nationwide database. Our data suggest that patients with colorectal perforation should choose to be treated at a specialized hospital or a hospital that treats five or more cases of colorectal perforation per year. The results of this study indicate that specialized hospitals may provide higher quality medical care, which in turn proves that government policy on healthcare is effective at improving the medical system in Japan.

Predictors of Morbidity and Mortality After Surgery for Intestinal Perforation

Purpose

An intestinal perforation is a rare condition, but has a high mortality rate, even after immediate surgical intervention. The clinical predictors of postoperative morbidity and mortality are still not well established, so this study attempted to identify risk factors for postoperative morbidity and mortality after surgery for an intestinal perforation.

Methods

We retrospectively analyzed the cases of 117 patients who underwent surgery for an intestinal perforation at a single institution in Korea from November 2008 to June 2014. Factors related with postoperative mortality at 1 month and other postoperative complications were investigated.

Results

The mean age of enrolled patients was 66.0 ± 15.8 years and 66% of the patients were male. Fifteen patients (13%) died within 1 month after surgical treatment. Univariate analysis indicated that patient-related factors associated with mortality were low systolic and diastolic blood pressure, low serum albumin, low serum protein, low total cholesterol, and high blood urea nitrogen; the surgery-related factor associated with mortality was feculent ascites. Multivariate analysis using a logistic regression indicated that low systolic blood pressure and feculent ascites independently increased the risk for mortality; postoperative complications were more likely in both females and those with low estimated glomerular filtration rates and elevated serum C-reactive protein levels.

Conclusion

Various factors were associated with postoperative clinical outcomes of patients with an intestinal perforation. Morbidity and mortality following an intestinal perforation were greater in patients with unstable initial vital signs, poor nutritional status, and feculent ascites.

The Practice Guidelines for Primary Care of Acute Abdomen 2015

BACKGROUND

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines [all clinical questions (CQs) and recommendations are shown in supplementary information].

METHODS

A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen.

RESULTS

A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended.

CONCLUSIONS

The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Diverticulosis and Diverticulitis

Diverticular disease is a common condition that is associated with variable presentations. For this review article, we performed a review of articles in PubMed through February 1, 2016, by using the following MeSH terms: colon diverticula, colonic diverticulitis, colonic diverticulosis, colonic diverticulum, colonic diverticula, and diverticula. Diverticula are structural alterations within the colonic wall that classically form "pockets" referred to as diverticula. Diverticula form from herniation of the colonic mucosa and submucosa through defects in the circular muscle layers within the colonic wall. Often this is at the sites of penetrating blood vessels in the colon. Diverticular disease is extremely common, which resulted in 2,682,168 outpatient visits and 283,355 hospitalization discharges for diverticulitis or diverticulosis in 2009. Diverticulosis is one of the most common detected conditions found incidentally on colonoscopy. Risk factors for the development of diverticulitis include obesity, smoking, nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates. In contrast, fiber may be protective, but recent studies have questioned the role of fiber in developing diverticular disease. Most patients with diverticulosis will be asymptomatic, but a subset of patients may develop nonspecific abdominal pain (isolated or recurrent), diverticulitis, or segmental colitis associated with diverticulosis. Classically, the treatment of diverticulitis has included antibiotics for all patients. More recent evidence indicates that in mild to even moderate uncomplicated diverticulitis, antibiotics may not be as necessary as initially believed. In more complicated diverticulitis, intravenous antibiotics and surgery may be necessary. Once a patient has had an attack of diverticulitis, increasing fiber may help prevent future attacks. Other modalities such as 5-aminosalicylate products, antibiotics, and probiotics are still of unclear benefit in preventing future episodes of diverticulitis. Similarly, even when patients develop recurrent episodes of diverticulitis, surgery may not be necessary as a prophylactic treatment.

Practice Guidelines for Primary Care of Acute Abdomen 2015

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Surgical outcomes and prognostic factors of emergency surgery for colonic perforation: would fecal contamination increase morbidity and mortality?

PURPOSE

Complications resulting from colonic perforation are related to secondary peritonitis due to bacterial or fecal contamination. We investigated outcomes of emergency surgery for colonic perforation associated with fecal contamination with regard to early and late postoperative complication rates and mortality rates, and investigated prognostic factors influencing those outcomes.

METHODS

A retrospective analysis of prospectively collected data on factors influencing complications and mortality rates was conducted on data from 152 patients who had undergone emergent operations for colonic perforation between January 2005 and December 2011. Patients were categorized into two groups: those with and without gross fecal contamination at the time of operation.

RESULTS

Forty-one (26.9 %) patients had gross fecal contamination. Patients who had fetal contamination had a higher Mannheim peritonitis index (31.3 ± 5.1 vs. 21.9 ± 7.2, p < 0.001), higher organ failure rate (53.7 vs. 24.3 %, p = 0.001), and longer operating time (168.8 ± 49.9 vs. 144.8 ± 66.1 min, p = 0.036) than patients without fecal contamination. Early complications (<30 days) occurred more frequently in the fecal contamination group (82.9 vs. 49.5 %, p = 0.001), although late complications (46.2 vs. 39.3 %, p = 0.942) and mortality (17.1 vs. 8.1 %, p = 0.110) did not differ. In multivariate analysis, fecal contamination significantly predicted early complications (odds ratio, 2.78; p = 0.037) but not late complications or mortality.

CONCLUSIONS

The frequency of early complications can increase if fecal contamination exists. However, when early complications are well managed, fecal contamination does not significantly influence occurrences late complications or mortality.

Prediction of mortality in patients with colorectal perforation based on routinely available parameters: a retrospective study

INTRODUCTION

Even after surgery and intensive postoperative management, the mortality rate associated with colorectal perforation is high. Identification of mortality markers using routinely available preoperative parameters is important.

METHODS

We enrolled consecutive patients with colorectal perforation who underwent operations from January 2010 to January 2015. We divided them into a mortality and survivor group and compared clinical characteristics between the two groups. Additionally, we compared the mortality rate between different etiologies: malignant versus benign and diverticular versus nondiverticular. We used the χ (2) and Mann-Whitney U tests and a logistic regression model to identify factors associated with mortality.

RESULTS

We enrolled 108 patients, and 52 (48 %) were male. The mean age at surgery was 71 ± 13 years. The postoperative mortality rate was 12 % (13 patients). Multivariate logistic regression analysis showed that a high patient age (odds ratio [OR], 1.09; 95 % confidence interval [CI], 1.020-1.181) and low preoperative systolic blood pressure (OR, 0.98; 95 % CI, 0.953-0.999) were independent risk factors for mortality in patients with colorectal perforation. In the subgroup analysis, there was no significant difference between the malignant and benign group (11.8 % vs. 23.9 %, respectively; p = 0.970), while the diverticular group had a significantly lower mortality rate than the nondiverticular group (2.6 % vs. 17.1 %, respectively; p = 0.027).

CONCLUSIONS

Older patients and patients with low preoperative blood pressure had a high risk of mortality associated with colorectal perforation. For such patients, operations and postoperative management should be performed carefully.

Postoperative arterial blood lactate level as a mortality marker in patients with colorectal perforation

PURPOSE

This study aims to assess the clinical relevance of postoperative arterial blood lactate (LAC) level as a prognostic factor in patients with colorectal perforation.

METHODS

Forty-two patients (22 males, 20 females; mean age, 70.8 years) underwent emergency surgery for colorectal perforation. The patients were divided into mortality and survivor groups. As a prognostic scoring system, Acute Physiological and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA), and Systemic Inflammatory Response Syndrome criteria were calculated. These scores, postoperative LAC level, and other data, including site and etiology of perforation, elapsed time from onset to surgery (eTIME), preoperative white blood cell (WBC) and platelet counts, preoperative C-reactive protein (CRP), and preoperative arterial blood base excess were assessed between the groups.

RESULTS

The total mortality rate was 33.3 %. On univariate analysis, the APACHE-II and SOFA scores were significantly higher, and eTIME was significantly longer in the mortality group than in the survivor group. The postoperative LAC level was significantly higher in the mortality group (43.1 ± 14.1 mg/dl) than in the survivor group (23.8 ± 12.7 mg/dl; p < 0.001), and the preoperative WBC was significantly lower in the mortality group than in the survivor group. Multivariate logistic regression analysis using the mortality risk factors determined by univariate analysis (eTIME, APACHE-II score, SOFA score, preoperative WBC count, and postoperative LAC) demonstrated that postoperative LAC level was an independent risk factor for mortality.

CONCLUSIONS

High postoperative LAC level was a useful factor for predicting high mortality rate in patients with colorectal perforation.

Less Common Nontraumatic Bowel Perforations: Diagnosis and Management through a Retrospective Study

Nontraumatic bowel perforation has always been a consideration because of associated morbidity and mortality. The aim of this study is to define etiologies, treatment, and outcomes as well as to highlight difficulties in the diagnosis and management of nontraumatic bowel perforation. We conducted a retrospective study of 35 patients with less common nontraumatic bowel perforations hospitalized during a six-year period. The most common cause was ulcerative colitis (34.3%). Abdominal pain was the constant symptom. Physical examination showed signs of peritoneal irritation in 29 cases. The abdominal radiograph failed to reveal abnormal findings in two patients; the abdominal computed tomography scan confirmed the diagnosis in all cases. Twenty patients (57.1%) were operated on within 24 hours of developing perforation, whereas seven patients (20%) were initially misdiagnosed. Most of the perforations were located only in the large intestine (60%). There was only one perforation in 25 patients (71.5%) and two or more perforations in 10 patients (28.5%). Many less common diseases are responsible for the spontaneous perforation of the bowel. Early diagnosis before the patient's general condition deteriorates decreases mortality and morbidity rates. Adequate resuscitation and emergency laparotomy followed by resection with or without anastomosis remains the treatment of choice.

Predictors of outcome following surgery in colonic perforation: an institution's experience over 6 years

BACKGROUND

Colonic perforation is associated with abysmal outcome. The aims of our study were to review the surgical outcome of patients with perforated colon and to identify factors predicting peri-operative complications.

METHODS

A retrospective review of all patients who underwent surgery for colonic perforation from January 2003 to August 2008 was performed. Patients with iatrogenic or traumatic perforation were excluded. The severity of abdominal sepsis was graded using the Mannheim peritonitis index (MPI).

RESULTS

A total of 129 patients, with median age of 65 years (22-97 years), formed the study group. While 29.5% had severe peritoneal contamination, 56.6% had an American Society of Anesthesiologists (ASA) score ≥3. Sigmoid colon (47.3%) and caecum (24.8%) were the most common sites of perforation. Diverticulitis and malignancy were the diagnoses in 51.9% and 34.9%, respectively. Hartmann's procedure and right hemicolectomy were performed in 43.4% and 34.1% of the patients, respectively. Stoma was created in 59.7%. The in-hospital mortality rate in our series was 15.5%. After multivariate analysis, the independent variables associated with worse peri-operative complications were ASA score ≥3, MPI >26 and creation of stoma. Malignant perforation was associated with higher ASA score and lower haematocrit level compared to diverticular perforation. Stoma was created more frequently in patients with MPI >26 and left-sided perforation, and was associated with worse complications.

CONCLUSIONS

Surgery for colonic perforation is associated with high morbidity and mortality rates. Short-term outcome is determined by ASA score and severity of peritonitis. A lower haematocrit level must alert the possibility of malignancy.

Right colonic perforation in an Asian population: predictors of morbidity and mortality

INTRODUCTION

Perforation of the colon is associated with significant morbidity and mortality. Pathologies arising from the right colon differ greatly between Asians and the Western population. The aims of our study were to evaluate the implications of perforated right colon in an Asian population and to identify factors that could predict the perioperative outcome.

METHODS

A retrospective review of all patients who underwent operative intervention for peritonitis from right colonic perforation from July 2003 to April 2008 was performed. Patients were identified from the hospital's diagnostic index and operating records. The severity of abdominal sepsis for all patients was graded using the Mannheim peritonitis index (MPI). All the complications were graded according to the classification proposed by Clavian and colleagues.

RESULTS

Fifty-one patients with a median age of 60 years (range, 22-93 years) formed the study group. Diverticulitis (47.1%) and malignancy (37.3%) accounted for the majority of the pathologies. Right hemicolectomy without diverting stoma (n = 34, 66.7%) was performed most commonly. Of our patients, 74.5% had perioperative morbidity with 19 (37.3%) patients having grade III or worse complications. In our series, five (9.8%) patients died. On univariate analysis, American Society of Anesthesiologists (ASA) score >or=3, >or=2 premorbid conditions, raised MPI, raised creatinine, and stoma creation were related to more severe complications (grade III/IV). The following variables were correlated with in-hospital mortality: ASA score >or=3, raised MPI, hematocrit <33%, raised creatinine, malignant perforation, and stoma creation. On multivariate analysis, a higher ASA score >or=3 was predictive of significant morbidity, while both malignant perforation and stoma creation were associated with mortality.

CONCLUSION

Diverticulitis is the commonest cause of right colonic perforation in Asians. Patients with higher ASA score and malignant perforation are at risk of higher morbidity and mortality. Resection with primary anastomosis is safe and patients who require stomas are more likely to do worse.

[Morbidity and mortality after a Hartmann operation due to peritonitis originating from a sigmoid diverticulum disease (Hinchey grade III-IV)]

INTRODUCTION

Hartmann's operation has occasionally been criticised for its high morbidity-mortality and permanent stomas. To compare risk factors is difficult due to different severity scores for diverticulitis with no standardisation. We attempted to define the morbidity-mortality of Hartmann's operation for sigmoid diverticulitis with peritonitis Hinchey III-IV and to identify some factors associated with morbidity-mortality and non-restoration of intestinal continuity.

PATIENTS AND METHOD

Retrospective analysis of 72 patients: age, gender, ASA score, length of time between symptoms and surgery, Hinchey's score, Mannheim index, preoperative creatinine and co-morbidities.

RESULTS

Hinchey's score III, 75%. Male, 35. Median age, 66.5 years. Morbidity-mortality: 48.6% and 23.6%, respectively. ASA > 2 (p = 0.03) and age > 65 years (p = 0.03) in bivariate analysis; and ASA > 2 (p = 0.002) and a history of ischaemic cardiac disease (p = 0.04) in multivariate analysis were associated with postoperative complications. In bivariate analysis mortality was associated with ASA > 2 (p = 0.02), age > 65 years (p = 0.02), chronic obstructive pulmonary disease (p = 0.001), Mannhein index >or= 25 (p = 0.01) and pulmonary postoperative complications (p = 0.003). Multivariate analyses were statistical significant: chronic obstructive pulmonary disease (p = 0.001) and postoperative respiratory infection (p = 0.02). Fifty-five patients survived and 65.5% continued to restoration of intestinal continuity. Age > 65 years (p = 0.004) and ASA score > 2 at first operation (p = 0.004) were predictive for non-reversal of Hartmann's procedure.

CONCLUSIONS

Hartmann's operation is highly associated with morbidity-mortality in severe peritonitis of sigmoid diverticular origin, Hinchey III-IV. The majority of patients have severe co-morbidities and high-grade risk factors which are related to the incidence of morbidity and mortality.

Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers

PURPOSE

Perforated colonic diverticular disease is associated with a high rate of late sequel and mortality. The risk of colonic perforation may relate to intracolonic pressure and mucosal barrier function in the wall of diverticula. The use of substances affecting these parameters may therefore be associated with the risk of developing a perforation. The aim was to study the effect of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, calcium channel blockers, and antimuscarinics on perforation in diverticular disease.

MATERIALS AND METHODS

A review of 54 patients with colonic diverticular perforation-forming the case group-and 183 patients with verified colonic diverticular disease-forming the control group-was done. Patient characteristics and drug use was registered.

RESULTS

Case group and control group were comparable with respect to sex, age, and comorbidity. In multivariate analysis, the use of NSAIDs (OR 3.56; 95% CI 1.50-8.43), opioids (OR 4.51; 95% CI 1.67-12.18), and corticosteroids (OR 28.28; 95% CI 4.83-165.7) were significantly associated with perforated diverticular disease. Acetylsalicylic acid in cardiologic dose did not affect the rate of perforation (OR 0.66; 95% CI 0.27-1.61). The use of calcium channel blockers was associated with a reduced rate of diverticular complications (OR 0.14; 95% CI 0.02-0.95).

CONCLUSIONS

The administration of NSAIDs, opioids, and corticosteroids are associated with an increased risk of colonic diverticular perforation. Acetylsalicylic acid in cardiologic dose does not affect the risk of perforation. Calcium channel blockers are associated with a reduced risk of perforation.

Gastrointestinal perforation and the acute abdomen

The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.

Evaluation of prognostic factors and scoring system in colonic perforation

AIM: To study the significance of scoring systems assessing severity and prognostic factors in patients with colonic perforation.

METHODS: A total of 26 patients (9 men, 17 women; mean age 72.7 ± 11.6 years) underwent emergency operation for colorectal perforation in our institution between 1993 and 2005. Several clinical factors were measured preoperatively and 24 h postoperatively. Acute physiology and chronic health evaluation II (APACHE II), Mannheim peritonitis index (MPI) and peritonitis index of Altona (PIA II) scores were calculated preoperatively.

RESULTS: Overall postoperative mortality rate was 23.1% (6 patients). Compared with survivors, non-survivors displayed low blood pressure, low serum protein and high serum creatinine preoperatively, and low blood pressure, low white blood cell count, low pH, low PaO₂/FiO₂, and high serum creatinine postoperatively. APACHE II score was significantly lower in survivors than in non-survivors (10.4 ± 3.84 vs 19.3 ± 2.87, P = 0.00003). Non-survivors tended to display high MPI score and low PIA II score, but no significant difference was identified.

CONCLUSION: Pre- and postoperative blood pressure and serum creatinine level appear related to prognosis of colonic perforation. APACHE II score is most associated with prognosis and scores ≥ 20 are associated with significantly increased mortality rate.

Coagulation disorder as a prognostic factor for patients with colorectal perforation

BACKGROUND

Although sepsis after surgery for colorectal perforation frequently results in severe coagulation disorders and consequent death of the patient, the correlation between coagulation abnormalities and postoperative mortality of colorectal perforation has not been clarified.

METHODS

The medical records of 101 consecutive patients receiving surgery for colorectal perforations between January 1994 and July 2006 were retrospectively reviewed. The abnormalities of preoperative laboratory data reflecting coagulation disorders and other possible risk factors were analyzed by univariate and multivariate analysis.

RESULTS

Prolonged prothrombin time and activated partial thromboplastin time significantly correlated with a poor prognosis (both P < 0.001). Among the several risk factors analyzed, only the presence of coagulation disorders was an independent predictive factor of postoperative mortality.

CONCLUSIONS

Prolonged prothrombin time and activated partial thromboplastin time are useful prognostic factors for predicting the surgical outcome for patients with colorectal perforation.

Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature

OBJECTIVE

To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with acute complicated sigmoid diverticulitis.

SEARCH STRATEGY

MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann's procedure. The term "diverticulitis, colonic" with the sub-heading "surgery" was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: "surgical procedures, operative", "surgical anastomosis", and "Hartmann procedure", combined with the term "diverticulitis, colonic". The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied.

RESULTS

Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann's procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann's procedure.

CONCLUSIONS

This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of peri-operative complications. The need for revision of Hartmann's procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias.