Early and Late Outcome after Surgery for Colorectal Cancer Elective versus Emergency Surgery

Timing of readmissions for complications following emergency colectomy: follow-up beyond post-operative day 30 matters

BACKGROUND AND PURPOSE

Emergency colectomies are associated with a higher risk of complications compared to elective ones. A critical assessment of complications occurring beyond post-operative day 30 (POD30) is lacking. This study aimed to assess the readmission rate and factors associated with readmission 6-months following emergency colectomy.

METHODS

A retrospective cohort study of adult patients who underwent emergency colectomy (2010-2018) was performed using the Nationwide Readmissions Database. The cohort was divided into two groups: (i) no readmission and (ii) emergency readmission(s) for complications related to colectomy (defined using ICD-9/10 codes). Readmissions were categorized as either "early" (POD0-30) or "late" (> POD30). Differences between groups were described and multivariable regression controlling for relevant covariates defined a priori were used to identify factors associated with timing of readmission and cost.

RESULTS

Of 141,481 eligible cases, 13.22% (n = 18,699) were readmitted within 6-months of emergency colectomy for colectomy-related complications, 61.63% of which were "late" readmissions (> POD30). The most common reasons for "late" readmission were for bleeding, gastrointestinal, and infectious complications (20.80%, 25.30%, and 32.75%, respectively). On multiple logistic regression, female gender (OR 1.12; 95%CI 1.04-1.21), open procedures (OR 1.12, 95%CI 1.011-1.24), and sigmoidectomies (OR 1.51, 95%CI 1.39-1.65, relative to right hemicolectomies) were the strongest predictors of "late" readmission. On multiple linear regression, "late" readmissions were associated with a $1717.09 USD (95%CI $1717.05-$1717.12) increased cost compared to "early" readmissions.

DISCUSSION

The majority of colectomy-related readmissions following emergency colectomy occur beyond POD30 and are associated with cases that are of overall higher morbidity, as well as open sigmoidectomies. Given the associated increased cost of care, mitigation of such readmissions by close follow-up prior to and beyond POD30 is advisable.

Oncological outcomes of elective versus emergency surgery for colon cancer: A tertiary academic center experience

Background

In this study, we aimed to identify the oncological outcomes in colon cancer patients who underwent elective versus emergency curative resection.

Methods

All patients who underwent curative resection for colon cancer between July 2015 and December 2019 were retrospectively reviewed and analyzed. Patients were divided into two groups based on the presentation into elective and emergency groups.

Results

A total of 215 patients with colon cancer were admitted and underwent curative surgical resection. Of those, 145 patients (67.4%) were elective cases, and 70 (32.5%) were emergency cases. Family history of malignancy was positive in 44 patients (20.5%) and significantly more common in the emergency group (P = 0.016). The emergency group had higher T and TNM stages (P = 0.001). The 3-year survival rate was 60.9% and significantly less in the emergency group (P = 0.026). The mean duration from surgery to recurrence, 3-year disease-free survival, and overall survival were 1.19, 2.81, and 3.11, respectively.

Conclusion

Elective group was associated with better 3-year survival, longer overall, and 3-year disease-free survival compared to the emergency group. The disease recurrence rate was comparable in both groups, mainly in the first two years after curative resection.

Laparoscopic versus open Hartmann reversal: a propensity score matching analysis

PURPOSE

The purpose of this study was to compare the short-term outcomes between laparoscopic Hartmann reversal (LHR) and open Hartmann reversal (OHR) in patients who had undergone Hartmann surgery for colorectal cancer (CRC).

METHODS

The patients who underwent Hartmann reversal (HR) at the First Affiliated Hospital of Chongqing Medical University from Jun 2013 to Jun 2022 were retrospectively enrolled. The LHR group and the OHR group were compared using propensity score matching (PSM) analysis.

RESULTS

A total of 89 patients who underwent Hartmann reversal (HR) were enrolled in this study. There were 48 (53.9%) patients in the LHR group and 41 (46.1%) patients in the OHR group. After 1:1 ratio PSM, no difference in baseline information remained (p > 0.05). There was no significant difference in operation time, blood loss, postoperative hospital stay, and postoperative complications (p > 0.05) before and after PSM. In the multivariable logistic regression analysis, pre-operative albumin < 42.0 g/L was an independent risk factor (p = 0.013 < 0.05, OR = 0.248, 95% CI = 0.083-0.741) for the HR-related complications; however, LHR/OHR was not a predictive risk factor (p = 0.663, OR = 1.250, 95% CI = 0.500-3.122).

CONCLUSION

Based on the current evidence, although there was no difference in short-term prognosis, LHR still had some advantages considering that it was less invasive to the patient.

Colorectal cancer in an Eastern Caribbean nation: are we missing an opportunity for secondary prevention?

Objective.

To establish whether there was any difference in disease stage in patients with screening-detected colorectal cancer (CRC) in a Caribbean country.

Methods.

The mode of presentation (elective vs. emergent), method of diagnosis (screening vs. symptomatic), and disease stage were retrospectively compared in all consecutive patients who had resections for CRC over a five-year period. Early CRC was defined as disease that could be completely resected with no involvement of adjacent organs, lymph nodes, or distant sites. Locally advanced CRC was disease that involved contiguous organs without distant metastases that was still amenable to curative resection.

Results.

There were 97 patients at a mean age of 64.9 ± 12.2 years treated for CRC, and only 21 (21.6%) had their diagnoses made through screening. Significantly more screening-detected lesions were early-stage CRCs (21.7% vs. 9.3%; p < 0.001). At the time of diagnosis, patients who did not have screening-detected lesions had a greater proportion of locally advanced (42.3% vs. 0) and metastatic (26.8% vs. 0) CRC. Those who did not have screening-detected lesions had a greater incidence of emergency presentations at diagnosis (26.8% vs. 0).

Conclusions.

The incidence of screening-detected CRC in this Caribbean nation was low. Consequently, most patients presented with locally advanced or metastatic CRC, for which there is less opportunity to achieve a cure. Significantly more screening-detected lesions were early-stage CRCs. It is time for policymakers to develop a national CRC screening program.

Predictors of 30-Day Mortality Among Dutch Patients Undergoing Colorectal Cancer Surgery, 2011-2016

IMPORTANCE

Quality improvement programs for colorectal cancer surgery have been introduced with benchmarking based on quality indicators, such as mortality. Detailed (pre)operative characteristics may offer relevant information for proper case-mix correction.

OBJECTIVE

To investigate the added value of machine learning to predict quality indicators for colorectal cancer surgery and identify previously unrecognized predictors of 30-day mortality based on a large, nationwide colorectal cancer registry that collected extensive data on comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

All patients who underwent resection for primary colorectal cancer registered in the Dutch ColoRectal Audit between January 1, 2011, and December 31, 2016, were included. Multiple machine learning models (multivariable logistic regression, elastic net regression, support vector machine, random forest, and gradient boosting) were made to predict quality indicators. Model performance was compared with conventionally used scores. Risk factors were identified by logistic regression analyses and Shapley additive explanations (ie, SHAP values). Statistical analysis was performed between March 1 and September 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome of this cohort study was 30-day mortality. Prediction models were trained on a training set by performing 5-fold cross-validation, and outcomes were measured by the area under the receiver operating characteristic curve on the test set. Machine learning was further used to identify risk factors, measured by odds ratios and SHAP values.

RESULTS

This cohort study included 62 501 records, most patients were male (35 116 [56.2%]), were aged 61 to 80 years (41 560 [66.5%]), and had an American Society of Anesthesiology score of II (35 679 [57.1%]). A 30-day mortality rate of 2.7% (n = 1693) was found. The area under the curve of the best machine learning model for 30-day mortality (0.82; 95% CI, 0.79-0.85) was significantly higher than the American Society of Anesthesiology score (0.74; 95% CI, 0.71-0.77; P < .001), Charlson Comorbidity Index (0.66; 95% CI, 0.63-0.70; P < .001), and preoperative score to predict postoperative mortality (0.73; 95% CI, 0.70-0.77; P < .001). Hypertension, myocardial infarction, chronic obstructive pulmonary disease, and asthma were comorbidities with a high risk for increased mortality. Machine learning identified specific risk factors for a complicated course, intensive care unit admission, prolonged hospital stay, and readmission. Laparoscopic surgery was associated with a decreased risk for all adverse outcomes.

CONCLUSIONS AND RELEVANCE

This study found that machine learning methods outperformed conventional scores to predict 30-day mortality after colorectal cancer surgery, identified specific patient groups at risk for adverse outcomes, and provided directions to optimize benchmarking in clinical audits.

[Palliative Surgery in Colorectal Cancer - Which Factors Should Influence the Choice of the Surgical Procedure?]

BACKGROUND

The surgical procedure for patients with colorectal cancer (CRC) in the palliative situation cannot be adequately standardised. The present study was initiated to identify criteria for the decision for resection of the malignancy with or without anastomosis.

PATIENTS/MATERIAL AND METHODS

In a unicentric retrospective analysis, 103 patients after palliative resection with or without anastomosis due to CRC were examined. Using univariate and logistic regression analysis, the influence of a total of 40 factors on postoperative morbidity and mortality was assessed.

RESULTS

In 46 cases, resection with primary anastomosis and in 57 cases a discontinuity resection was performed. Postoperative morbidity was 44.7% and mortality 17.5%. After one-stage resection with anastomosis, nicotine abuse (OR 4.2; p = 0.044), hypalbuminaemia (OR 4.0; p = 0.012), ASA score > 2 (OR 3.7; p = 0.030) and liver remodelling/cirrhosis (OR 3.6; p = 0.031) increased the risk for postoperative complications. Hypalbuminaemia (OR 1.8; p = 0.036), cachexia (OR 1.8; p = 0.043), anaemia (OR 1.5; p = 0.038) and known alcohol abuse (OR 1.9; p = 0.023) were identified as independent risk factors for early postoperative mortality. After discontinuity resection, renal failure (OR 2.1; p = 0.042) and cachexia (OR 1.5; p = 0.045) led to a significant increase in the risk of postoperative morbidity, alcohol abuse (OR 1.8; p = 0.041) in mortality. Hypalbuminaemia (OR 2.8; p = 0.019) and an ASA score > 2 (OR 2.6; p = 0.004) after resection and reconstruction increased the risk of major complications according to Clavien-Dindo, while pre-existing renal failure (OR 1.6; p = 0.023) increased the risk after discontinuity resection. In univariate analysis, an ASA score > 2 (p = 0.038) after simultaneous tumour resection and reconstruction, and urgent surgery in both groups with or without primary anastomosis were additionally identified as significant parameters with a negative influence on mortality (p = 0.010 and p = 0.017).

CONCLUSION

Palliative resections of colorectal carcinomas have high morbidity and mortality. Especially in cases of pre-existing alcohol abuse and/or urgent indication for surgery, more intensive monitoring should be performed. In the case of anaemia, cachexia, hypalbuminemia and an ASA score > 2, discontinuity resection may be the more appropriate procedure.

Endoscopic Management of Malignant Colonic Obstruction

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer

PURPOSE

Long-term outcomes in patients undergoing emergency versus elective resection for colorectal cancer (CRC) are discussed controversially. This study aims to assess long-term outcomes of emergency versus elective CRC surgery.

METHODS

Single-center retrospective cohort study. Patients undergoing emergency or elective CRC surgery from July 2002 to January 2013 were included. Primary outcome was 5-year survival, secondary outcomes were in-hospital mortality and local tumor recurrence.

RESULTS

Overall, 475 patients were included. Median age was 69.0 (IQR 59.0-77.0) years. A total of 141 patients (30%) were operated for rectal cancer and 334 patients (70%) for colon cancer. Median follow-up was 445 (IQR 67-1409) days. Emergency resection was performed in 105 patients (22%) due to obstruction, perforation, or bleeding. Stage IV tumors and ASA scores≥ 3 were significantly more frequent in the emergency than in the elective resection group (39.0% vs. 33.5%, p < 0.001; 75.5% vs. 61.3%, p = 0.003). The rate of patients with positive lymph nodes was similar in the two groups (46.2% vs. 46.3%, p = 1.000). In-hospital mortality was significantly higher in the emergency CRC versus the elective CRC group (8.4% vs. 3.0%, p = 0.023). Five-year survival (aHR 1.38; 95%CI 0.81-2.37, p = 0.237) or local tumor recurrence (aHR 1.48; 95%CI 0.47-4.66, p = 0.500) were not significantly different in patients undergoing emergency versus elective surgery for CRC.

CONCLUSION

In-hospital mortality was increased in emergency versus elective CRC resections. However, 5-year survival and local recurrence after surgery for CRC were determined by the tumor stage, and not by the emergency versus elective setting of surgical resection.

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

Clinical Outcomes of Self-Expandable Metal Stents for Malignant Rectal Obstruction

BACKGROUND

Self-expandable metal stents are widely used to treat malignant colorectal obstruction. However, data on clinical outcomes of stent placement for rectal obstruction specifically are lacking.

OBJECTIVE

We aimed to investigate the clinical outcomes of self-expandable metal stents in malignant rectal obstruction in comparison with those in left colonic obstruction and to identify factors associated with clinical failure and complication.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted at a tertiary care center.

PATIENTS

Between January 2005 and December 2013, medical charts of patients who underwent stent placement for malignant rectal or left colonic obstruction were reviewed retrospectively.

INTERVENTION

Study intervention included self-expandable metal stent placement.

MAIN OUTCOME MEASURES

Technical success, clinical success, and complications were measured.

RESULTS

Technical success rates for the 2 study groups (rectum vs left colon, 93.5% vs 93.1%; p = 0.86) did not differ significantly; however, the clinical success rate was lower in patients with rectal obstruction (85.4% vs 92.1%; p = 0.02). In addition, the complication rate was higher in patients with rectal obstruction (37.4% vs 25.1%; p = 0.01). Patients with rectal obstruction showed higher rates of obstruction because of extracolonic malignancy (33.8% vs 15.8%; p < 0.001) and stent use for palliation (78.6% vs 56.3%; p < 0.001). Multivariate analysis indicated obstruction attributed to extracolonic malignancy and covered stent usage to be independent risk factors for clinical failure. Factors predictive of complications in the palliative group were total obstruction, obstruction because of extracolonic malignancy, and covered stent usage.

LIMITATIONS

This was a retrospective, single-center study.

CONCLUSIONS

The efficacy and safety of stent placement for malignant rectal obstruction were comparable with those for left colonic obstruction. However, obstruction attributed to extracolonic malignancy, use of covered stents, and total obstruction negatively impacted clinical outcomes of self-expandable metal stent placement and must be considered by endoscopists. See Video Abstract at http://links.lww.com/DCR/A417.

Psychiatric disease in surgically treated colorectal cancer patients

BACKGROUND

Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery).

MATERIALS AND METHODS

Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities.

RESULTS

Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery.

CONCLUSIONS

Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.

Consequences of CT colonography in stenosing colorectal cancer

BACKGROUND

In patients with stenosing colorectal cancer (CRC), visualization of the entire colon prior to surgery is recommended to exclude synchronous tumors. Therefore, most centers combine computed tomographic colonography (CTC) with staging CT. The aims of this study were to evaluate the yield and clinical implications of CTC.

METHODS

In this multicenter retrospective study, patients with stenosing CRC that underwent CTC and subsequent surgery between April 2013 and November 2015 were included. Result of the CTC, its influence on the surgical treatment plan, and final histology report were evaluated.

RESULTS

One hundred sixty-two patients with stenosing CRC were included. Nine (5.6 %) synchronous cancers proximal to the stenosing tumor were suspected with CTC. In four of nine patients, the CTC did not change the primary surgical plan because the tumors were located in the same surgical segment. In five of nine patients, CTC changed the surgical treatment plan. Three of these five patients underwent an extended resection and the presence of the tumors was confirmed. Two of these three synchronous CRCs were also visible on abdominal staging CT. In the other two patients, the result of CTC was false positive which led to an unnecessary extended resection in one patient.

CONCLUSION

The yield of CTC was relatively low. In only three patients (1.9 %), CTC correctly changed the primary surgical plan, but in two of them, the tumor was also visible on abdominal staging CT. Moreover, in two patients, CTC was false positive. The clinical value of CTC in stenosing CRC appears to be limited.

Open surgery versus laparoscopic surgery after stent insertion for obstructive colorectal cancer

PURPOSE

To compare the outcomes of laparoscopic surgery vs. open surgery after insertion of a colonic stent for obstructive colorectal cancer.

METHODS

Between April 2005 and August 2013, 58 patients underwent surgery after the insertion of a colonic stent for obstructive colorectal cancer. We analyzed the outcomes of the patients who underwent laparoscopic surgery vs. those who underwent open surgery.

RESULTS

We compared blood loss, operative time, hospital stay, and complications in 26 patients who underwent laparoscopic surgery and 32 patients who underwent open surgery. Blood loss was significantly less in the laparoscopic surgery group, but operative time was significantly shorter in the open surgery group. The length of hospital stay was shorter in the laparoscopic surgery group than in the open surgery group, but the difference was not significant. There was no significant difference in postoperative surgical complications between the groups.

CONCLUSION

The patients who underwent laparoscopic resection had less blood loss, although no significant difference was found in postoperative morbidity or mortality. Thus, laparoscopic resection after stent insertion is a feasible and safe option for patients with obstructive colorectal cancer.

Incremental Cost of Emergency Versus Elective Surgery

OBJECTIVE

To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery.

BACKGROUND

Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist.

METHODS

Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses.

RESULTS

A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures.

CONCLUSIONS

Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

Can we respect the principles of oncologic resection in an emergency surgery to treat colon cancer?

Patients with colorectal cancer admitted to the emergency room are generally at more advanced stage of the disease and are usually submitted to a resection with curative intent in a smaller scale. In such scenario, one of the aspects to be considered is whether the principles of oncologic resection are observed when those patients diagnosed with colon cancer are treated with surgery. We selected 87 patients with adenocarcinoma of colon and/or upper rectum submitted to an emergency surgical resection. The major variables reviewed retrospectively were: the extent of resection performed, the number of dissected regional lymph nodes and the overall survival rate. Intestinal obstruction was observed in 67 patients (77%) while perforation was found in 20 patients (23%). Seven (8%) specimens had circumferential compromised margins, all found in patients with T4 tumors combine with poor clinical status. The number of dissected regional lymph nodes was greater than, or equal to, 12 in 71% of patients. While the average days of stay in the ICU was 5.7 days, the median was 3 days. The morbidity and peri-operative mortality stood at 33.6% and 20%, respectively. The outcome of an emergency surgery of colorectal cancer observed in this study was similar to those found in the literature. The principles of oncologic resection were respected when considering and analyzing the extent of the resection, the surgical margins and the number of dissected lymph nodes.

Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes

BACKGROUND

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking.

OBJECTIVES

This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting.

METHODS

A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed.

RESULTS

From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen.

CONCLUSIONS

Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.

[Analysis of postoperative complications following acute surgery for colorectal cancer]

Our aim was to improve the outcome of emergency surgeries for colorectal cancer (CRC). Authors compared two periods: 2004-2006 and 2007-2011. Targeted cases were emergency admissions, in which the diagnosis of colorectal cancer is only revealed during work-up or during surgery. No other exclusion criteria were set. Analyzed main endpoints were anastomotic leak, postoperative mortality, resecability. ASA classification and TNM stages were assessed in order to learn morbidity and general condition prior to acute surgery. Considering the experience gained in prior period, in 2007, authors have made a change in treatment strategy. In following years leakage ratio became ten times lower and mortality was reduced by 5%. There is a great chance that fast work-up and preparation for surgery may decrease complications and mortality. The aim would be for CRC patients, is to reach surgery in an early stage of disease as possible, at least before complications develop.

State-by-state variation in emergency versus elective colon resections: room for improvement

BACKGROUND

Compared with elective surgical procedures, emergency procedures are associated with higher cost, morbidity, and mortality. This study seeks to investigate potential state-by-state variations in the incidence of emergent versus elective colon resections.

METHODS

A retrospective analysis of all adult patients (aged ≥18 years) included in the Nationwide Inpatient Sample from 2005 to 2009 who underwent hemicolectomy (right or left) or sigmoidectomy was conducted. Discharge-level weights were applied, and generalized linear models were used to assess the odds of a patient undergoing emergent versus elective colon surgery nationally and for each state after adjusting for patient and hospital factors. Odds ratios (ORs) were estimated with the national average as the reference.

RESULTS

The final study cohort included 203,050 observations composed of 83,090 emergent and 119,960 elective colectomies. The state with the highest unadjusted proportion of emergent procedures was Nevada (53.6%), whereas Texas had the lowest (22.8%) [corrected]. Compared with the national average, the adjusted odds of undergoing emergency colectomy remained highest in Nevada (OR, 1.70; 95% confidence interval, 1.54-1.87) and lowest in Texas (OR, 0.43; 95% confidence interval, 0.36-0.51).

CONCLUSION

Substantial state variations exist in rates of emergency colon surgery within the United States. Identification of these differences suggests significant variations in practice and a potential to decrease the number of emergent colon operations.

Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery

OBJECTIVE

Children who undergo cardiac surgery are at high risk for renal insufficiency and abdominal compartment syndrome. Peritoneal dialysis catheter (PDC) implantation is used in this population for abdominal decompression and access for dialysis. However, there is no consensus regarding PDC use, and the practice varies widely. This study was undertaken to assess associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery.

METHODS

The cohort was obtained from the Kids' Inpatient Database, years 2006 and 2009. Patients who underwent cardiac surgery were included and the subset that underwent PDC implantation during the same hospitalization was identified. Univariable and multivariable analyses assessed factors associated with PDC and survival.

RESULTS

A cohort of 28,259 patients underwent cardiac surgery, of whom 558 (2%) had PDCs placed. In the PDC group, 39.1% (n = 218) had acute renal failure whereas 3.5% or patients (n = 974) in the non-PDC group had acute renal failure. Among patients receiving PDC, mortality was 20.3% (n = 113; vs 3.4% overall mortality, n = 955). Excluding patients with acute renal failure, mortality remained 12% (n = 41) for the PDC group. Factors associated significantly with PDC placement in the overall cohort were younger age, greater surgical complexity, nonelective admission, hospital region, use of cardiopulmonary bypass, and acute renal failure.

CONCLUSIONS

Patients receiving PDC after cardiac surgery had 20% mortality, which remained 12% after excluding patients with acute renal failure. Given the variability in PDC use and poor outcomes, further research is needed to assess the possible benefit of earlier intervention for peritoneal access in this high-risk cohort.

Stenting for colorectal cancer obstruction compared to surgery--a study of consecutive patients in a single institution

BACKGROUND

Colonic obstruction is a common complication to colorectal cancer and surgical treatment is associated with high morbidity and mortality. Stenting has emerged as an alternative to surgery. The aim of this study was to compare short-term morbidity, mortality and hospital stay between treatment with self-expandable metallic stent and emergency surgery performed at our department during a 5-year period in a non-randomized setting.

METHODS

Patients with colonic obstruction due to rectal or colon cancer referred to the Endoscopic Unit or Surgical Department for insertion of a colonic stent between 1 August 2003 and 1 August 2008 were prospectively registered and followed (n = 112). A control group was identified using the hospital records of operations with the International Classification Code-10 (ICD-10) for bowel obstruction and colorectal cancer (n = 60). Age, gender, indication, preoperative investigations, surgical procedure, complications and procedure-related mortality were registered. Patients were followed in accordance with local guidelines.

RESULTS

The complication rate was similar in the two groups, although there was a trend toward a higher number of severe complications in the surgical group. The hospital stay was significantly lower in the stent group, median of 4 vs. 9 days (p < 0.0001). The procedure-related mortality was lower in the stent group; 7% vs. 20% (p < 0.05).

CONCLUSIONS

Stenting can be safely performed with lower or similar complication rate and lower mortality rate compared to surgery and results in significantly shorter hospital stay. The results support stenting as the treatment of choice in patients with acute colonic obstruction, especially in disseminated disease.

Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis

BACKGROUND

We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease.

METHODS

Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome.

RESULTS

Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, -3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, -2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, -3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, -2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, -3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, -3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation.

CONCLUSIONS

Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.

Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer

BACKGROUND

Only a few small studies have evaluated risk factors related to early death following emergency surgery for colonic cancer. The aim of this study was to identify risk factors for death within 30 days after such surgery.

METHODS

Some 2157 patients who underwent emergency treatment for colonic cancer from May 2001 to December 2005 were identified from the national colorectal cancer registry. Thirty-day mortality rates were calculated and risk factors for early death were identified using logistic regression analysis.

RESULTS

The overall 30-day mortality rate was 22.1 per cent. The strongest risk factor for early death was postoperative medical complications (cardiopulmonary, renal, thromboembolic and infectious), with an odds ratio of 11.7 (95 per cent confidence interval 8.8 to 15.5). Such complications occurred in 24.4 per cent of patients, of whom 57.8 per cent died. Other independent risk factors were age at least 71 years, male sex, American Society of Anesthesiologists grade III or more, palliative outcome, tumour perforation, splenectomy and adverse intraoperative surgical events. Postoperative surgical complications were noted in 20.4 per cent of the patients but had no statistically significant influence on mortality.

CONCLUSION

Emergency surgery for colonic cancer is still associated with an increased risk of death. There is a need for a system providing increased safety in the perioperative period.

The importance of differentiating between elective and emergency postoperative critical care patients

PURPOSE

The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units.

MATERIALS AND METHODS

A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours).

RESULTS

In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality.

CONCLUSIONS

Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE

Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study.

PATIENTS AND METHODS

In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma.

RESULTS

The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction.

CONCLUSION

Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.

Assessing risk factors for adverse outcomes in emergent colorectal surgery

BACKGROUND

A variety of factors influence the increased morbidity and mortality seen in patients undergoing emergent colon surgery. Understanding comorbid conditions and variations in preoperative laboratory values that effect both morbidity and mortality can influence clinical decision making.

METHODS

During a 5-year period 185 patients underwent colon surgery at the Veterans Administration Hospital in West Haven, CT. Through a retrospective chart review patients were classified as having either emergent or elective surgery. Patient characteristics and postoperative outcomes were analyzed using Chi Square and logistic regression models.

RESULTS

Differences existed in preoperative variables as well as postoperative outcomes when comparing emergent and elective paitents. In those patients undergoing emergent colorectal surgery, both morbidity and mortality were increased and overall survival decresed when compared to a non-emergent population.

CONCLUSIONS

Through identification of preoperative variables such as a hematocrit <30, the use of steroids, an albumin <3.5, and a creatinine of >1.4, those patients at risk for postoperative morbidity and mortality can be identified and clinical decision making can be appropriately adjusted.

Identifying high-risk patients undergoing urgent and emergency surgery

INTRODUCTION

The aim was to identify high-risk patients undergoing non-elective orthopaedic and general surgery.

PATIENTS AND METHODS

This was a retrospective cohort study of all non-elective general and orthopaedic surgical procedures performed in a 1-year interval in a district general hospital. A total of 1869 patients underwent urgent or emergency surgery in the calendar year 2000. Outcomes were identified from various related hospital databases. Case notes of those who died were reviewed. Risk factors for mortality were examined using univariate and multivariate analysis.

RESULTS

The mortality rates were 89/1869 (5%) at 30 days and 216 (12%) after 1 year. The high initial death rate continued for about 100 days after surgery. Increasing age (P < 0.0001), size of operation (P = 0.004) and American Society of Anesthesiologists (ASA) fitness grade (P < 0.0001) were associated with significantly higher risk of death at 1 year on multivariate analysis. A high risk group was identified of 273 patients aged over 50 years, of ASA Grade III or above who needed major surgery; they had a 30-day mortality rate of 18%.

CONCLUSIONS

A simple scoring system could be used to identify high-risk patients who require non-elective surgery that could be a target for interventions to try and reduce their risk of death.

Impact of emergency surgery in the outcome of rectal and left colon carcinoma

The negative results in terms of morbidity, mortality and survival among emergency treated patients affected by colorectal cancer are well known. The specific contribution of emergency surgery to adverse outcome is not clear because of the presence in all series of other possible determinants of a poor prognosis. We used a case-control study design to compare a group of 50 patients operated on for cancer of the rectum and left colon presented as emergencies in our department during the last 14 years, and an equal number of patients who underwent elective procedures during the same period. All records of these patients were reviewed and matched for age, stage, tumor location, and medical comorbidities (coronaropathy, diabetes mellitus, cerebral vascular deficiency, chronic obstructive pulmonary disease). Outcome measures included length of hospital stay, morbidity, mortality, and actuarial 5-year survival. Univariate and multivariate analysis of factors potentially influencing survival was performed on the entire population of 100 patients. Age, tumor location, stage of disease, and medical comorbidities were well matched by intent of the study design. Overall surgical morbidity (44% versus 12% P = 0.0004), length of hospital stay (16, 64 versus 10, 97 days P = 0.0026) and postoperative mortality (4% versus 0% P = 0.4949) resulted higher in the emergency group. Actuarial overall 5-year survival was not different between the two groups. The only variables independently predictive of survival in multivariate analysis were age and rectal location of the tumor. Postoperative surgical mortality and long-term survival appear not to be influenced by emergency presentation of colorectal cancer; the negative impact of the emergency procedures is confined to the immediate postoperative period and is probably connected to the acute medical pathology often presented by patients in emergency situations. Dealing with this kind of patient's accurate preoperative assessment and solution of acute medical pathologies before surgical treatment are mandatory.

Laparotomy for acute colorectal conditions in moribund patients: is it worthwhile?

INTRODUCTION

Colorectal surgeons are sometimes asked to operate on moribund patients, classified by the American Society of Anesthesiology as Class 5--patients who are likely to die with or without surgery. There is a concern that surgery may precipitate the patient's demise; however, there are few data concerning outcomes in this group. It is, therefore, difficult to counsel patients and their families about the advisability of surgery. This study was performed to show what sort of results can be expected from operating on American Society of Anesthesiology Class 5 patients and to see whether there are any factors that can be used to predict outcome within this American Society of Anesthesiology class.

METHODS

Since March 1989, a prospective database of all surgeries has been maintained. Included in the data is the American Society of Anesthesiology Classification. All patients classified as 5 were identified and their history reviewed. The 30-day postoperative survival was the primary end point of the study. Also abstracted were data on comorbidity, indication for colorectal surgery, surgery performed, length of postoperative hospital stay, estimated intraoperative blood loss, and duration of anesthesia.

RESULTS

There were 4,163 surgeries recorded, including 2,040 (49 percent) laparotomies. There were 21 laparotomies in American Society of Anesthesiology Class 5 patients (1 percent of all laparotomies). Eighteen surgeries were performed as emergencies, and three were urgent. Nine patients survived 30 days or longer (41 percent), whereas 12 did not. Seven patients lived to be discharged from the hospital.

CONCLUSION

Expeditious, safe surgery may save moribund patients with an acute colorectal problem.

Evaluation of P-POSSUM in surgery for obstructing colorectal cancer and correlation of the predicted mortality with different surgical options

PURPOSE

This study examined the accuracy of Portsmouth Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity system (P-POSSUM) in predicting the mortality of patients who underwent operations for obstructing colorectal cancer. It also is attempted to analyze the actual mortality and the predicted P-POSSUM mortality of different surgical options for obstructing left-sided cancer.

METHODS

Data on patients who underwent surgery for obstructing colorectal cancer during 1998 to 2002 were collected. Mortality predicted by P-POSSUM was compared to the actual mortality with the method of linear analysis. The accuracy of using P-POSSUM to predict mortality in this group of patients was assessed by Hosmer and Lemeshow goodness of fit test and Receiver Operator Characteristic curve analysis. The predicted and actual mortality of patients who underwent different surgical options also were analyzed.

RESULTS

A total of 160 patients were included in the study and 18 patients died postoperatively. The operative mortality was 11.3 percent. P-POSSUM predicted overall mortality of 15 percent. The observed and predicted mortality was found to have no significant lack of fit (chi-squared = 5.98; degree of freedom = 3; P = 0.11). The area under Receiver Operator Characteristic curve analysis was 0.75. For patients with left-sided tumors, P-POSSUM predicted mortality and actual mortality of patients who had resection without anastomosis were both significantly higher than patients with single-stage resection and primary anastomosis (P = 0.044 and 0.011, respectively).

CONCLUSIONS

P-POSSUM system is valid for prediction of overall mortality in patients with operations for obstructing colorectal cancer. Estimation of P-POSSUM predicted mortality during operation and its ability to correlate with choice of procedure is an area that is worth further study in emergency colorectal surgery.

Comparison of multivisceral resection and standard operation for locally advanced colorectal cancer: analysis of prognostic factors for short-term and long-term outcome

PURPOSE

The aim of the present study is to clarify the characteristics of multivisceral resection and to discuss strategies for improving the overall outcome of multivisceral resection for locally advanced colorectal cancer.

METHODS

The study included 323 patients who electively underwent curative surgery for pT3-pT4 colorectal carcinoma without distant metastasis. We evaluated the short-term and long-term outcome of multivisceral resection relative to that of the standard operation by means of multivariate analysis of the prognostic factors.

RESULTS

Of 323 patients, 53 (16.4 percent) received multivisceral resection because of adhesion to other organs. Multivisceral resection was significantly associated with tumor size, depth of invasion, operative blood loss, operation time, and blood transfusion (all: P < 0.0001). Overall morbidity rates were 49.1 percent after multivisceral resection vs. 17.8 percent after the standard operation (P < 0.0001), and postoperative mortality rate was 0 percent in both groups (not significant). Only multivisceral resection (odds ratio, 2.725; 95 percent confidence interval, 1.125-6.623; P = 0.0264) was an independent factor for overall postoperative complications. The survival rate of patients after multivisceral resection was similar to that after the standard operation (5-year rate, 76.6 percent vs. 79.5 percent, P = 0.9347). Lymph node metastasis (hazard ratio, 2.510; 95 percent confidence interval, 1.460-4.315; P = 0.0009) and blood transfusion (hazard ratio, 2.353; 95 percent confidence interval, 1.185-4.651; P = 0.0145) were independently associated with patient survival.

CONCLUSIONS

For locally advanced colorectal cancer, the long-term outcome after multivisceral resection is comparable to that after the standard operation. However, it should be recognized that multivisceral resection is associated with higher postoperative morbidity. In addition, a reduction in the incidence of blood transfusion may contribute to improving patient survival.