Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

Abstract

Background Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization. Methods A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically. Results Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)). Conclusion Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

Swiss consensus on the management of acute diverticulitis

“…Damage-control surgery (DCS) is an option in unstable patients. A retrospective study of 203 consecutive patients treated with DCS by applying a decision algorithm for severe intra-abdominal sepsis confirmed that it was feasible and 65% of patients were stoma free at hospital discharge 16 . However, none of the guidelines recommends DCS over a Hartmann procedure 4 , 5 .…”

Cancer colique en occlusion : quelle prise en charge en 2022 ?

“…En traitant l'urgence occlusive, on peut alors optimiser d'éventuelles comorbidités décompensées (reconditionnement), permettre au côlon dilaté de se recalibrer, compléter le bilan d'extension, puis enfin réaliser une colectomie oncologique à froid. 10 Deux options sont mises en balance : 1) la CDD préférentiellement de localisation transverse droite, facilitant la résection-anastomose du 2 e temps ; 2) la prothèse colique endoscopique ou stent.…”