Original Paper Received: December 20, 2013 Accepted after revision: June 15, 2014 Published online: August 28, 2014
Dig Surg 2014;31:197–203 DOI: 10.1159/000365254
Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period Gianluca Costa Marco La Torre Brabara Frezza Pietro Fransvea Federico Tomassini Vincenzo Ziparo Genoveffa Balducci Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome ‘La Sapienza’, St. Andrea Hospital, Rome, Italy
Key Words Colon surgery · Emergency surgery · Morbidity and mortality after colon surgery
Abstract Purpose: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. Materials and Methods: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. Results: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). Conclusions: Emergency colon surgery is today primarily performed for benign diseases,
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0197$39.50/0 E-Mail [email protected] www.karger.com/dsu
of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not. © 2014 S. Karger AG, Basel
Introduction
Colorectal surgery represents 10–25% of all emergency abdominal surgeries. Despite advances in surgery, antimicrobial therapies, and postoperative intensive care, emergency colonic surgery remains a high-risk procedure, especially in elderly patients with morbidity and mortality rates of 11–35 and 9–22%, respectively; age, comorbidities, and American Society of Anesthesiologists (ASA) score, among others, have been reported as significant risk factors. The appropriate surgical approach for colonic emergencies is difficult to determine given the various etiologies of colonic disease [1–5]; the debate continues to evolve despite the recent shift toward onestage treatment strategies. The present study aims to assess the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any Marco La Torre, MD, PhD Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome ‘La Sapienza’ St. Andrea Hospital, Via di Grottarossa, 1035-39, IT–00189 Rome (Italy) E-Mail marco.latorre @ uniroma1.it
change in the incidence of different types of pathological conditions and in surgical treatment over the last 15 years. Patients and Methods This retrospective study includes the review of a series of patients who had undergone emergency colonic surgery between January 1997 and December 2011. Patient records and data were retrieved from a prospective database concerning all cases of emergency surgery. All patients had been treated by surgeons who had completed the same surgical residency training program at La Sapienza University of Rome, formerly at the 1st Department of Surgery of the Umberto I Hospital in Rome and, more recently, at the Department of Surgery of the Sant’Andrea Hospital in Rome. In order to avoid bias in the study design due to surgeon experience, only procedures performed by colorectal senior staff surgeons (G.C., V.Z., G.B.) were considered suitable for the study. Patients were classified into two groups according to the date of the surgical procedure, namely between January 1997 and February 2006 (group 1) and between March 2006 and December 2011 (group 2). For statistical analysis and comparison, both patient groups were further stratified into two subgroups comprising patients affected by malignant or benign disease. The clinical and demographic findings were analyzed in order to evaluate and define any parameters associated with morbidity and mortality. The preoperative variables studied were sex, age, type of disease (malignant or benign), onset symptoms, associated diseases, ASA score, reason for surgery, tumor stage, and surgical procedure. The left colorectal resection procedure was defined as follows: in cancer patients, a typical left resection involving inferior mesenteric artery ligation and sectioning of the upper third of the rectum with colorectal anastomosis to the rectal stump; while in benign disease, segmental resection of the affected colon without inferior mesenteric artery ligation followed by anastomosis almost always preformed at the recto-sigmoid junction. Onset symptoms requiring emergency surgery were defined as follows: obstruction, peritonitis, and significant lower gastrointestinal bleeding. The reasons for surgery were classified into four main groups: neoplasia, diverticulitis, ischemic colitis, and other disorders. Tumor staging was performed according to the TNM classification system. The preoperative medical comorbidities analyzed were cardiovascular disease, respiratory disease, diabetes, chronic renal failure, immunodeficiency, and corticoid or chemotherapeutic treatment. Analysis of the morbidity outcome variables included only major surgically related or general complications such as sepsis, acute myocardial infarction, pneumonia and/ or major pleural effusion, deep vein thrombosis, pulmonary embolism, and ictus. Major surgically related complications were colonic stoma ischemia, eventration, and anastomotic leakage; the latter refers only to a clinically detected leakage which affected the hospital length of stay. Postoperative mortality was defined as any death occurring during the postoperative course regardless of the interval between primary operation and death. Statistical analysis was performed using the 17.0 version of the PASW Statistics Program (SPSS Italy, Bologna) for MacOsX. The
198
Dig Surg 2014;31:197–203 DOI: 10.1159/000365254
one-way analysis of variance (ANOVA) test, the χ2 test or Fisher’s exact test, and the Student’s t test were used when appropriate for univariate comparisons. Multivariate analysis was then performed with the stepwise logistic regression model using poor outcome as a dependent variable. The significance level was set at p < 0.05. A post hoc analysis for the χ2 test and t test, by G-Power for Windows version 3.0, was made in order to evaluate the power estimation aimed at assessing the adequacy of the group and subgroup sample sizes.
Results
A total of 319 patients who underwent emergency colon surgery were analyzed; 157 patients operated between January 1997 and February 2006 (group 1) and 162 patients operated between March 2006 and December 2011 (group 2). The patient characteristics are shown in table 1. No statistically significant difference was observed between the two groups with regard to age. There was a prevalence for the female sex in group 2 compared to group 1 (54.3 vs. 33.8%, p < 0.001). Preoperative medical comorbidities were found to be significantly more numerous in group 2 (67.9 vs. 41.4%, p < 0.001). The incidence of benign disease in group 2 was significantly higher than in group 1 (53.7 vs. 32.5%, p < 0.001). Group 1 included 106 (67.5%) patients with malignant disease and 51 (32.5%) patients with benign disease, while group 2 included 75 (46.3%) patients with malignant disease and 87 (53.7%) patients with benign disease. Diverticular disease was the most frequent benign disease in both groups (27 (52.9%) patients in group 1 and 33 (37.9%) patients in group 2), followed by ischemic colitis (16 (18.4%) patients in group 1 and 6 (11.8%) patients in group 2). The most frequent T stage detected was pT3 in both groups with an overall higher rate of advanced tumor stage in group 2 (p < 0.001) (table 1). The surgical procedures performed in the two groups are reported in table 2. A significant overall increased rate of primary resection and anastomosis after left colorectal resection was observed in group 2 compared to group 1 (18 vs. 0.6%, p < 0.001) for both malignant (20 vs. 0%, p < 0.001) and benign subgroups (16.1 vs. 2.0%, p < 0.001). Similar findings were observed when protective ileostomy was associated to primary resection (table 2). No particular trend was noted regarding the number of primary anastomoses performed over each year within each time period. The overall postoperative morbidity and mortality rates observed in the 319 patients were 25.3% (81 patients) and 17.2% (55 patients), respectively. Group 1 showed overall postoperative morbidity and mortality Costa/La Torre/Frezza/Fransvea/ Tomassini/Ziparo/Balducci
rates of 19.1% (30 patients) and 12.7% (20 patients), respectively. The morbidity and mortality rates in Hartmann’s and one-stage procedures performed for left-sided disease are reported in table 3. No significant differences in patient characteristics were found between patients who underwent the one-stage surgery or Hartmann’s procedure. It is noteworthy that the overall reversal rate of the Hartmann procedure was 72.9% (78 of 107 cases) in the present series, but such patients were obviously not included in this study. Primary anastomosis after left colorectal resection was performed in 53 patients, with overall morbidity and mortality rates of 28.4% (15 cases) and 11.4% (6 cases), respectively. Anastomotic leak, always observed after left colorectal resection, was clinically diagnosed in 6 (11.8%) patients. Comparisons of morbidity and mortality rates in the two groups and subgroups are reported in tables 4 and 5. The overall morbidity and mortality rates observed in group 2 were statistically higher than those in group 1 (51 (31.5%) vs. 30 (19.1%) patients, p < 0.004, and 35 (21.6%) vs. 20 (12.7%) patients, p < 0.003, respectively). It was found that, in group 1, patients with malignant disease showed an increased morbidity rate compared to patients with benign disease (25 patients (23.6%) vs. 5 patients (9.8%), p < 0.01). Group 2 showed an overall postoperative morbidity and mortality rate of 31.5% (51 patients) and 21.6% (35 patients), respectively; in this group, patients with malignant disease presented a reduced mortality rate compared to patients with benign disease (9 (12.0%) vs. 26 (29.9%) patients, p < 0.01) (tables 4, 5). Statistically significant differences in the morbidity and mortality rates were also found when patients affected by benign disease were compared between groups 1 and 2 (9.8 and 7.8% in group 1 vs. 32.2 and 29.9% in group 2, p < 0.004 and p < 0.003, respectively). Results of the multivariate analysis of mortality and morbidity in group 2 are summarized in table 6. The factors affecting morbidity were white blood cell count at onset and the ischemic colon pattern. The factors affecting mortality were female sex, advanced age, presence of comorbidities, ASA score, and vascular colon disease.
Discussion
Table 1. Characteristics of patients
Group 1 Gender Male 104 (66.2) Female 53 (33.8) Age 71.9±9.3 Range 34–98 Onset symptoms Occlusive 86 (54.7) Bleeding 7 (4.5) Acute abdomen 64 (40.8) ASA score I 20 (12.7) II 36 (22.9) III 57 (36.3) IV 40 (25.5) V 4 (2.6) Associated disease 65 (41.4) Cardiovascular disease 64 (40.7) Respiratory disease 45 (28.6) Diabetes 34 (21.6) Chronic renal failure 15 (10.0) Obesity (BMI >30) 13 (8.2) Immunodeficiency 5 (3.0) Tumor 6 (3.8) Other 6 (3.8) Affected disease Benign 51 (32.5) Malignant 106 (67.5) Type of benign disease 27 (52.9) Diverticula 6 (11.8) Ischemic colitis 4 (7.8) IBD 3 (5.9) Perforation NOS 3 (5.9) Volvulus 8 (15.7) Others Type of treatment Open 157 (100.0) Laparoscopic 0 (0.0) TNM stage pT1 3 (2.8) pT2 35 (33.0) pT3 44 (41.5) pT4 20 (18.9) Not evaluable 4 (3.8) Hinchey classification I 2 (7.4) II 7 (25.9) III 7 (25.9) IV 11 (40.8)
Group 2
p
Dig Surg 2014;31:197–203 DOI: 10.1159/000365254
Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period Gianluca Costa Marco La Torre Brabara Frezza Pietro Fransvea Federico Tomassini Vincenzo Ziparo Genoveffa Balducci Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome ‘La Sapienza’, St. Andrea Hospital, Rome, Italy
Key Words Colon surgery · Emergency surgery · Morbidity and mortality after colon surgery
Abstract Purpose: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. Materials and Methods: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. Results: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). Conclusions: Emergency colon surgery is today primarily performed for benign diseases,
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0197$39.50/0 E-Mail [email protected] www.karger.com/dsu
of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not. © 2014 S. Karger AG, Basel
Introduction
Colorectal surgery represents 10–25% of all emergency abdominal surgeries. Despite advances in surgery, antimicrobial therapies, and postoperative intensive care, emergency colonic surgery remains a high-risk procedure, especially in elderly patients with morbidity and mortality rates of 11–35 and 9–22%, respectively; age, comorbidities, and American Society of Anesthesiologists (ASA) score, among others, have been reported as significant risk factors. The appropriate surgical approach for colonic emergencies is difficult to determine given the various etiologies of colonic disease [1–5]; the debate continues to evolve despite the recent shift toward onestage treatment strategies. The present study aims to assess the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any Marco La Torre, MD, PhD Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome ‘La Sapienza’ St. Andrea Hospital, Via di Grottarossa, 1035-39, IT–00189 Rome (Italy) E-Mail marco.latorre @ uniroma1.it
change in the incidence of different types of pathological conditions and in surgical treatment over the last 15 years. Patients and Methods This retrospective study includes the review of a series of patients who had undergone emergency colonic surgery between January 1997 and December 2011. Patient records and data were retrieved from a prospective database concerning all cases of emergency surgery. All patients had been treated by surgeons who had completed the same surgical residency training program at La Sapienza University of Rome, formerly at the 1st Department of Surgery of the Umberto I Hospital in Rome and, more recently, at the Department of Surgery of the Sant’Andrea Hospital in Rome. In order to avoid bias in the study design due to surgeon experience, only procedures performed by colorectal senior staff surgeons (G.C., V.Z., G.B.) were considered suitable for the study. Patients were classified into two groups according to the date of the surgical procedure, namely between January 1997 and February 2006 (group 1) and between March 2006 and December 2011 (group 2). For statistical analysis and comparison, both patient groups were further stratified into two subgroups comprising patients affected by malignant or benign disease. The clinical and demographic findings were analyzed in order to evaluate and define any parameters associated with morbidity and mortality. The preoperative variables studied were sex, age, type of disease (malignant or benign), onset symptoms, associated diseases, ASA score, reason for surgery, tumor stage, and surgical procedure. The left colorectal resection procedure was defined as follows: in cancer patients, a typical left resection involving inferior mesenteric artery ligation and sectioning of the upper third of the rectum with colorectal anastomosis to the rectal stump; while in benign disease, segmental resection of the affected colon without inferior mesenteric artery ligation followed by anastomosis almost always preformed at the recto-sigmoid junction. Onset symptoms requiring emergency surgery were defined as follows: obstruction, peritonitis, and significant lower gastrointestinal bleeding. The reasons for surgery were classified into four main groups: neoplasia, diverticulitis, ischemic colitis, and other disorders. Tumor staging was performed according to the TNM classification system. The preoperative medical comorbidities analyzed were cardiovascular disease, respiratory disease, diabetes, chronic renal failure, immunodeficiency, and corticoid or chemotherapeutic treatment. Analysis of the morbidity outcome variables included only major surgically related or general complications such as sepsis, acute myocardial infarction, pneumonia and/ or major pleural effusion, deep vein thrombosis, pulmonary embolism, and ictus. Major surgically related complications were colonic stoma ischemia, eventration, and anastomotic leakage; the latter refers only to a clinically detected leakage which affected the hospital length of stay. Postoperative mortality was defined as any death occurring during the postoperative course regardless of the interval between primary operation and death. Statistical analysis was performed using the 17.0 version of the PASW Statistics Program (SPSS Italy, Bologna) for MacOsX. The
198
Dig Surg 2014;31:197–203 DOI: 10.1159/000365254
one-way analysis of variance (ANOVA) test, the χ2 test or Fisher’s exact test, and the Student’s t test were used when appropriate for univariate comparisons. Multivariate analysis was then performed with the stepwise logistic regression model using poor outcome as a dependent variable. The significance level was set at p < 0.05. A post hoc analysis for the χ2 test and t test, by G-Power for Windows version 3.0, was made in order to evaluate the power estimation aimed at assessing the adequacy of the group and subgroup sample sizes.
Results
A total of 319 patients who underwent emergency colon surgery were analyzed; 157 patients operated between January 1997 and February 2006 (group 1) and 162 patients operated between March 2006 and December 2011 (group 2). The patient characteristics are shown in table 1. No statistically significant difference was observed between the two groups with regard to age. There was a prevalence for the female sex in group 2 compared to group 1 (54.3 vs. 33.8%, p < 0.001). Preoperative medical comorbidities were found to be significantly more numerous in group 2 (67.9 vs. 41.4%, p < 0.001). The incidence of benign disease in group 2 was significantly higher than in group 1 (53.7 vs. 32.5%, p < 0.001). Group 1 included 106 (67.5%) patients with malignant disease and 51 (32.5%) patients with benign disease, while group 2 included 75 (46.3%) patients with malignant disease and 87 (53.7%) patients with benign disease. Diverticular disease was the most frequent benign disease in both groups (27 (52.9%) patients in group 1 and 33 (37.9%) patients in group 2), followed by ischemic colitis (16 (18.4%) patients in group 1 and 6 (11.8%) patients in group 2). The most frequent T stage detected was pT3 in both groups with an overall higher rate of advanced tumor stage in group 2 (p < 0.001) (table 1). The surgical procedures performed in the two groups are reported in table 2. A significant overall increased rate of primary resection and anastomosis after left colorectal resection was observed in group 2 compared to group 1 (18 vs. 0.6%, p < 0.001) for both malignant (20 vs. 0%, p < 0.001) and benign subgroups (16.1 vs. 2.0%, p < 0.001). Similar findings were observed when protective ileostomy was associated to primary resection (table 2). No particular trend was noted regarding the number of primary anastomoses performed over each year within each time period. The overall postoperative morbidity and mortality rates observed in the 319 patients were 25.3% (81 patients) and 17.2% (55 patients), respectively. Group 1 showed overall postoperative morbidity and mortality Costa/La Torre/Frezza/Fransvea/ Tomassini/Ziparo/Balducci
rates of 19.1% (30 patients) and 12.7% (20 patients), respectively. The morbidity and mortality rates in Hartmann’s and one-stage procedures performed for left-sided disease are reported in table 3. No significant differences in patient characteristics were found between patients who underwent the one-stage surgery or Hartmann’s procedure. It is noteworthy that the overall reversal rate of the Hartmann procedure was 72.9% (78 of 107 cases) in the present series, but such patients were obviously not included in this study. Primary anastomosis after left colorectal resection was performed in 53 patients, with overall morbidity and mortality rates of 28.4% (15 cases) and 11.4% (6 cases), respectively. Anastomotic leak, always observed after left colorectal resection, was clinically diagnosed in 6 (11.8%) patients. Comparisons of morbidity and mortality rates in the two groups and subgroups are reported in tables 4 and 5. The overall morbidity and mortality rates observed in group 2 were statistically higher than those in group 1 (51 (31.5%) vs. 30 (19.1%) patients, p < 0.004, and 35 (21.6%) vs. 20 (12.7%) patients, p < 0.003, respectively). It was found that, in group 1, patients with malignant disease showed an increased morbidity rate compared to patients with benign disease (25 patients (23.6%) vs. 5 patients (9.8%), p < 0.01). Group 2 showed an overall postoperative morbidity and mortality rate of 31.5% (51 patients) and 21.6% (35 patients), respectively; in this group, patients with malignant disease presented a reduced mortality rate compared to patients with benign disease (9 (12.0%) vs. 26 (29.9%) patients, p < 0.01) (tables 4, 5). Statistically significant differences in the morbidity and mortality rates were also found when patients affected by benign disease were compared between groups 1 and 2 (9.8 and 7.8% in group 1 vs. 32.2 and 29.9% in group 2, p < 0.004 and p < 0.003, respectively). Results of the multivariate analysis of mortality and morbidity in group 2 are summarized in table 6. The factors affecting morbidity were white blood cell count at onset and the ischemic colon pattern. The factors affecting mortality were female sex, advanced age, presence of comorbidities, ASA score, and vascular colon disease.
Discussion
Table 1. Characteristics of patients
Group 1 Gender Male 104 (66.2) Female 53 (33.8) Age 71.9±9.3 Range 34–98 Onset symptoms Occlusive 86 (54.7) Bleeding 7 (4.5) Acute abdomen 64 (40.8) ASA score I 20 (12.7) II 36 (22.9) III 57 (36.3) IV 40 (25.5) V 4 (2.6) Associated disease 65 (41.4) Cardiovascular disease 64 (40.7) Respiratory disease 45 (28.6) Diabetes 34 (21.6) Chronic renal failure 15 (10.0) Obesity (BMI >30) 13 (8.2) Immunodeficiency 5 (3.0) Tumor 6 (3.8) Other 6 (3.8) Affected disease Benign 51 (32.5) Malignant 106 (67.5) Type of benign disease 27 (52.9) Diverticula 6 (11.8) Ischemic colitis 4 (7.8) IBD 3 (5.9) Perforation NOS 3 (5.9) Volvulus 8 (15.7) Others Type of treatment Open 157 (100.0) Laparoscopic 0 (0.0) TNM stage pT1 3 (2.8) pT2 35 (33.0) pT3 44 (41.5) pT4 20 (18.9) Not evaluable 4 (3.8) Hinchey classification I 2 (7.4) II 7 (25.9) III 7 (25.9) IV 11 (40.8)
Group 2
p
