The age-adjusted Charlson Comorbidity Index as an outcome predictor of patients with acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) is a catastrophic surgical condition, especially in older patients with multiple comorbidities. The aim of this study was to evaluate the impact of comorbidity on perioperative mortality and overall survival in patients surgically treated for AMI. A series of 186 consecutive patients (106 men and 80 women) who underwent surgery because of AMI in a university tertiary care center between 1990 and 2006 were retrospectively studied. The Charlson Comorbidity Index (CCI) score, unadjusted and adjusted by age, was preoperatively calculated in each patient. Perioperative mortality and overall survival were also recorded. The association between unadjusted and adjusted by age CCI and perioperative mortality and overall survival were analyzed. The mean age of the studied population was 72.1 years (SE +/-13.7 years). Hospital mortality was 64.5%. One-year, 3-year, and 5-year overall estimated survival by the Kaplan-Meier method after surgery for AMI was 26%, 23% and 21%, respectively. Perioperative mortality was not related to the unadjusted preoperative CCI (p = 0.093). Nevertheless, a statistically significant association was found between mortality and preoperative adjusted CCI (p = 0.007). Likewise, CCI unadjusted was almost related to overall survival (p = 0.055), but the values of the categorized CCI adjusted by age showed a statistically significant difference in overall survival (p = 0.012). In multivariate analysis, CCI adjusted by age remained independent prognostic factor of mortality. Comorbidity adjusted by age may play a role as a predictive factor for perioperative mortality and long-term survival in patients operated on for AMI.

[Predictive factors of massive intestinal necrosis in acute mesenteric ischemia]. / Factores predictivos de necrosis masiva intestinal en la isquemia mesentérica aguda.

INTRODUCTION: Suspicion of intestinal necrosis in patients with mesenteric ischemia is mandatory in surgery. Many patients develop massive necrosis after open surgery. However, in some frail, elderly patients, preoperative prediction of massive intestinal necrosis could avoid an unnecessary laparotomy. The aim of this study was to assess predictive factors of massive intestinal necrosis in acute mesenteric ischemia. PATIENTS AND METHOD: We retrospectively evaluated a consecutive sample of 155 patients, 88 men and 67 women, with a mean age of 71.9 years (SD +/- 13.6), who underwent surgery for acute mesenteric ischemia in our institution from 1990 to 2004. Age, sex, clinical features, laboratory findings, and delay to surgery were recorded and assessed as possible risk factors for massive intestinal necrosis. A logistic regression model was used to identify independent prognostic factors. RESULTS: Of the 155 patients, massive intestinal necrosis was recorded in 48 (31%; 95% CI: 23.4-38.6). A statistically significant association was found between massive intestinal necrosis and age (p = 0.04), previous digoxin use (p = 0.01), shock (p = 0.009), hemoconcentration (hemoglobin levels > 16 g/dL) (p = 0.02), hyperamylasemia (p < 0.001), acidosis (p = 0.012), and alkalosis (p = 0.048). Multiple stepwise logistic regression analysis identified three independent prognostic factors that were significantly associated with a higher risk of massive intestinal necrosis: shock (OR = 3.4; 95% CI: 1.1-10), hemoconcentration (OR = 6; 95% CI: 1.6-22.8), and hyperamylasemia (OR = 4.2; 95% CI: 1.5-12.2). CONCLUSIONS: Massive intestinal necrosis can be observed in at least 25% of patients undergoing surgery for acute mesenteric ischemia. Within the limitations of a retrospective study, the variables of shock, hemoconcentration and elevated serum amylase levels may be considered as independent predictive factors of fatal necrosis of the bowel.

Factores predictivos de necrosis masiva intestinal en la isquemia mesentérica aguda / Predictive factors of massive intestinal necrosis in acute mesenteric ischemia

Introducción. La sospecha de necrosis intestinal en un paciente con isquemia mesentérica es indicación absoluta de cirugía. Una vez realizada la laparotomía, muchos pacientes presentan necrosis masiva. En un determinado tipo de pacientes, muy ancianos y debilitados, su reconocimiento preoperatorio podría evitar la laparotomía. Presentamos un estudio que analiza los factores preoperatorios relacionados con necrosis masiva. Pacientes y método. Se estudió retrospectivamente a 155 pacientes, 88 varones y 67 mujeres, con una media de edad de 71,9 ± 13,6 (intervalo de confianza [IC] del 95%, 69,7-74) años, intervenidos quirúrgicamente por isquemia mesentérica entre 1990 y 2004 en nuestra institución. Se recogieron las variables demográficas, antecedentes personales, síntomas clínicos, tiempo de espera y hallazgos de laboratorio y se analizó si se relacionaban o no con necrosis masiva intestinal. Para identificar los factores pronósticos independientes se utilizó un modelo de regresión logística. Resultados. De los 155 pacientes, 48 (31%) presentaron necrosis masiva (IC del 95%, 23,4-38,6). Se relacionaron con la necrosis masiva las variables edad (p = 0,04), ingesta previa de digoxina (p = 0,01), shock (p = 0,009), hemoconcentración (Hb > 16 g%; p = 0,02), hiperamilasemia (p 16 g/dl (OR = 6; IC del 95%, 1,6-22,8) e hiperamilasemia (OR = 4,2; IC del 95%, 1,5-12,2). Conclusiones. Entre los pacientes intervenidos por isquemia mesentérica, como mínimo un 25% presenta necrosis masiva. Con las limitaciones propias de un estudio retrospectivo, se puede concluir que la tríada shock, hemoconcentración e hiperamilasemia constituye un buen predictor de necrosis masiva (AU)

Introduction. Suspicion of intestinal necrosis in patients with mesenteric ischemia is mandatory in surgery. Many patients develop massive necrosis after open surgery. However, in some frail, elderly patients, preoperative prediction of massive intestinal necrosis could avoid an unnecessary laparotomy. The aim of this study was to assess predictive factors of massive intestinal necrosis in acute mesenteric ischemia. Patients and method. We retrospectively evaluated a consecutive sample of 155 patients, 88 men and 67 women, with a mean age of 71.9 years (SD ± 13.6), who underwent surgery for acute mesenteric ischemia in our institution from 1990 to 2004. Age, sex, clinical features, laboratory findings, and delay to surgery were recorded and assessed as possible risk factors for massive intestinal necrosis. A logistic regression model was used to identify independent prognostic factors. Results. Of the 155 patients, massive intestinal necrosis was recorded in 48 (31%; 95% CI: 23.4-38.6). A statistically significant association was found between massive intestinal necrosis and age (p = 0.04), previous digoxin use (p = 0.01), shock (p = 0.009), hemoconcentration (hemoglobin levels > 16 g/dL) (p = 0.02), hyperamylasemia (p < 0.001), acidosis (p = 0.012), and alkalosis (p = 0.048). Multiple stepwise logistic regression analysis identified three independent prognostic factors that were significantly associated with a higher risk of massive intestinal necrosis: shock (OR = 3.4; 95% CI: 1.1-10), hemoconcentration (OR = 6; 95% CI: 1.6-22.8), and hyperamylasemia (OR = 4.2; 95% CI: 1.5-12.2). Conclusions. Massive intestinal necrosis can be observed in at least 25% of patients undergoing surgery for acute mesenteric ischemia. Within the limitations of a retrospective study, the variables of shock, hemoconcentration and elevated serum amylase levels may be considered as independent predictive factors of fatal necrosis of the bowel (AU)

Analysis of the factors related to the decision of restoring intestinal continuity after Hartmann's procedure.

BACKGROUND AND AIMS: Hartmann's operation is widely used for the surgical treatment of complicated left colonic disease. However, many patients never undergo reanastomosis. This study analyzes the factors related to the decision of restoring intestinal continuity. MATERIALS AND METHODS: Between 1997 and 2004, 162 patients underwent Hartmann's operation in our institution. Age, sex, anesthetic risk evaluation (ASA score), underlying disorder (neoplastic vs non-neoplastic), prevalence of colonic reconstruction, as well as postoperative length of hospital stay, perioperative mortality and complications due to the latter procedure were analyzed. Long-term survival was also recorded. RESULTS: Patients' mean age was 68.7 years (SD +/- 14.9); 104 were men (64.2%) and 58 were women (35.8%). Hartmann's operation mortality was 20.4%. Forty-two colonic continuity restorations were performed (25.9%). Mean time until reconstruction procedure was 13.3 months. There were no deaths (mortality 0%), but 23 cases suffered complications (54.8%). No suture dehiscence was observed. Estimated probability of being alive 1, 3, and 5 years after the initial operation was 64.1, 50.4, and 44.3%, respectively. Significant univariate predictors of reversal were male sex (p = 0.003), non-neoplastic disorder (p = 0.004), younger age (p = 0.001) and lower anesthetic risk (p = 0.009). In the multivariate analysis, independent predictive factors were age (OR: 0.94; 95% CI: 0.91-0.98), non-neoplastic disorder (OR: 0.16; 95% CI: 0.05-0.45), and lower anesthetic risk (OR: 0.22; 95% CI: 0.08-0.58). CONCLUSIONS: Hartmann's procedure implies a high mortality and a low percentage of restoration of intestinal continuity. In selected patients, closure of Hartmann's colostomy is a safe procedure, but has a significant morbidity.

Identification of risk factors for perioperative mortality in acute mesenteric ischemia.

INTRODUCTION: Acute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI). METHODS: A total of 132 consecutive patients (73 men, 59 women), mean+/-SD age 71.96+/-13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality. RESULTS: Of 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P=0.01), cardiopathy (P=0.002), digoxin intake (P=0.015), shock (P=0.01), urea plasma level (P<0.001), creatinine (P<0.001), potassium (P=0.042), low pH (P=0.015) and bicarbonate (P=0.035); hemoglobin>or=2.48 mmol/L (P=0.035); time delay to surgery (P=0.023); colonic involvement (P<0.001); small and large bowel involvement (P<0.001); arterial versus venous ischemia (P=0.007); and intestinal resection (P<0.001). In the multivariate analysis, the variables previous cardiac illness (P=0.045), urea plasma levels (P<0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P<0.001) was a favorable predictor. CONCLUSIONS: Age, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.

Cirugía de la isquemia mesentérica aguda en pacientes octogenarios / Surgery for acute mesenteric ischemia in octogenarians

Introducción: la isquemia mesentérica conlleva una alta mortalidad, especialmente en los pacientes ancianos. En este estudio se compara los resultados de la cirugía de la isquemia mesentérica en octogenarios con los de los no octogenarios. Material y métodos: se estudió a 132 pacientes intervenidos consecutivamente por isquemia mesentérica entre 1988 y 2002 en un servicio de cirugía general. Se establecieron 2 grupos en función de la edad: 80 o más años y menores de 80 años. Se analizó en cada grupo el sexo, la presentación del cuadro en forma de shock y la etiología de la isquemia, así como diferencias entre ambos grupos en cuanto a mortalidad inmediata por isquemia masiva, mortalidad operatoria, estancia y supervivencia a largo plazo, mediante un seguimiento predefinido. Resultados: la población octogenaria fue de 35 pacientes, 17 varones y 18 mujeres (edad media ± desviación estándar, 85,4 ± 4,3 años). Los menores de 80 años fueron 97, 56 varones y 41 mujeres (edad media, 67,1 ± 12,6 años). Ambos grupos fueron similares en cuanto al sexo, cuadro de shock al inicio y etiología de la isquemia. No se encontraron diferencias estadísticamente significativas en cuanto a mortalidad inmediata por isquemia masiva (el 40,0% octogenarios, el 26,8% no octogenarios), así como en mortalidad operatoria (el 74,3% octogenarios, el 61,9% no octogenarios). Tampoco se encontraron diferencias estadísticamente significativas en cuanto a supervivencia global, supervivencia a largo plazo tras ser dado de alta el paciente y estancia mediana. Conclusiones: se ha de considerar la cirugía de la isquemia mesentérica en el paciente mayor de 80 años una opción terapéutica válida en pacientes seleccionados

Introduction and objective: acute mesenteric ischemia carries high mortality, especially in old patients. The present study compared the results of surgery in octogenarian patients with those in non-octogenarian patients. Material and methods: one-hundred and thirty-two consecutive patients who underwent surgery for acute mesenteric ischemia between 1988 and 2002 in our general surgery department were studied. Patients were divided into two groups based on age: those aged 80 years old or older and those aged less than 80 years old. Gender, shock as the initial clinical presentation and the etiology of the ischemia were evaluated. Early mortality due to massive intestinal ischemia, operative mortality, length of hospital stay, and overall and long-term survival were recorded and analysed in both groups through a follow-up analysis. Results: the octogenarian group comprised 35 patients (17 men and 18 women) with a mean age of 85.4 ± 4.3 years). The non-octogenarian group included 97 patients (56 men and 41 women), with a mean age of 67.1 ± 12.6 years. Both groups were similar in sex, initial clinical presentation as shock, and ischemic etiology. There were no statistically significant differences between octogenarian and non-octogenarian patients with regard to immediate mortality due to massive ischemia (40.0% in the octogenarian group versus 26.8% in the non-octogenarian group), or in operative mortality (74.3% versus 61.9%, respectively). Likewise, overall survival, long-term survival, and median length of hospital stay showed no statistically significant differences between the two groups. Conclusions: surgical treatment for acute mesenteric ischemia should be considered a valid therapeutic option in octogenarian patients

Consentimiento informado en cirugía de urgencias. Un reto / Informed consent in emergency surgery: a challenge

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