Colorectal resection in emergency general surgery: An EAST multicenter trial

Abstract

OBJECTIVE Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ2, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53–71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1–6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

Non-malignant left colon emergency surgery: evaluation of factors affecting clinical outcomes and complications

“…Similarly, a multicenter study of 439 patients found stoma creation, open abdomen management, and intraoperative blood transfusions linked to morbidity; additionally, preoperative vasopressor and steroid use, as well as intraoperative transfusions, were significant predictors of mortality. [11] Other research aligning with our results highlighted the significance of low serum albumin, elevated blood urea nitrogen levels, and hypotension requiring perioperative vasopressor support. [18,19] It should be noted, however, that these studies include a wider range of colorectal surgeries and patients with colonic malignancies, in contrast to the present study's focus on isolated left colon surgeries.…”

“…Aligning with literature, the leading non-malignant cause for surgery was diverticular disease, whose rising incidence in our population may be attributed to changes in dietary habits. [10,11] The Hartmann procedure emerged as the most frequently employed surgical technique. Key considerations in selecting the surgical approach include the patients' clinical and hemodynamic statuses, intraoperative findings, and the availability of an experienced colorectal surgeon.…”

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement

“…Given the paucity of studies relating to emergency laparotomy closure and bundles we felt abdominal domain closure, the "Surgeon's signature", is one of the keys to laparotomy. As surgeons, we understand that technical elements are important and Aicher's recent multicentre study throws light on outcomes following emergency colorectal surgery; there was a 27.3% surgical site infection rate and 5.3% fascial dehiscence in 469 patients operated on in 21 medical centres in the US between 2018 and 2019 [56].…”

Overuse of Proximal Fecal Diversion in Colorectal Surgery

“…Primary anastomoses performed during hemodynamic instability are more likely to leak, as evidenced by trauma and acute care surgery literature. 14 However, in the setting of hemodynamic instability, often the safest option for unstable patients is an end ostomy (as opposed to anastomosis and diversion) to decrease time under general anesthesia.…”