Hartmann's reversal as a safe procedure for selected patients: analysis of 199 patients at a high-volume center in Sao Paulo.

PURPOSE: We analyzed the morbidity and mortality associated with Hartmann's reversal (HR) and the risk factors for major complications and mortality. METHODS: The subjects of this retrospective study were patients who underwent HR in a high-volume center. We evaluated complications as categorical variables using univariate analyses. RESULTS: Between 2003 and 2018, 199 patients underwent HR at our hospital [56.5 years; body mass index (BMI): 26.3 kg/m2; American Society of Anesthesiology score (ASA) 3: 7.5%; 36.2% had hernias]. The mean time to HR was 20.2 months and the mean operation time was 302 min. The anastomosis was stapled in 71.4% and was performed in the low/medium rectum in 21.6%. Midline hernias were repaired with mesh in 80.1%. The mean hospitalization period was 10.1 days. Surgical site infection (SSI) developed in 27.1% of the patients, 94.4% of whom were treated at the bedside. BMI was a risk factor for SSI (27.8 vs. 25.6; p = 0.047). Major complications (Clavien-Dindo III-V) developed in 27 patients (13.5%), including anastomosis dehiscence in 2.5%. ASA, BMI, age, hernia repair, and rectal stump size were not associated with major complications. The mortality rate was 2.5%. An ASA of 3 was associated with high mortality (p = 0.03). CONCLUSION: Hartmann's reversal remains challenging but can have low complication and mortality rates if performed on selected patients in a reference center. An ASA of 3 was the only predictor of mortality.

Laparotomía abreviada y terapia de presión negativa para el cierre temporal del abdomen como tratamiento de la peritonitis diverticular Hinchey III/IV / Abbreviated laparotomy and negative pressure therapy for temporary closure of the abdomen as treatment of diverticular peritonitis Hinchey III/IV

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)

Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)

Resultados terapéuticos en pacientes con traumas de colon y recto tratados con sutura primaria o colostomía / Therapeutic Results in patients with Colon and Rectal Traumas Treated with Primary Suture or Colostomy

RESUMEN Introducción: El trauma de abdomen tiene alta incidencia y con frecuencia afecta el colon y el recto, se aboga por el tratamiento mediante sutura primaria. Objetivo: Identificar diferencias en las características clínico-quirúrgicas y resultados terapéuticos de pacientes con lesiones traumáticas de colon y recto, tratados con sutura primaria y técnicas derivativas. Método: Se realizó un estudio multicéntrico descriptivo ambispectivo para determinar características clínico-quirúrgicas y resultados terapéuticos en pacientes con lesiones traumáticas de colon y recto en los hospitales Carlos J. Finlay, Joaquín Albarrán, Calixto García y Enrique Cabrera de La Habana, en el periodo 2010-2015. El universo estuvo conformado por todos los pacientes intervenidos quirúrgicamente por trauma de colon y/o recto. Resultados: La colostomía fue el proceder más frecuente (53,1 por ciento). Los pacientes en edades medias de la vida (promedio: 43,5 años), sexo masculino (71,4 por ciento), evolución hasta el tratamiento quirúrgico menor de 12 horas (73,4 por ciento); causadas por empalamientos y otros (49 por ciento) y heridas con arma blanca (38,8 por ciento). La magnitud del daño de colon y recto fue baja, con mayor afectación de colon izquierdo. La frecuencia de complicaciones graves y mortalidad fue alta en la colostomía. Conclusiones: La sutura primaria muestra mejores resultados terapéuticos y debe ser la técnica de elección en las lesiones traumáticas de colon y recto intraperitoneal(AU)

ABSTRACT Introduction: Abdominal trauma presents high incidence and often affects the colon and rectum; primary suture is the preferred treatment. Objective: To identify differences between the clinical-surgical characteristics and the therapeutic outcomes in patients with traumatic lesions of the colon and rectum, treated with primary suture and derivative techniques. Method: A multicentric, descriptive and ambispective study was carried out to determine the clinical-surgical characteristics and the therapeutic outcomes in patients with traumatic colon and rectal lesions in Carlos J. Finlay, Joaquín Albarrán, Calixto García and Enrique Cabrera Hospitals in Havana, in the period from 2010 to 2015. The study population was made up of all patients surgically intervened for colon and/or rectal trauma. Results: The colostomy was the most frequent procedure (53.1 percent). Patients in middle ages of life (average: 43.5 years), male sex (71.4 percent), evolution to surgical treatment under 12 hours (73.4 percent); caused by impalement and others (49 percent) and cutting wounds (38.8 percent). The magnitude of colon and rectum damage was low, with greater involvement of the left colon. The frequency of serious complications and mortality was high in the colostomy. Conclusions: Primary suture shows better therapeutic results and should be the technique of choice in traumatic lesions of the intraperitoneal colon and rectum(AU)

The influence of diverting loop ileostomy vs. colostomy on postoperative morbidity in restorative anterior resection for rectal cancer: a systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate the morbidity of loop ileostomy (LI) and loop colostomy (LC) creation in restorative anterior resection for rectal cancer as well as the morbidity of their reversal. METHODS: PubMed, EMBASE, MEDLINE via Ovid, and Cochrane Library were systematically searched for records published from 1980 to 2017 by three independent researchers. The primary endpoint was overall morbidity after stoma creation and reversal. Mantel-Haenszel odds ratio (OR) was used to compare categorical variables. Clinical significance was evaluated using numbers needed to treat (NNT). RESULTS: Six studies (two randomized controlled trials and four observational studies) totaling 1063 patients (666 LI and 397 LC) were included in the meta-analysis. Overall morbidity rate after both stoma creation and closure was 15.6% in LI vs. 20.4% in LC [OR(95%CI) = 0.67 (0.29, 1.58); p = 0.36] [NNT(95%CI) = 21 (> 10.4 to benefit, > 2430.2 to harm)]. Morbidity rate after stoma creation was both statistically and clinically significantly lower after LI [18.2% vs. 30.6%; OR(95%CI) = 0.42 (0.25, 0.70); p = 0.001; NNT(95%CI) = 9 (4.7, 29.3)]. Dehydration rate was 3.1% (8/259) in LI vs. 0% (0/168) in LC. The difference was not statistically or clinically significant [OR(95%CI) = 3.00 (0.74, 12.22); p = 0.13; NNT (95%CI) = 33 (19.2, 101.9)]. Ileus rates after stoma closure were significantly higher in LI as compared to LC [5.2% vs. 1.7%; OR(95%CI) = 2.65 (1.13, 6.18); p = 0.02]. CONCLUSIONS: This meta-analysis found no difference between LI and LC in overall morbidity after stoma creation and closure. Morbidity rates following the creation of LI were significantly decreased at the cost of a risk for dehydration.

[Intestinal stomas. Are they as simple as they seem?] / Enterostomías, ¿son tan simples como parecen?

OBJECTIVES: To examine the morbidity and mortality of the formation and closure of enterostomies. METHODS: Retrospective study between 2000-2014 of patients younger than 14 years old who underwent an enterostomy. We evaluated: surgical technique, underlying pathology, general and stoma complications, sex, age and weight at the time of formation. At the closure we evaluated: surgical technique, age, weight, hemoglobin, hematocrit and albumin, as well as complications. RESULTS: We performed 120 enterostomies in 114 patients: 69 (57.5%) colostomies, 43 (35.8%) ileostomies and 8 (6.7%) yeyunostomy. The most frequent causes were: anorectal malformation (45/69), necrotizing enterocolitis (24/43) and intestinal atresia (4/8) respectively. 39 (32.5%) complications related to the stoma (colostomy 21, Ileostomy 15, Yeyunostomy 3; p= 0.845), 11 (9.2%) required surgery (colostomy 8, Ileostomy 2, Yeyunostomy 1; p= 0.439), and 17 (14.2%) general complications (colostomy 9, Ileostomy 7, Yeyunostomy 1; p= 0.884). We found a higher rate of complications requiring surgery in loop enterostomy 8/38 (21.1%), separated 3/54 (5.3%) or double-barrel 0/25 (p= 0.007). We closed 96 (80%), presenting complications in 14; yeyunostomy 4/6 (66.7%), colostomies 5/59 (8.5%), ileostomies 5/31 (16.1%) (p= 0.001). Hematocrit and hemoglobin below age average, and albumin under normal values are associated with complications when closing enterostomies (p< 0.05). Six patients (25%) who didn't went to closure died as a result of the underlying pathology and 5 (20.8%) of other causes. CONCLUSION: The formation and closing of enterostomies remains a procedure with a high rate of complications. However, there are no clear risk factors, excepting the use of loop enterostomy and lower albumin, hemoglobin or hematocrit at the time of closure.

OBJETTIVO: Examinar la morbimortalidad de la realización y cierre de las enterostomías. MATERIAL Y METODOS: Estudio retrospectivo entre 2000-2014, de pacientes menores de 14 años a los que se les realizó una enterostomía. Evaluamos: técnica quirúrgica, patología base, complicaciones del estoma y generales, sexo, edad y peso al momento de la cirugía. Al cierre evaluamos: técnica quirúrgica, edad, peso, hemoglobina, hematocrito y albúmin, así como complicaciones. RESULTADOS: En 114 pacientes, realizamos 120 enterostomías: colostomías 69 (57,5%), ileostomías 43 (35,8%) y yeyunostomías 8 (6,7%); las causas más frecuentes para cada una: malformación ano-rectal (45/69), enterocolitis necrotizante (24/43) y atresia intestinal (4/8) respectivamente. Complicaciones relacionadas al estoma 39 (32,5%) (colostomía 21, ileostomía 15, yeyunostomía 3; p= 0,845), requirieron cirugía 11 (9,2%) (colostomía 8, ileostomía 2, yeyunostomía 1; p= 0,439), y complicaciones generales 17 (14,2%) (colostomía 9, ileostomía 7, yeyunostomía 1; p= 0,884). Encontrando mayor índice de complicaciones que requirieron cirugía en la enterostomía en asa 8/38 (21,1%), separada 3/54 (5,3%) o cañón 0/25 (p= 0,007). Cerramos 96 (80%), presentando complicaciones 14; yeyunostomías 4/6 (66,7%), colostomías 5/59 (8,5%), ileostomías 5/31 (16,1%) (p= 0,001). Se asocian a complicaciones del cierre hemoglobina y hematocrito por debajo de la media para la edad, y albúmina bajo valores normales (p< 0,05). De los pacientes no anastomosados, 6 (25%) fallecieron por patología base y 5 (20,8%) por otra causa. CONCLUSION: La elaboración y cierre de enterostomías sigue siendo un procedimiento con alto índice de complicaciones. Sin embargo, no existen factores de riesgo claros, a excepción del uso de la enterostomía en asa y de albúmina, hemoglobina y hematocrito bajos al cierre.

The impact of surgeon volume on colostomy reversal outcomes after Hartmann's procedure for diverticulitis.

BACKGROUND: Colostomy reversal after Hartmann's procedure for diverticulitis is a morbid procedure, and studies investigating factors associated with outcomes are lacking. This study identifies patient, surgeon, and hospital-level factors associated with perioperative outcomes after stoma reversal. METHODS: The Statewide Planning and Research Cooperative System was queried for urgent/emergency Hartmann's procedures for diverticulitis between 2000-2012 in New York State and subsequent colostomy reversal within 1 year of the procedure. Surgeon and hospital volume were categorized into tertiles based on the annual number of colorectal resections performed each year. Bivariate and mixed-effects analyses were used to assess the association between patient, surgeon, and hospital-level factors and perioperative outcomes after colostomy reversal, including a laparoscopic approach; duration of stay; intensive care unit admission; complications; mortality; and 30-day, unscheduled readmission. RESULTS: Among 10,487 patients who underwent Hartmann's procedure and survived to discharge, 63% had the colostomy reversed within 1 year. After controlling for patient, surgeon, and hospital-level factors, high-volume surgeons (≥40 colorectal resections/yr) were independently associated with higher odds of a laparoscopic approach (unadjusted rates: 14% vs 7.6%; adjusted odds ratio = 1.84, 95% confidence interval = 1.12, 3.00), shorter duration of stay (median: 6 versus 7 days; adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.81, 0.95), and lower odds of 90-day mortality (unadjusted rates: 0.4% vs 1.0%; adjusted odds ratio = 0.30, 95% confidence interval = 0.10, 0.88) compared with low-volume surgeons (1-15 colorectal resections/yr). CONCLUSION: High-volume surgeons are associated with better perioperative outcomes and lower health care utilization after Hartmann's reversal for diverticulitis. These findings support referral to high-volume surgeons for colostomy reversal.

Short-term Outcomes After Open and Laparoscopic Colostomy Creation.

BACKGROUND: Colostomy creation is a common procedure performed in colon and rectal surgery. Outcomes by technique have not been well studied. OBJECTIVE: This study evaluated outcomes related to open versus laparoscopic colostomy creation. DESIGN: This was a retrospective review of patients undergoing colostomy creation using univariate and multivariate propensity score analyses. SETTINGS: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. PATIENTS: Data on patients were obtained from the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 Participant Use Data Files. MAIN OUTCOME MEASURES: We measured 30-day mortality, 30-day complications, and predictors of 30-day mortality. RESULTS: A total of 2179 subjects were in the open group and 1132 in the laparoscopic group. The open group had increased age (open, 64 years vs laparoscopic, 60 years), admission from facility (17.0% vs 14.9%), and disseminated cancer (26.1% vs 21.4%). All were statistically significant. The open group had a significantly higher percentage of emergency operations (24.9% vs 7.9%). Operative time was statistically different (81 vs 86 minutes). Thirty-day mortality was significantly higher in the open group (8.7% vs 3.5%), as was any 30-day complication (25.4% vs 17.0%). Propensity-matching analysis on elective patients only revealed that postoperative length of stay and rate of any wound complication were statistically higher in the open group. Multivariate analysis for mortality was performed on the full, elective, and propensity-matched cohorts; age >65 years and dependent functional status were associated with an increased risk of mortality in all of the models. LIMITATIONS: This study has the potential for selection bias and limited generalizability. CONCLUSIONS: Colostomy creation at American College of Surgeons National Surgical Quality Improvement Program hospitals is more commonly performed open rather than laparoscopically. Patient age >65 years and dependent functional status are associated with an increased risk of 30-day mortality.

Race and socioeconomic disparities in national stoma reversal rates.

BACKGROUND: Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. METHODS: Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. RESULTS: The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001). CONCLUSIONS: Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.

Manejo actual de las lesiones colorectales traumáticas / Current management of traumatic colo-rectal injuries

El tratamiento de las lesiones traumátcas del colon ha experimentado cambios importantes durante los últmos años, que nos han permitdo ofrecermejores opciones al manejo de éste tpo de trauma y por consiguiente un mejor “confort” para el paciente que, en el pasado, tenía que soportar losefectos indeseables de una cirugía derivatva como la colostomía, y luego someterse a una segunda intervención para su tratamiento defnitvo contodos los riesgos que esto conlleva. Aún existen controversias que están relacionadas con el tempo de evolución principalmente en cuanto al tratamientoprimario retrasado, presencia de shock, lesiones asociadas y grado de contaminación que podrían estar relacionadas con incremento en latasa de morbilidad y mortalidad. Hemos hecho una revisión crítca de la literatura relacionada con estos tópicos que nos ofrecen un mejor panoramade las mejores opciones de tratamiento utlizando una mejor evidencia y en consecuencia ofrecer recomendación adecuada debido a que aún existeincertdumbre acerca de su seguridad.

During recent years, colon injury treatment has experimented important changes that allow us to ofer beter optons for treatng this trauma andconsequently a beter “comfort” for the patents who, in the past, had to deal with the undesirable efects of a derivatve surgery like colostomy, andthen had a second interventon for their defnitve treatment with all the risks that it takes. There are stll controversies related with evoluton tme,mainly concerned the delayed primary treatment, shock presence, associated injuries and contaminaton grade, that could be related with increase ofmorbidity and mortality rates. A critcal literature review related with those topics has been done, that ofers a beter scene of the top treatment choicesusing beter evidence and consequently, ofers an appropriate recommendaton, because there is stll uncertainty about its safety.

Stoma-Const--the technical aspects of stoma construction: study protocol for a randomised controlled trial.

BACKGROUND: The construction of a colostomy is a common procedure, but the evidence for the different parts of the construction of the colostomy is lacking. Parastomal hernia is a common complication of colostomy formation. The aim of this study is to standardise the colostomy formation and to compare three types of colostomy formation (one including a mesh) regarding the development of parastomal hernia. METHODS/DESIGN: Stoma-Const is a Scandinavian randomised trial comparing three types of colostomy formation. The primary endpoint is parastomal herniation as shown by clinical examination or CT scan within one year. Secondary endpoints are re-admission rate, postoperative complications (classified according to Clavien-Dindo), stoma-related complications (registered in the case record form at stoma care nurse follow-up), total length of hospital stay during 12 months, health-related quality of life and health economic analysis as well as re-operation rate and mortality within 30 days and 12 months of primary surgery. Follow-up is scheduled at 4-6 weeks, and 6 and 12 months. Inclusion is set at 240 patients. DISCUSSION: Parastomal hernia is a common complication after colostomy formation. Several studies have been performed with the aim to reduce the rate of this complication. However, none are fully conclusive and data on quality of life and health economy are lacking. The aim of this study is to develop new standardised techniques for colostomy formation and evaluate this with patient reported outcomes as well as clinical and radiological assessment. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01694238.2012-09-24.

More patients should undergo surgery after sigmoid volvulus.

AIM: To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus. METHODS: We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery. RESULTS: Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality. CONCLUSION: Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible.

Emergency surgery for acute diverticulitis: which operation? A National Surgical Quality Improvement Program study.

BACKGROUND: The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann's procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. METHODS: This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. RESULTS: There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38-1.56; p = 0.465), 0.47 (95% CI, 0.06-3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19-13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. CONCLUSION: Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Model for End-stage Liver Disease (MELD) in predicting postoperative mortality of patients undergoing colorectal surgery.

The Model for End-stage Liver Disease (MELD) score was previously shown to predict perioperative mortality in patients with cirrhosis undergoing a variety of nontransplant surgical procedures. We sought to determine its usefulness in predicting postoperative mortality in patients undergoing colorectal procedures. National Surgical Quality Improvement Program data were gathered for adult patients undergoing elective and emergent colorectal procedures (Current Procedural Terminology codes 44005 through 45563 excluding appendectomy) during 2005 and 2006 at participating centers. The preoperative MELD score was calculated for all patients and assessed using logistic regression modeling. A total of 10,033 patients met study inclusion criteria. Overall 30-day mortality was 6.6 per cent. In all patients undergoing colorectal surgery, MELD was an independent predictor of mortality (2.95 [2.27 to 3.84]). Other independent predictors included age, functional status, American Society of Anesthesiologists classification, ascites, esophageal varices, disseminated cancer, chronic steroid use, cardiac disease, renal failure, malnutrition, sepsis, emergency, and ventilator dependence. The MELD score is an independent predictor of mortality in patients undergoing colorectal procedures. These data can be used to assign risk and assist in clinical decision-making.

Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis.

BACKGROUND: A laparoscopic approach has been proposed to reduce the high morbidity and mortality associated with the Hartmann procedure for the emergency treatment of diverticulitis. OBJECTIVE: The objective of our study was to determine whether a laparoscopic Hartmann procedure reduces early morbidity or mortality for patients undergoing an emergency operation for diverticulitis. DESIGN: This is a comparative effectiveness study. A subset of the entire American College of Surgeons National Surgical Quality Improvement Program patient sample matched on propensity for undergoing their procedure with the laparoscopic approach were used to compare postoperative outcomes between laparoscopic and open groups. SETTING: This study uses data from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2009. PATIENTS: All patients who underwent an emergency laparoscopic or open partial colectomy with end colostomy for colonic diverticulitis were reviewed. MAIN OUTCOME MEASURES: The main outcome measures were 30-day mortality and morbidity. RESULTS: Included in the analysis were 1186 patients undergoing emergency partial colectomy with end colostomy for diverticulitis. Among the entire cohort, the laparoscopic group had fewer overall complications (26% vs 41.7%, p = 0.008) and shorter mean length of hospitalization (8.9 vs 11.6 days, p = 0.0008). Operative times were not significantly different between groups. When controlling for potential confounders, a laparoscopic approach was not associated with a decrease in morbidity or mortality. In comparison with a propensity-match cohort, the laparoscopic approach did not reduce postoperative morbidity or mortality. LIMITATIONS: This study is limited by its retrospective nature and the absence of pertinent variables such as postoperative pain indices, time for return of bowel function, and rates of readmission. CONCLUSIONS: A laparoscopic approach to the Hartmann procedure for the emergency treatment of complicated diverticulitis does not significantly decrease postoperative morbidity or mortality in comparison with the open technique.

Retrospective analysis of protective stoma after low anterior resection for rectal cancer with total mesorectal excision: three-year follow-up results.

BACKGROUND/AIMS: Anastomotic leakage is a complication of low anterior resection (LAR) for rectal cancer with total mesorectal excision (TME). This study evaluated the need for a protective stoma by a three-year follow-up. METHODOLOGY: A retrospective study of 56 LAR patients was conducted. Thirty patients (53.6%) had a protective stoma. C-reactive protein (CRP), interleukin 6 (IL-6) and tumor necrosis factor (TNF) in peripheral blood on the first and third day after surgery were compared, in addition to short-term and later complications, long-term mortality and quality of life (QOL). RESULTS: There was significant difference between patients with and without a stoma in CRP, IL-6 on the third day after surgery (p<0.05). Anastomotic leakage occurred in two patients (6.7%) with a stoma and seven (26.9%) without (p=0.039). The incidence of leaks requiring re-operation was significantly lower with a stoma (p=0.012). After a mean follow-up of three years, there was no difference in long-term mortality, survival or scores on QOL questionnaires. CONCLUSIONS: A protective stoma can reduce the stress reaction, promote recovery of bowel function and reduce anastomotic leakage and re-operation rates in LAR for rectal cancer with TME. No significant difference was observed in long-term mortality or QOL.

Mortality following Hartmann's procedure--correlation of Dr. Foster's report with CR-POSSUM.

AIMS: Dr. Foster Intelligence highlighted a higher than expected mortality rate from emergency Hartmann's procedure at a district general hospital from April 2007 to March 2009 (6.5% expected, 30% actual mortality). A retrospective audit of all Hartmann's procedures over 4 years was performed. METHODS: Notes were examined for all emergency Hartmann's procedures between April 2006 and March 2010. CR-POSSUM scores were calculated for each patient. Results were analysed in SPSS (IBM Corp.). RESULTS: The mean CR-POSSUM score for the entire cohort was 27.78%, which compared to an observed mortality rate of 22.5% (18/80 cases, p=0.61). There was a significant correlation between mortality and CR-POSSUM score (p=0.001) and ASA grade (p=0.001). Those aged 81 and above had a significantly higher mortality (P≤0.05). There was no statistically significant correlation between grade of surgeon and mortality (p=0.42). Overall consultant presence in theatre was 72.5% (58/79 cases) and in those that died 82.4% (14/17 cases). Those patients who had an admission to diagnosis time of 10 days or more were at significantly greater risk of death (p<0.05). CONCLUSIONS: Dr. Foster's data does not sufficiently take into account the pre-operative state of each patient. The CR-POSSUM predicted mortality scores for the studied patient population and the actual mortality were similar. This suggests that the studied patient population were of a higher risk group than presumed by Dr. Foster's data. This study has highlighted that an older population and a delay in diagnosis following admission may have contributed to the increase in mortality in some cases.

Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis.

BACKGROUND: The use of a colonic stent as a bridge to surgery aims to provide patients with elective one-stage surgical resection while reducing stoma creation and postoperative complications. This study used meta-analytic techniques to compare the outcomes of stent use as a bridge to surgery and emergency surgery in the management of obstructive colorectal cancer. METHODS: A literature search of Medline, Embase, Cochrane controlled trials registry, and the Chinese Biomedical Literature Database was performed on all studies comparing stent as a bridge to surgery and emergency surgery for obstructive colorectal cancer. A meta-analysis of the included studies was carried out to identify the differences in outcomes between the two procedures. RESULTS: Eight studies matched the criteria for inclusion and reported on the outcomes of 601 patients, of whom 232 (38.6%) underwent stent insertion and 369 (61.4%) underwent emergency surgery. Fewer patients in the stent group needed intensive care (risk ratio [RR], 0.42; 95% confidence interval [CI], 0.19-0.93; p = 0.03) and stoma creation (RR, 0.70; 95% CI, 0.50-0.99; p = 0.04). The primary anastomosis rate in the stent group was higher (RR, 1.62; 95% CI, 1.21-2.16; p = 0.001). Overall complications (RR, 0.42; 95% CI, 0.24-0.71; p = 0.001), including anastomotic leakage (RR, 0.31; 95% CI, 0.14-0.69; p = 0.004), were reduced by stent insertion. Stent placement before elective surgery did not adversely affect mortality and long-term survival. CONCLUSIONS: The use of a stent as a bridge to surgery for obstructive left-sided colorectal cancer could increase the chance of primary anastomosis and reduce the need for stoma creation and postprocedural complications. Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.

How often do patients return to the operating room after colorectal resections?

AIM: We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors. METHOD: This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008. RESULTS: From a total cohort of 635, 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54, 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P < 0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality compared with those patients who did not return to the operating room. CONCLUSION: Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.

Who performs proctectomy for rectal cancer in the United States?

BACKGROUND: There is wide variation in surgical care for rectal cancer in the United States. OBJECTIVE: This study aimed to assess the differences in individual surgeon procedural profiles that might explain variations in the rates of restorative vs nonrestorative proctectomy for rectal cancer. DESIGN: This study was a retrospective examination of a cohort derived from trackable state hospital discharge data from 11 states. PATIENTS: We identified all patients with rectal cancer that underwent restorative proctectomy (sphincter-sparing surgery) vs nonrestorative proctectomy (colostomy formation) over a 24-month study period (January 1, 2003 through December 31, 2004). INTERVENTION: We developed an inpatient procedural profile of each treating surgeon's practice across general surgery procedure codes and summed the number of restorative vs nonrestorative proctectomies for rectal cancer by surgeon. MAIN OUTCOME MEASURES: The primary outcome measures were nonrestorative proctectomy, mortality, and length of stay. RESULTS: A total of 7519 proctectomies were performed for rectal cancer by 2588 surgeons. During the 24-month study period, 1003 (38.8%) surgeons performed only nonrestorative procedures for rectal cancer. On multivariate analysis, the likelihood that a surgeon performed only nonrestorative procedures was increased if that surgeon performed more integumentary procedures and decreased if the surgeon performed at least one ileoanal pouch procedure or more anorectal procedures. Patients who underwent proctectomy by surgeons who performed only nonrestorative procedures had significantly higher mortality (2.5 ± 0.7%) and longer length of stay (11.3 ± 8.8 days) in comparison with those patients treated by surgeons who performed both restorative and nonrestorative procedures (1.3 ± 0.3% mortality and 9.2 ± 6.9 days, P < .001 for both analyses). The volume of proctectomy performed significantly affected all analyses. LIMITATIONS: : The retrospective design introduces potential selection bias. CONCLUSIONS: Over a 24-month period, 38.8% of surgeons performed only nonrestorative procedures for rectal cancer. These surgeons did not regularly perform anorectal or ileoanal pouch procedures, suggesting that they may not have a focus on colorectal disease in their practice; they had significantly higher mortality and length of stay for their patients who underwent proctectomy for rectal cancer.

Management of anorectal malformation: Changing trend over two decades in Zaria, Nigeria.

BACKGROUND: Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. MATERIALS AND METHODS: A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. RESULTS: There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pull through (Stephen's operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05). CONCLUSION: There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.