Ricardo Frago

Large Bowel Obstruction: Predictive Factors for Postoperative Mortality

PURPOSEThe aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction.METHODSTwo-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann’s procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit ≤30 percent, hemoglobin ≤10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality.RESULTSOne or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III–IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression.CONCLUSIONLarge bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.

Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis?

PurposeHartmann’s procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience.MethodsFrom January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP.ResultsA total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation.ConclusionsRPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Impact of Surgical Specialization on Emergency Colorectal Surgery Outcomes

OBJECTIVE To evaluate the impact of surgeon specialization on emergency colorectal resection in terms of mortality, morbidity, and type of operation performed. DESIGN Observational study from January 1, 1993, through December 31, 2006. SETTING Bellvitge University Hospital, Barcelona, Spain. PATIENTS A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS). MAIN OUTCOME MEASURES Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables. RESULTS Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence. CONCLUSIONS Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Recurrence and virulence of colonic diverticulitis in immunocompromised patients

BACKGROUND To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. METHODS Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. RESULTS Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). CONCLUSIONS After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

Resultados y factores pronósticos de mortalidad en la intervención de Hartmann

INTRODUCTION The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. PATIENTS AND METHODS From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. RESULTS The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively). CONCLUSION The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.Resumen Introduccion La introduccion, hace ya muchos anos, de la cirugia colica urgente en un tiempo ha relegado la intervencion de Hartmann para los pacientes mas graves. Este hecho ha conducido a que las tasas de morbimortalidad asociadas a la tecnica de Hartmann sean elevadas. El objetivo de nuestro estudio fue analizar los resultados obtenidos con la intervencion de Hartmann en el periodo de estudio y analizar los factores pronosticos de mortalidad postoperatoria en este grupo de pacientes. Pacientes y metodos Durante el periodo comprendido entre enero de 1995 y diciembre de 2000 se intervino quirurgicamente a 79 pacientes (34 varones y 45 mujeres), con una edad media de 71,5 anos, a los que se les realizo una intervencion de Hartmann. Casi la totalidad de los pacientes (91,1%) tenia una o mas enfermedades asociadas. En este grupo de pacientes se analizaron retrospectivamente los resultados de morbimortalidad y, mediante un estudio de regresion logistica multivariable, los factores pronosticos de mortalidad postoperatoria. Resultados En toda la serie, la indicacion de cirugia fue: peritonitis aguda (77,2%), oclusion intestinal (18,9%) y hemorragia digestiva baja (3,7%). La causa etiologica mas frecuente fue la diverticulitis aguda complicada (36 casos) y el cancer colorrectal complicado (18 casos). El 70,9% de los pacientes (56 casos) presento 1 o mas complicaciones durante el postoperatorio; 15 casos fueron reintervenidos (18,9%), y la mortalidad postoperatoria fue del 45,5%. La insuficiencia renal (creatinina ≥ 120 μmol/l) y el riesgo quirurgico ASA avanzado (III o IV) alcanzaronsignificacion estadistica como factores predictivos de mortalidad en estos pacientes (p = 0,001 y 0,005, respectivamente). Conclusion Los pacientes a los que se les practico una intervencion de Hartmann y que tenian un mayor riesgo quirurgico anestesico (ASA) y/o una alteracion de la funcion renal tuvieron un riesgo de mortalidad significativamente mas elevado.

Complicaciones del tratamiento de la oclusion del colon distal con protesis endoluminales

INTRODUCTION The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion. The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications. MATERIAL AND METHODS A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010. RESULTS A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes. The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy. The overall mortality was 17.2%. CONCLUSIONS Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.

Valor de la resección tumoral en el cáncer colorrectal con metástasis irresecables

In spite of the lack of scientific evidence, the resection of primary tumors in asymptomatic patients with colorectal cancer (CRC) with unresectable synchronous metastases was a common practice in many centers until the mid-1990s. This method was able to control any possible complications derived from the primary tumor, which occurred in about 20% of patients. Nonetheless, after the implementation of new chemotherapy drugs and the improvement in overall survival of patients with stage IV CRC, current publications, as well as the American Society of Clinical Oncology (ASCO), advocate chemotherapy as initial treatment for these patients, reserving surgery for patients with symptoms derived from the primary tumor or with risk of intestinal obstruction. This change in treatment strategy is based on the fact that chemotherapy has beneficial effects not only on metastatic disease but also on the primary tumor. In this way, the number of complications related with the primary tumor has been seen to decrease to about 7%. The effect of chemotherapy on survival becomes apparent when we compare the periods of treatment when only fluoropyrimidines were used with current treatment regimes, after the implementation of modern chemotherapy drugs (oxaliplatin or irinotecan) and biological agents (bevacizumab, cetuximab). Some recent studies conclude that the resection of the primary tumor before administering systemic chemotherapy in patients with CRC, unresectable metastases and good performance status improves the prognosis in these patients. At the same time, other groups argue that the benefits of initial primary tumor resection on survival have not been demonstrated; in addition, the morbidity and mortality of surgery should be avoided, especially since this could delay the start of chemotherapy and its potential benefits on survival. Different studies observe a longer mean survival in patients with resection of the primary tumor compared to those who are not resected. These are retrospective, non-randomized studies, which could mean that the patients who were treated surgically presented a better performance status or had a lower tumor load. Greater toxicity to chemotherapy has also been observed in patients without resection when compared to a group of patients with resection of the primary tumor. Recently, the Dutch Colorectal Cancer Group published a study that evaluated the prognostic value of primary tumor resection depending on the first line of treatment received according to the CAIRO and CAIRO2 studies. The results showed a mean survival of 13 months in the non-resection group versus 22–24 months in the resection group. Despite the difference observed, the patients were not randomized before the tumor resection, which could mean that the characteristics of the patients were not homogeneous. Our group has observed that the 2-year survival in patients with intestinal obstruction due to unresectable stage IV colorectal cancer who had tumor resection is greater than in the patients without tumor resection (39.3% versus 1%, respectively). Other workgroups have tried to resolve this dilemma by formulating different questions. Such is the case of The National Surgical Adjuvant Breast and Bowel Project C-10 (NASBP C-10) group, which specifically asked if the addition of bevacizumab to FOLFOX increases the number of complications in patients with stage IV CRC without resection of the primary tumor. The results showed that only 14% of patients presented major complications (obstruction, perforation, or hemorrhage), so the authors concluded that the incidence of severe complications was acceptable when the primary lesion was not resected. In addition, they emphasized that the c i r e s p . 2 0 1 3 ; 9 1 ( 6 ) : 3 4 9 – 3 5 1