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Yokota H, Akamine Y, Kobayashi M, Kitabayashi T, Horie M, Endo T, Yamada T, Kikuchi M. Naldemedine-induced perforation of a diverticulum in the sigmoid colon of a patient with opioid-related constipation: a case report. J Pharm Health Care Sci 2024; 10:50. [PMID: 39143638 PMCID: PMC11325720 DOI: 10.1186/s40780-024-00371-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 08/12/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Naldemedine is an orally available peripherally acting μ-opioid receptor antagonist approved to treat opioid-induced constipation (OIC). It is contraindicated for patients with known or suspected gastrointestinal obstruction to protect against naldemedine-induced perforation. Here, we report a clinical case of suspected perforation of a diverticulum in the sigmoid colon associated with naldemedine. CASE PRESENTATION The patient was a 65-year-old man with a history of oral cancer who had been prescribed oxycodone (20 mg/day) for cancer pain. On day 0, the patient started naldemedine 0.2 mg once daily before bedtime for OIC. The dose of oxycodone was increased for pain control up to 60 mg/day. On day 35 of naldemedine treatment, the patient developed fever and abdominal pain, and his frequency of defecation had decreased. Initial laboratory results showed a C-reactive protein (CRP) level of 28.5 mg/dL and white blood cell (WBC) count of 13,500/µL. On day 37, the patient still had tenderness in his lower abdomen. Abdominal computed tomography revealed free air in the abdominal cavity suggesting an intestinal perforation. A Hartmann procedure was performed. Histopathological findings showed numerous diverticula in the sigmoid colon, some of which were perforated. CONCLUSIONS These results suggest that the effects of OIC may have compressed the intestinal tract, which was followed by naldemedine-activation of peristalsis, which led to the onset of intestinal perforation. In patients with pre-existing diverticular disease, we should monitor for increased WBC counts and CRP levels after the initiation of treatment with naldemedine, and consider performing appropriate tests early in the event of abdominal complaints.
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Affiliation(s)
- Hayato Yokota
- Department of Pharmacy, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Mizuki Kobayashi
- Department of Pharmacy, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Takuro Kitabayashi
- Department of Otorhinolaryngology & Head and Neck Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Misato Horie
- Department of Gastroenterological Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Tentaro Endo
- Department of Otorhinolaryngology & Head and Neck Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takechiyo Yamada
- Department of Otorhinolaryngology & Head and Neck Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Masafumi Kikuchi
- Department of Pharmacy, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
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Sugita S, Ishikawa M, Sakuma T, Iizuka M, Hanai S, Sakamoto A. Intraoperative serum lactate levels as a prognostic predictor of outcome for emergency abdominal surgery: a retrospective study. BMC Surg 2023; 23:162. [PMID: 37328824 DOI: 10.1186/s12893-023-02075-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The relationship between intraoperative lactate levels and prognosis after emergency gastrointestinal surgery remains unclear. The purpose of this study was to investigate the prognostic value of intraoperative lactate levels for predicting in-hospital mortality, and to examine intraoperative hemodynamic managements. METHODS We conducted a retrospective observational study of emergency GI surgeries performed at our institution between 2011 and 2020. The study group comprised patients admitted to intensive care units postoperatively, and whose intraoperative and postoperative lactate levels were available. Intraoperative peak lactate levels (intra-LACs) were selected for analysis, and in-hospital mortality was set as the primary outcome. The prognostic value of intra-LAC was assessed using logistic regression and receiver operating characteristic (ROC) curve analysis. RESULTS Of the 551 patients included in the study, 120 died postoperatively. Intra-LAC in the group who survived and the group that died was 1.80 [interquartile range [IQR], 1.19-3.01] mmol/L and 4.22 [IQR, 2.15-7.13] mmol/L (P < 0.001), respectively. Patients who died had larger volumes of red blood cell (RBC) transfusions and fluid administration, and were administered higher doses of vasoactive drugs. Logistic regression analysis showed that intra-LAC was an independent predictor of postoperative mortality (odds ratio [OR] 1.210, 95% CI 1.070 -1.360, P = 0.002). The volume of RBCs, fluids transfused, and the amount of vasoactive agents administered were not independent predictors. The area under the curve (AUC) of the ROC curve for intra-LAC for in-hospital mortality was 0.762 (95% confidence interval [CI], 0.711-0.812), with a cutoff value of 3.68 mmol/L by Youden index. CONCLUSIONS Intraoperative lactate levels, but not hemodynamic management, were independently associated with increased in-hospital mortality after emergency GI surgery.
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Affiliation(s)
- Shinji Sugita
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.
- Department of Anesthesiology, Nippon Medical School Musashi-Kosugi Hospital, 1-383 Kosugi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-8533, Japan.
| | - Masashi Ishikawa
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Takahiro Sakuma
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Masumi Iizuka
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
- Department of Anesthesia, Urasoe General Hospital, 4-16-1 Iso, Urasoe-shi, Okinawa, 901-2132, Japan
| | - Sayako Hanai
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
- Department of Anesthesiology, Keiyu Hospital, 3-7-3 Minatomirai, Nishi-ku, Yokohama-shi, Kanagawa, 220-8521, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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Darwen C, Bryan A, Quraishi-Akhtar T, Moore J. Postoperative hyperlactataemia and preoperative cardiopulmonary exercise testing in an elective noncardiac surgical cohort: a retrospective observational study. BJA OPEN 2023; 5:100124. [PMID: 37587998 PMCID: PMC10430863 DOI: 10.1016/j.bjao.2023.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 01/03/2023] [Indexed: 08/18/2023]
Abstract
Background Blood lactate concentration in the postoperative period is a marker of physiological stress and a predictor of complications and mortality. Cardiopulmonary exercise testing (CPET) is a common preoperative risk stratification tool. We aimed to investigate the association between preoperative CPET results and postoperative lactate concentration with postoperative mortality after major noncardiac surgery. Methods We analysed data from patients undergoing major noncardiac surgery in a tertiary UK centre between 2007 and 2014 who had preoperative CPET and postoperative lactate measurements. Univariate and multivariate analyses were performed to assess the association between lactate concentration, CPET results, or both and mortality. Results We analysed data from 1075 patients. A mean lactate concentration >2 mM in the first 12, 24, and 48 h after surgery was associated with odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality of 3.9 (2.1-7.3; P<0.005), 4.5 (2.4-8.4; P<0.005), and 6.1 (3.3-11.5; P<0.005), respectively. The dichotomous CPET variable, ventilatory equivalence for CO2 (V̇E/V̇co2; cut-off 34), was associated with increased risk of 30-day mortality (OR 2.5; 95% CI: 1.3-4.8; P<0.005). In a multivariable model, hyperlactataemia and poor V̇E/V̇co2 retained their significant associations with 30- and 90-day mortality when adjusted for age, BMI, and surgical risk. When looking at the combined effect of the dichotomous hyperlactataemia in the first 24 h (cut-off 2 mM) and preoperative V̇E/V̇co2, the OR for 30-day mortality was 11.53 (95% CI: 4.6-28.8; P≤0.005). Conclusions Our study suggests that postoperative hyperlactataemia and preoperative poor V̇E/V̇co2 are independently associated with an increased risk of mortality after major noncardiac surgery.
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Affiliation(s)
| | - Angella Bryan
- Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Tanviha Quraishi-Akhtar
- Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - John Moore
- Manchester University NHS Foundation Trust, Manchester, UK
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Kang MK, Oh SY, Lee H, Ryu HG. Pre and postoperative lactate levels and lactate clearance in predicting in-hospital mortality after surgery for gastrointestinal perforation. BMC Surg 2022; 22:93. [PMID: 35264127 PMCID: PMC8908642 DOI: 10.1186/s12893-022-01479-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to compare the prognostic significance of pre and postoperative lactate levels and postoperative lactate clearance in the prediction of in-hospital mortality after surgery for gastrointestinal (GI) perforation. Methods Among patients who underwent surgery for GI perforation between 2013 and 2017, only patients whose lactate were measured before and after surgery were included and divided into an in-hospital mortality group and a survival group. Data on demographics, comorbidities, pre and postoperative laboratory test results, and operative findings were collected. Risk factors for in-hospital mortality were identified, and receiver-operating characteristic (ROC) curve analysis was performed for pre and postoperative lactate levels and postoperative lactate clearance. Results Of 104 included patients, 17 patients (16.3%) died before discharge. The in-hospital mortality group demonstrated higher preoperative lactate (6.3 ± 5.1 vs. 3.5 ± 3.2, P = 0.013), SOFA score (4.5 ± 1.7 vs. 3.4 ± 2.3, P = 0.004), proportions of patients with lymphoma (23.5% vs. 2.3%, P = 0.006), and rates of contaminated ascites (94.1% vs. 68.2%, P = 0.036) and lower preoperative hemoglobin (10.4 ± 1.6 vs. 11.8 ± 2.4, P = 0.018) compare to the survival group. Multivariate analysis revealed that postoperative lactate (HR 1.259, 95% CI 1.084–1.463, P = 0.003) and preoperative hemoglobin (HR 0.707, 95% CI 0.520–0.959, P = 0.026) affected in-hospital mortality. In the ROC curve analysis, the largest area under the curve (AUC) was shown in the postoperative lactate level (AUC = 0.771, 95% CI 0.678–0.848). Conclusion Of perioperative lactate levels in patients underwent surgery for GI perforation, postoperative lactate was the strongest predictor for in-hospital mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01479-1.
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Affiliation(s)
- Min Kyu Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. .,Department of Critical Care Medicine , Seoul National University Hospital, Seoul, Korea.
| | - Hannah Lee
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Geol Ryu
- Department of Critical Care Medicine , Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea
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Huang M, Tian W, Luo S, Xu X, Yao Z, Zhao R, Huang Q. Duration of postoperative hyperlactatemia has predictive value in recurrent fistula after major definitive surgery for intestinal fistula. BMC Surg 2022; 22:14. [PMID: 35033052 PMCID: PMC8761294 DOI: 10.1186/s12893-022-01465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery (DS) for intestinal fistula. Methods If the initial postoperative lactate (IPL) > 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L < IPL ≤ 4 mmol/L), group B (mmol/L < IPL ≤ 6 mmol/L), and group C (IPL > 6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C. Results The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR: 12–24) vs 24 (IQR: 12–24), p = 0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR = 1.061; 95% CI: 1.029–1.094; p < 0.001) and group C (adjusted OR = 1.059; 95% CI: 1.012–1.129; p = 0.017). In group B, the cutoff point of duration of 42 h had the optimal predictive value (area under ROC = 0.791, sensitivity = 0.717, specificity = 0.794, p < 0.001). In group C, the cutoff point of duration of 54 h had the optimal predictive value (area under ROC = 0.781, sensitivity = 0.730, specificity = 0.804, p < 0.001). Conclusion The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.
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Affiliation(s)
- Ming Huang
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - Shikun Luo
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China.
| | - Xi Xu
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Zheng Yao
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China.
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
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6
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Wu J, Shu P, He H, Li H, Tang Z, Sun Y, Liu F. Predictors of mortality in patients with acute small-bowel perforation transferred to ICU after emergency surgery: a single-centre retrospective cohort study. Gastroenterol Rep (Oxf) 2021; 10:goab054. [PMID: 35382163 PMCID: PMC8972993 DOI: 10.1093/gastro/goab054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/05/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
Background Although small-bowel perforation is a life-threatening emergency even after immediate surgical intervention, studies have rarely investigated surgical outcomes due to its relatively low incidence. This study aimed to investigate the outcomes of emergency surgery for patients with small-bowel perforation transferred to the intensive care unit (ICU) and the risk factors for mortality. Methods Consecutive patients with small-bowel perforation who were confirmed via emergency surgery and transferred to the ICU in Zhongshan Hospital, Fudan University (Shanghai, China) between February 2011 and May 2020 were retrospectively analysed. Medical records were reviewed to determine clinical features, laboratory indicators, surgical findings, and pathology. Results A total of 104 patients were included in this study, among whom 18 (17.3%), 59 (56.7%), and 27 (26.0%) underwent perforation repair, segmental resection with primary anastomosis, and small-bowel ostomy, respectively. Malignant tumours were the leading cause of perforation in these patients (40.4%, 42/104). The overall post-operative complication rate and mortality rates were 74.0% (77/104) and 19.2% (20/104), respectively. Malignant tumour-related perforation (odds ratio [OR], 4.659; 95% confidence interval [CI], 1.269–17.105; P = 0.020) and high post-operative arterial blood-lactate level (OR, 1.479; 95% CI, 1.027–2.131; P = 0.036) were identified as independent risk factors for post-operative mortality in patients with small-bowel perforation transferred to the ICU. Conclusions Patients with small-bowel perforation who are transferred to the ICU after emergency surgery face a high risk of post-operative complications and mortality. Moreover, those patients with malignant tumour-related perforation and higher post-operative blood-lactate levels have poor prognosis.
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Affiliation(s)
- Jianzhang Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Ping Shu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Hongyong He
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Haojie Li
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Zhaoqing Tang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Yihong Sun
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Fenglin Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
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7
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Lee HJ, Kim KH, Lee SC, Song S. Prognostic Factors of Patients with Stercoral Perforation of the Colon. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:191-198. [PMID: 33100314 DOI: 10.4166/kjg.2020.76.4.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/04/2020] [Accepted: 09/19/2020] [Indexed: 12/14/2022]
Abstract
Background/Aims The incidence of stercoral perforation of the colon (SPC) is expected to rise, given the increased life expectancy and the aging population. On the other hand, the prognostic factors of mortality after surgery for SPC remain unclear. This study examined the prognostic factors of patients with SPC after surgery. Methods The medical records of 145 patients who underwent surgery for colonic perforation between April 2010 and May 2019 were reviewed retrospectively. In 145 patients, 22 patients who underwent SPC surgery were categorized into the following two groups according to in-hospital survival after surgery: alive (group A, n=15) and dead (group B, n=7). Results In all enrolled patients, the mean age was 75.7±9.0 years, with a female predominance (female patients, n=19, 86.4%). Sixteen patients (72.7%) had chronic constipation with medications, and five patients (22.7%) were bedridden. The rate of preoperative bedridden status was significantly higher in group B than group A (6.7% vs. 57.1%; p=0.021). Univariate analysis revealed immobility, a sequential organ failure assessment (SOFA) score, and lactate levels of more than 2.0 mmol/L to be factors associated with increased mortality rates in the postoperative period. Multivariate analysis revealed abnormal lactate levels to be the only factor related to mortality (hazard ratio 16.50, 95% CI 1.48-183.07, p=0.022). Conclusions Preoperative abnormal serum lactate levels may be a risk factor for mortality after surgery in patients with stercoral perforation. Further research will be needed to identify the postoperative prognostic SPC factors.
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Affiliation(s)
- Hyung Jin Lee
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Kil Hwan Kim
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Sung Chul Lee
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Sanghyun Song
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Ishikawa D, Takehara Y, Takata A, Takamura K, Sato H. Combination of dirty mass volume and APACHE II score predicts mortality in patients with colorectal perforation. World J Emerg Surg 2021; 16:17. [PMID: 33785047 PMCID: PMC8008772 DOI: 10.1186/s13017-021-00359-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background “Dirty mass” is a specific computed tomography (CT) finding that is seen frequently in colorectal perforation. The prognostic significance of this finding for mortality is unclear. Methods Fifty-eight consecutive patients with colorectal perforation who underwent emergency surgery were retrospectively reviewed in the study. Dirty mass identified on multi-detector row CT (MDCT) was 3D-reconstructed and its volume was calculated using Ziostation software. Dirty mass volume and other clinical characteristics were compared between survivor (n = 45) and mortality groups (n = 13) to identify predictive factors for mortality. Mann–Whitney U test and Χ2 test were used in univariate analysis and logistic regression analysis was used in multivariate analysis. Results Dirty mass was identified in 36/58 patients (62.1%) and located next to perforated colorectum in all cases. Receiver-operating characteristic (ROC) curve analysis identified the highest peak at 96.3 cm3, with sensitivity of 0.643 and specificity of 0.864. Univariate analysis revealed dirty mass volume, acute disseminated intravascular coagulation (DIC) score, acute physiology and chronic health evaluation II (APACHE II) score, and sequential organ failure assessment (SOFA) score as prognostic markers for mortality (p<0.01). Multivariate analysis revealed dirty mass volume and APACHE II score as independent prognostic indicators for mortality. Mortality was stratified by dividing patients into four groups according to dirty mass volume and APACHE II score. Conclusions The combination of dirty mass volume and APACHE II score could stratify the postoperative mortality risk in patients with colorectal perforation. According to the risk stratification, surgeons might be able to decide the surgical procedures and intensity of postoperative management.
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Affiliation(s)
- Daichi Ishikawa
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan.
| | - Yukako Takehara
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Atsushi Takata
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Kazuhito Takamura
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Hirohiko Sato
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
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9
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Peacock O, Yanni F, Kuryba A, Cromwell D, Lockwood S, Anderson I, Vohra RS. Failure to rescue patients after emergency laparotomy for large bowel perforation: analysis of the National Emergency Laparotomy Audit (NELA). BJS Open 2021; 5:6145788. [PMID: 33609399 PMCID: PMC7896807 DOI: 10.1093/bjsopen/zraa060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/01/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- O Peacock
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Yanni
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - I Anderson
- University of Manchester School of Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - R S Vohra
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Negi R, Bhardwaj S, Singh S, Gupta S, Kaushik R. Peritonitis-associated hyperlactatemia for evaluating mortality in secondary peritonitis. ANZ J Surg 2020; 90:2463-2466. [PMID: 32902097 DOI: 10.1111/ans.16278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In sepsis, lactate measurements correlate with mortality; however, the role of lactate in predicting mortality in patients of secondary peritonitis is not yet fully established. METHODS Data were maintained prospectively on 224 patients of secondary peritonitis over a period of 10 years. Arterial lactate measurements were performed twice in each patient - once, initially on admission (ALI ) and the other, 24 h after surgery (AL24 ); from these values, percentage lactate clearance was calculated. These lactate indices and other demographic factors were correlated with mortality. RESULTS Overall mortality was 16.07% (36 patients) and morbidity was 63.39% (pulmonary complications commonest); preoperative lactate (more than 2.35 mmol/L), 24-h postoperative lactate (more than 2.05 mmol/L), need for vasopressors and mechanical ventilation independently correlated with morbidity and mortality. A simple prognostic scale constructed using cut-off values of ALI , AL24 , need for vasopressor support and mechanical ventilation showed a sensitivity of 97.22% and specificity of 52.13% for predicting mortality. CONCLUSION Preoperative and postoperative arterial lactate levels, need for vasopressors and mechanical ventilation, are independent predictors of mortality. Using these parameters, it may be possible to identify high risk patients that can benefit from early, goal directed therapy to reduce the mortality of secondary peritonitis.
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Affiliation(s)
- Ravikanta Negi
- Departments of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Sushma Bhardwaj
- Departments of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Simrandeep Singh
- Departments of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Seema Gupta
- Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Robin Kaushik
- Departments of General Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India
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11
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Nakamura F, Yui R, Muratsu A, Sakuramoto K, Muroya T, Ikegawa H, Kuwagata Y. Study of the prognostic factor of the colon perforation case with the pan-peritonitis that needed emergency surgery: a single-center observational study. Acute Med Surg 2019; 6:379-384. [PMID: 31592322 PMCID: PMC6773627 DOI: 10.1002/ams2.429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 04/07/2019] [Indexed: 12/02/2022] Open
Abstract
Aim We divided patients treated with emergency surgery for pan‐peritonitis caused by colon perforation into the survival group and the death group based on outcome at postoperative day 30 and examined the prognostic factors for colon perforation. Methods The prognostic factors for colon perforation in 76 consecutive patients who underwent emergency surgery at Kansai Medical University Hospital (Hirakata, Japan) from April 2011 to March 2017 were investigated based on outcome at postoperative day 30. Results The average age of the 76 patients (41 men/35 women) was 73 years, and the causative disease of colon perforation was malignant/benign in 18/58 cases, with ileocecal perforation site in 8 cases, ascending colon in 6, transverse colon in 2, descending colon in 4, sigmoid colon in 49, and rectum in 7. All patients received laparotomy with irrigation drainage, and 9 patients (11.8%) were dead at 30 days. Upon comparing the 67 survivors with the 9 dead patients, we recognized a significant difference on preoperative spread of ascites on computed tomography (CT) (P = 0.002) in univariate analysis and on acute disseminated intravascular coagulation (DIC) score (odds ratio 2.289; 95% confidence interval, 1.188–4.410; P = 0.013) in multivariate analysis. Conclusion In our hospital, the preoperative acute DIC score was found to be a prognostic factor for colon perforation accompanied by pan‐peritonitis. Appropriate evaluation of the spread of ascites on the preoperative CT might also help predict patient prognosis.
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Affiliation(s)
- Fumiko Nakamura
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Rintaro Yui
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Arisa Muratsu
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
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12
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Veličković J, Palibrk I, Miličić B, Veličković D, Jovanović B, Rakić G, Petrović M, Bumbaširević V. The association of early postoperative lactate levels with morbidity after elective major abdominal surgery. Bosn J Basic Med Sci 2019; 19:72-80. [PMID: 29679531 DOI: 10.17305/bjbms.2018.3186] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/01/2018] [Indexed: 01/03/2023] Open
Abstract
Lactate levels are widely used as an indicator of outcome in critically ill patients. We investigated the prognostic value of postoperative lactate levels for postoperative complications (POCs), mortality and length of hospital stay after elective major abdominal surgery. A total of 195 patients were prospectively evaluated. Lactate levels were assessed on admission to the intensive care unit (ICU) [L0], at 4 hours (L4), 12 hours (L12), and 24 hours (L24) after the operation. Demographic and perioperative clinical data were collected. Patients were monitored for complications until discharge or death. Receiver operating characteristic (ROC) curves were used to determine the predictive value of lactate levels for postoperative outcomes. The best cut-off lactate values were calculated to differentiate between patients with and without complications, and outcomes in patients with lactate levels above and below the cut-off thresholds were compared. Univariate and multivariate analyses were used to identify variables associated with POCs and mortality. Seventy-six patients developed 184 complications (18 deaths), while 119 had no complications. Serum lactate levels were higher in patients with complications at all time points compared to those without complications (p < 0.001). L12 had the highest predictive value for complications (AUROC12 = 0.787; 95% CI: 0.719-0.854; p < 0.001) and mortality (AUROC12 = 0.872; 95% CI: 0.794-0.950; p < 0.001). The best L12 cut-off value for complications and mortality was 1.35 mmol/l and 1.85 mmol/l, respectively. Multivariate analysis revealed that L12 ≥ 1.35 mmol/l was an independent predictor of postoperative morbidity (OR 2.58; 95% CI 1.27-5.24, p = 0.001). L24 was predictive of POCs after major abdominal surgery. L12 had the best power to discriminate between patients with and without POCs and was associated with a longer hospital stay.
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Affiliation(s)
- Jelena Veličković
- Clinic for Digestive Surgery, Clinical Center of Serbia, Belgrade, Serbia Department of Surgery and Anesthesia, School of Medicine, University of Belgrade, Belgrade, Serbia.
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13
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Abe T, Uchino S, Sasabuchi Y, Takinami M. The incidence and outcome of hyperlactatemia in patients admitted to the intensive care unit after elective surgery. Am J Surg 2018; 216:886-892. [PMID: 29739621 DOI: 10.1016/j.amjsurg.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/17/2018] [Accepted: 04/11/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although hyperlactatemia is often developed in critically ill patients, it is unclear whether hyperlactatemia is associated with poor prognosis for surgical ICU (SICU) patients. METHODS We performed a retrospective analysis in an academic hospital in Tokyo. The maximum lactate was defined as the highest value within the SICU stay. The primary outcome was the composite outcome of in-hospital mortality, re-admission to the SICU or admission to the general ICU and emergency reoperation. RESULTS There were 3421 patients with normal lactate (<2 mmoL/L), 1642 with moderate hyperlactatemia (2-3.9 mmoL/L) and 299 with severe hyperlactatemia (≥4 mmoL/L). The composite outcome occurred in 6.2%. In multivariable logistic regression analysis, the odds ratio for the composite outcome was 1.49 for moderate hyperlactatemia and 1.42 for severe hyperlactatemia. CONCLUSIONS The odds ratio was similar between moderate and severe hyperlactatemia, so the cause and meaning of hyperlactatemia might be different among patients with elective surgery.
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Affiliation(s)
- Tatsuhiko Abe
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Yusuke Sasabuchi
- Data Science Centre, Jichi Medical University, 3311, Yakushiji, Shinotsuke-shi, Tochigi, 329-0431, Japan.
| | - Masanori Takinami
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
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14
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Lee JY, Lee SH, Jung MJ, Lee JG. Perioperative risk factors for in-hospital mortality after emergency gastrointestinal surgery. Medicine (Baltimore) 2016; 95:e4530. [PMID: 27583863 PMCID: PMC5008547 DOI: 10.1097/md.0000000000004530] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Few studies have evaluated the risk factors for in-hospital mortality in critically ill surgical patients who have undergone emergency gastrointestinal (GI) surgery. The aim of this study was to identify the risk factors associated with in-hospital mortality in critically ill surgical patients after emergency GI surgery.The medical records of 362 critically ill surgical patients who underwent emergency GI surgery, admitted to intensive care unit between January 2007 and December 2011, were reviewed retrospectively. Perioperative biochemical and clinical parameters of survivors and nonsurvivors were compared. Logistic regression multivariate analysis was performed to identify the independent risk factors of mortality.The in-hospital mortality rate was 15.2% (55 patients). Multivariate analyses revealed cancer-related perforation (odds ratio [OR] 16.671, 95% confidence interval [CI] 2.629-105.721, P = 0.003), preoperative anemia (hemoglobin <10 g/dL; OR 6.976, 95% CI 1.376-35.360, P = 0.019), and preoperative hypoalbuminemia (albumin <2.7 g/dL; OR 9.954, 95% CI 1.603-61.811, P = 0.014) were independent risk factors of in-hospital mortality after emergency GI surgery.The findings of this study suggest that in critically ill patients undergoing emergency GI surgery, cancer-related peritonitis, preoperative anemia, and preoperative hypoalbuminemia are associated with in-hospital mortality. Recognizing risk factors at an early stage could aid risk stratification and the provision of optimal perioperative care.
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Affiliation(s)
| | | | | | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Correspondence: Jae Gil Lee, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (e-mail: )
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15
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Arterial Lactate Concentration at the End of an Elective Hepatectomy Is an Early Predictor of the Postoperative Course and a Potential Surrogate of Intraoperative Events. Ann Surg 2016; 262:787-92; discussion 792-3. [PMID: 26583667 DOI: 10.1097/sla.0000000000001468] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To test the prognostic impact of arterial lactate concentration at the end-of-surgery (LCT-EOS) on postoperative outcome after elective liver-resections and to identify the predictors of an increase in LCT-EOS. BACKGROUND DATA A recent systematic-review of risk-prediction-models for liver resections has evidenced their poor accuracy and a deficit in the evaluation of intraoperative events. LCT-EOS is a marker of impaired tissue oxygenation. METHODS This prospectively-designed study was based on a training-cohort of 519 patients and a validation-cohort of 466 patients. For each of the endpoints (high comprehensive complication index (CCI) scores, 90-day-mortality and severe-morbidity), prognostic-models were built by logistic-regression using the training-cohort. These models were thereafter tested in the validation-cohort and their performance (discrimination, accuracy, calibration) assessed. Independent predictors of LCT-EOS were also identified. RESULTS In the training-cohort, LCT-EOS cutoff best discriminating high-CCI, 90-day-mortality and severe-morbidity were 3, 3 and 2.8 mmol/L (and the corresponding AUROC 0.86, 0.87 and 0.76). LCT-EOS was an independent predictor of endpoints and adding LCT-EOS to the other predictors increased by 16.4%, 34.5% and 17.7% the accuracy of the models for high-CCI, 90-day-mortality and severe-morbidity, respectively. The models had high calibration and accuracy. Diabetes, repeat-hepatectomy, major-hepatectomy, synchronous-major-procedure, inflow-occlusion and blood-transfusion were independent predictors of LCT-EOS >3 mmol/L. CONCLUSIONS LCT-EOS >3 mmol/L is an early predictor of postoperative-outcome and should be used as a tool to determine patients requiring critical-care and as an endpoint in studies measuring the impact of perioperative interventions.
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Yamamoto T, Kita R, Masui H, Kinoshita H, Sakamoto Y, Okada K, Komori J, Miki A, Uryuhara K, Kobayashi H, Hashida H, Kaihara S, Hosotani R. Prediction of mortality in patients with colorectal perforation based on routinely available parameters: a retrospective study. World J Emerg Surg 2015. [PMID: 26213564 PMCID: PMC4513392 DOI: 10.1186/s13017-015-0020-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Takehito Yamamoto
- Department of Surgery, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ogimachi, Kita-ku, Osaka, 530-8480 Japan
| | - Ryosuke Kita
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hideyuki Masui
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiromitsu Kinoshita
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Yusuke Sakamoto
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Kazuyuki Okada
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Junji Komori
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Akira Miki
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Kenji Uryuhara
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiroyuki Kobayashi
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiroki Hashida
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Satoshi Kaihara
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Ryo Hosotani
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
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