Surgery after colonic stenting.

Colonic stenting is an accepted treatment of large bowel obstruction. The literature is sparse regarding surgical difficulties associated with an indwelling stent. We report our experience focusing on outcomes, complications, and whether the stent created intraoperative concerns. In this retrospective review, 6 patients were identified between 2007 and 2010 that had surgery after colonic stents were placed. Their charts were reviewed to compare clinical variables, surgical procedures, outcomes, and complications. One obstruction was due to diverticulitis. The stent reobstructed, leading to emergent transverse loop colostomy, and subsequent sigmoidectomy with stoma reversal. Four patients' obstructing masses were malignant. The final patient's stent was placed through a Hartmann's stump to drain a pelvic abscess. These 5 patients had no stent complications. Surgery occurred an average of 9.8 weeks after stent placement; four had low anterior resections and one underwent Hartmann's reversal. All 6 patients had colorectal anastomoses and five underwent laparoscopic surgery; one had an anastomotic leak requiring reoperation. Colonic stenting allows for the immediate relief of obstruction while permitting diagnosis and treatment of coexisting medical problems. The colon can be prepared for an elective rather than emergency operation, and a colostomy may be avoided.

Adverse outcomes associated with the use of drotrecogin alfa (activated) in patients with severe sepsis and baseline bleeding precautions.

BACKGROUND: Key clinical trials involving drotrecogin alfa (activated) (or recombinant human activated protein C) excluded patients with specific baseline bleeding precautions. However, not all such precautions are considered contraindications to treatment with recombinant human activated protein C in current product labeling. OBJECTIVE: To compare outcomes of patients receiving recombinant human activated protein C with or without baseline bleeding precautions as defined by the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial. DESIGN: Retrospective medical record review. SETTING: Two tertiary care institutions: An academic medical center and an affiliated Veterans Affairs Medical Center. PATIENTS: All patients receiving recombinant human activated protein C for treatment of sepsis. INTERVENTIONS: Demographic information, characteristics associated with inclusion and exclusion criteria of the PROWESS trial, and 30-day postdischarge outcomes. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients received recombinant human activated protein C. Serious bleeding events occurred in 7 of 20 patients (35%) with any baseline bleeding precaution vs. only 2 of 53 patients (3.8%) without any bleeding precautions (p < 0.0001). More patients with a baseline bleeding precaution died compared with patients without any bleeding precautions (65% vs. 24.5%, p = 0.0015). Patients with a baseline bleeding precaution had a higher mean Acute Physiology and Chronic Health Evaluation II score (27.5 vs. 22.7, p = 0.015). Multivariate analysis demonstrated that the presence of a baseline bleeding precaution was the only independent variable associated with occurrence of serious bleeding events. The presence of a baseline bleeding precaution, increased Acute Physiology and Chronic Health Evaluation II score, and the presence of bloodstream infection were independent variables associated with mortality. CONCLUSIONS: Patients with severe sepsis who received recombinant human activated protein C with baseline bleeding precautions as defined by product labeling had significantly higher rates of both serious bleeding events and deaths compared with those without bleeding precautions. These data suggest that strict adherence to PROWESS trial exclusion criteria would further limit serious bleeding events associated with the use of recombinant human activated protein C.