Prognostic value of neutrophil-to-lymphocyte ratio at diagnosis in colorectal cancer: propensity score analysis.

INTRODUCTION: Baseline neutrophil-to-lymphocyte ratio (NLR) at the time of colorectal cancer (CRC) diagnosis has been proposed as a predictor of long-term survival. The aim of the study was to analyse its usefulness in a homogeneous population with control of the main confounding factors. METHODOLOGY: Observational study of 836 patients operated on for CRC who were divided into two groups: NLR ≤ 3.3 vs NLR > 3.3. To control for confounders, they were matched one-to-one by propensity analysis. A final sample of 526 patients remained for study. RESULTS: The two groups were mismatched in terms of age, comorbidity, tumour stage, rectal location, and neoadjuvant therapy. Once matching was performed, baseline NLR was statistically significantly associated with long-term survival (p < 0.001) and behaved as an independent prognostic factor for survival (p = 0.001; HR: 1,996; 95% CI: 1.32-3.00) when adjusted in a Cox regression model using age (p < 0,001; HR: 1,04; IC95%: 1,02-1,06) and the Charlson Comorbidity Index (p < 0,001; HR: 1,40; IC95%: 1,27-1,55). Neoadjuvant therapy lost its statistical significance (p = 0,137; HR: 1,59; IC95%: 0,86-2,93). CONCLUSIONS: A high baseline NLR (> 3.3) in patients with colorectal cancer at diagnosis represents a poor prognostic factor in terms of survival. Its use in routine practice could intensify therapeutic strategies and follow-up in these patients.

Utility of a new prognostic score based on the Comprehensive Complication Index (CCI®) in patients operated on for colorectal cancer (S-CRC-PC score).

BACKGROUND: Postoperative complications after colorectal cancer surgery have been associated with poor long-term prognosis. The aim of the present study was to investigate the prognostic impact of postoperative complications after colorectal cancer surgery assessed by the Comprehensive Complication Index (CCI®) and designing a new prognostic score based on this index. METHODS: This observational longitudinal study included a series of 604 patients who underwent colorectal surgery for cancer. Demographic data, comorbidity measured by Charlson Index, tumor characteristics, surgical data and postoperative complications were recorded as predictors. Univariate and multivariate analysis were performed and long-term survival was the output variable. Based on Hazard Ratios obtained on multivariate analysis, a new score, S-CRC-PC, was created for predicting long-term survival. RESULTS: Two-hundred and twelve (35.1%) patients developed some postoperative complication. The mean CCI was 11.6 (±19.19). Mild complications (CCI <26.2) were detected in 95 (15.7%) patients. Moderate complications (CCI 26.2-42.2) were detected in 64 (10.6%) patients. Severe complications (CCI >42.3) were detected in 53 patients (8.8%) patients. Mortality rate was 1.7%. In multivariate analysis, age (p < 0.001), Charlson score (p = 0.014), CCI (p < 0.001), and TNM stage (p < 0.001) were statistically significantly in relation to long-term survival rate. S-CRC-PC score was statistically associated with survival rate (HR: 1.34-95% CI: 1.27-1.41). Patients with S-CRC-PC values from 0 to 8 points (low risk), 8.1-16 points (medium risk), and scores above 16 points (high risk) had a cumulative survival rate at five-years of 98%, 83%, and 31% respectively. CONCLUSIONS: Postoperative complications after colorectal cancer surgery assessed by CCI are an independent prognostic factor of survival rate. The S-CRC-PC score may be helpful in predicting long-term cancer outcomes.

Diagnostic accuracy of C-reactive protein, procalcitonin and neutrophils for the early detection of anastomotic leakage after colorectal resection: a multicentric, prospective study.

AIM: The aim was to determine the accuracy of C-reactive protein (CRP), procalcitonin and neutrophils in the early detection (fourth postoperative day) of anastomotic leakage (AL) after colorectal surgery. METHODS: We conducted a multicentre, prospective study that included a consecutive series of patients who underwent colorectal resection with anastomosis without ostomy (September 2015 to December 2017). CRP, procalcitonin and neutrophil values on the fourth postoperative day after colorectal resection along with the postoperative outcome (60-day AL, morbidity and mortality) were prospectively included in an online, anonymous database. RESULTS: The analysis ultimately included 2501 cases. The overall morbidity and mortality was 30.1% and 1.6%, respectively, and the AL rate was 8.6%. The area under the receiver operating characteristic curve values (95% CI) for detecting AL were 0.84 (0.81-0.87), 0.75 (0.72-0.79) and 0.70 (0.66-0.74) for CRP, procalcitonin and neutrophils, respectively. The best cut-off level for CRP was 119 mg/l, resulting in 70% sensitivity, 81% specificity and 97% negative predictive value. After laparoscopic resection, the accuracy for CRP and procalcitonin was increased, compared with open resection. The combination of two or three of these biomarkers did not significantly increase their accuracy. CONCLUSION: On the fourth postoperative day, CRP was the most reliable marker for excluding AL. Its high negative predictive value, especially after laparoscopic resection, allows for safe hospital discharge on the fourth postoperative day. The routine use of procalcitonin or neutrophil counts does not seem to increase the diagnostic accuracy.

Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer.

BACKGROUND: Frailty has been shown to be a good predictor of post-operative complications and death in patients undergoing gastrointestinal surgery. The aim of this study was to analyze the differences between frail and non-frail patients undergoing colorectal cancer surgery, as well as the impact of frailty on long-term survival in these patients. METHODS: A cohort of 149 patients aged 70 years and older who underwent elective surgery for colorectal cancer was followed-up for at least 5 years. The sample was divided into two groups: frail and non-frail patients. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) was used to detect frailty. The two groups were compared with regard to demographic data, comorbidities, functional and cognitive statuses, surgical risk, surgical variables, tumor extent, and post-operative outcomes, which were mortality at 30 days, 90 days, and 1 year after the procedure. Univariate and multivariate analyses were also performed to determine which of the predictive variables were related to 5-year survival. RESULTS: Out of the 149 patients, 96 (64.4%) were men and 53 (35.6%) were women, with a median age of 75 years (IQR 72-80). According to the CSHA-CFS scale, 59 (39.6%) patients were frail, and 90 (60.4%) patients were not frail. Frail patients were significantly older and had more impaired cognitive status, worse functional status, more comorbidities, more operative mortality, and more serious complications than non-frail patients. Comorbidities, as measured by the Charlson Comorbidity Index (p = 0.001); the Lawton-Brody Index (p = 0.011); failure to perform an anastomosis (p = 0.024); nodal involvement (p = 0.005); distant metastases (p < 0.001); high TNM stage (p = 0.004); and anastomosis dehiscence (p = 0.013) were significant univariate predictors of a poor prognosis on univariate analysis. Multivariate analysis of long-term survival, with adjustment for age, frailty, comorbidities and TNM stage, showed that comorbidities (p = 0.002; HR 1.30; 95% CI 1.10-1.54) and TNM stage (p = 0.014; HR 2.06; 95% CI 1.16-3.67) were the only independent risk factors for survival at 5 years. CONCLUSIONS: Frailty is associated with poor short-term post-operative outcomes, but it does not seem to affect long-term survival in older patients with colorectal cancer. Instead, comorbidities and tumor stage are good predictors of long-term survival.

Colorectal cancer surgery in selected nonagenarians is relatively safe and it is associated with a good long-term survival: an observational study.

BACKGROUND: Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer. METHODS: Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival. RESULTS: Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0-42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3-7.2). CONCLUSIONS: Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.

Usefulness of pre- and intraoperative risk scores in nonagenarian surgical patients.

PURPOSE: Preoperative assessment at extreme ages would identify patients at a high risk of developing postoperative complications. The objective of this study was to compare the usefulness of different risk scales in a series of nonagenarian surgical patients. METHODS: A total of 244 surgical nonagenarians, 148 women (60.7%), median age 91 years (IQR: 90-93), were analysed. The following scales were evaluated: preoperative status (ASA-PS, Charlson Comorbidity Index, Lee Index, Reiss Index, and surgical mortality probability model-S-MPM); intraoperative status (Surgical Apgar Score and SASA score), and, as output variables, surgical outcomes (morbidity measured by the Comprehensive Complication Index-CCI, and death). Univariate analysis and receiver operating characteristic curves (ROC) were performed. Area under ROC curves (AUROC) were evaluated to define the best predictors of poor outcomes. RESULTS: Operative mortality was 27.0%, and 73.4% presented some type of postoperative complication. Operative mortality was associated with the ASA-PS score (p < 0.001), Reiss Index (p < 0.001), Lee Index (p = 0.010), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001), SASA score (p < 0.001), and emergency surgery (p < 0.001). Postoperative complications were related to the ASA-PS score (p = 0.001), Reiss Index (p < 0.001), Lee Index (p < 0.001), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001) and SASA score (p < 0.001). The best predictors of operative mortality and complications were the SASA and Surgical Apgar Score (AUROCs > 0.88). CONCLUSION: As in the general population, the Surgical Apgar Score and SASA score are the best predictors of operative mortality and morbidity in nonagenarian patients. These risk scales should be considered in the perioperative management of these patients.

The Comprehensive Complication Index is Related to Frailty in Elderly Surgical Patients.

BACKGROUND: Frailty has been proposed as an independent risk factor for predicting postsurgical outcomes in elderly surgical patients. The Comprehensive Complication Index (CCI) seems to be the most widely used grading of individual complications in many surgical fields. The objective of this study was to evaluate the association of frailty, measured by Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS), with the CCI in the elderly surgical patient. MATERIAL AND METHODS: A prospective cross-sectional study was carried out in 256 patients aged ≥70 y who underwent major gastrointestinal surgery. Sociodemographic characteristics, baseline disease, CSHA-CFS, and medical/surgical complication using the Comprehensive Comorbidity Index were evaluated. We hypothesized that frailty measured by CSHA-CFS and the CCI are associated. RESULTS: Of 256 patients, 154 (60%) were men and 102 (40%) were women, with mean age of 76.1 y (SD ± 5.1). One-hundred and eighty-five patients (74%) underwent surgery for a malignant cause, and 97 patients (38%) had some degree of frailty. Mean CCI was 16.1 (SD ± 23.0). Postoperative mortality was 3%. Pondering the scale CCI 0-100, frailty correlated well with postoperative complications (P = 0.035). For patients who developed at least 1 complication, for each unit that the CSHA-CFS was raised, the CCI increased by 5.2 points (P = 0.002). The multivariate analysis showed that the CSHA-CFS was the only independent prognostic factor associated with postoperative CCI in this series. CONCLUSIONS: Frailty determined by CSHA-CFS is closely associated with the CCI, being a good predictor of postoperative complications in the elderly patient operated on by a major gastrointestinal procedure.

Emergency surgery and American Society of Anesthesiologists physical status score are the most influential risk factors of death in nonagenarian surgical patients.

AIM: The number of nonagenarians undergoing surgery has increased considerably in recent decades as a result of population aging. Greater knowledge of the most influential factors affecting perioperative morbidity and mortality would improve the quality of care and provision of health resources for these patients. The objective of the present study was to analyze the perioperative mortality, and its most determinant factors, among nonagenarian patients who underwent a surgical procedure in the Department of General and Digestive Surgery. METHODS: A retrospective descriptive study was carried out in a cohort of 159 consecutive non-selected surgical nonagenarian patients. Clinical data, type of operation, perioperative hemodynamic instability, the need for blood transfusion and medical/surgical complications were evaluated as predictor variables. The outcome variable was operative mortality. RESULTS: The mean age was 91.8 years (SD ± 2.0); there were 60 men (37.7%) and 99 (62.3%) women. Perioperative mortality was 28.93% (46 patients). The variables age (P = 0.025), American Society of Anesthesiologists physical status score (P < 0.001), neoplastic pathology (P = 0.025), intestinal surgery (P = 0.001), emergent surgery (P ≤ 0.001), perioperative blood transfusion (P = 0.003), postoperative medical complications (P < 0.001) and surgical complications (P = 0.022) showed a statistically significant correlation with mortality. American Society of Anesthesiologists physical status score (P = 0.007), emergent surgery (P < 0.032) and perioperative blood transfusion (P = 0.047) were identified as independent predictors of mortality. CONCLUSIONS: Surgery should not be denied to nonagenarian patients based only on their age. Emergency surgery and American Society of Anesthesiologists physical status classification are the most significant factors when deciding whether to intervene. Geriatr Gerontol Int 2019; 19: 293-298.

Five-year survival after surgery in nonagenarian patients.

AIM: In countries with longer life expectancies, the nonagenarian population is increasing. Therefore, there is greater demand for healthcare, including surgical procedures. The aim of the present study was to determine the outcomes of surgery carried out on nonagenarians in terms of long-term survival after the procedure. METHODS: We carried out a cross-longitudinal study on a cohort of 159 nonagenarian patients, who underwent a non-cardiac, non-traumatic surgical procedure in our institution between January 1999 and December 2011. The following variables were recorded: sociodemographic characteristics, American Society of Anesthesiologists score, Charlson Comorbidity Index, surgical site, postoperative complications, operative mortality and long-term survival. The output variable was long-term survival. RESULTS: Of the 159 patients,99 women (62%) and 60 men (38%), with a mean age of 91.8 years (SD ± 2.0 years), 44 cases were operations for malignant disorders (28%), 117 cases (74%) under emergency conditions and 42 cases (26%) were elective treatments. The operative mortality was 29%, 4.8% for elective surgery and 37.6% for emergency surgery (P < 0.001). The postoperative complication rate, including death, was 60%. The probability of survival at 1, 3, and 5 years was 59.6%, 35.8% and 24.1%, respectively. In multivariate analysis, American Society of Anesthesiologists score (HR 2.07, 95% CI 1.58-2.72), emergency surgery (HR 1.64, 95% CI 1.05-2.57) and postoperative medical complications (HR 2.58, 95% CI 1.73-3.85) were independently related to 5-year survival. CONCLUSIONS: These findings support the perioperative safety of elective general surgery in nonagenarian patients. In selected nonagenarian patients with no cognitive impairment, surgery must not be denied. These data might be useful for surgical decision-making or informed consent for nonagerians. Geriatr Gerontol Int 2017; 17: 2389-2395.

Perioperative Blood Transfusion is Associated with an Increased Mortality in Older Surgical Patients.

BACKGROUND: More surgical interventions are being performed on octogenarian patients. The aim of this study was to identify factors associated with operative mortality and to determine if perioperative transfusions could affect mortality outcomes in a nonselected series of octogenarian patients undergoing surgery. METHODS: A descriptive cross-sectional study was performed on a population of 413 consecutive patients over 80 years old, treated surgically, and divided into two groups: transfused and nontransfused patients. The following variables were recorded: sociodemographic characteristics, main diagnoses, surgical procedure and its characteristics, ASA score, Charlson comorbidity index (CCI), National Nosocomial Infection Surveillance (NNIS) index, transfusion requirements, the Clavien-Dindo classification of surgical complications, and operative mortality. RESULTS: The mean age of the patients was 84.5 years (SD + 3.6). Transfused (25.2 %) and nontransfused patients had similar characteristics; except for neoplasia (P <0.001), NNIS (P = 0.008), operative mortality (P = 0.004), and complications according to Clavien-Dindo score (P <0.001). Operative mortality was 20.1 % (83 patients). The predictive variables associated with operative mortality were ASA score (P <0.001), emergency surgery (P <0.001), and blood transfusion (P = 0.004). After adjusting for the variables age, ASA class, NNIS, emergency surgery, and neoplasia, the multivariate analysis showed that the perioperative transfusion in octogenarian patients continued to be significantly associated with operative mortality (P = 0.019; OR 1.97, 95 % CI 1.12-3.47). CONCLUSION: Perioperative transfusion is an independent predictor of postoperative mortality in surgical octogenarian patients.

[Duodenal perforations after endoscopic retrograde cholangiopancreatography]. / Perforaciones duodenales tras colangiopancreatografía retrógrada endoscópica.

INTRODUCTION: Duodenal perforations after endoscopic retrograde cholangiopancreatography (ERCP) are an uncommon complication. The management of this kind of perforation is controversial. The aim of this study was to analyze the results of the management of a series of 15 patients who were diagnosed with this complication. METHODS: Retrospective study of duodenal perforations after ERCP diagnosed at a tertiary level hospital, between 2001 and 2011. The variables age, sex, ERCP indication, type of perforation, time of diagnosis, clinical presentation, radiographic findings, management, surgical technique, length of stay and intrahospital mortality were recorded and analyzed. RESULTS: Out of a total of 1923 ERCP performed, 15 duodenal perforations were detected (0,78%). Perforation site was the duodenal wall (3 cases) and periampullary (12 cases). Eleven perforations were suspected during the procedure. Patients with duodenal wall perforations underwent immediate surgery. Seven of 12 periampullary perforations were managed conservatively with a favorable outcome in 5 of them. Subsequent scheduled surgery was performed in 4 cases. The mean length of hospital stay was 21,2 days (range: 3-49) and intra-hospital mortality was 20%. CONCLUSIONS: Perforations after ERCP have high mortality rates, and require a complicated therapeutic approach that needs to be individualized. Selective conservative management is a valid and safe option in selected patients.

Morbidity- and mortality-related prognostic factors of nontraumatic splenectomies.

BACKGROUND: Splenectomy is a common surgical procedure, but few reports focus on nontraumatic splenectomies. The aim of this study was to determine the predictors of morbidity and mortality of patients submitted to elective nontraumatic splenectomy. METHODS: A descriptive cross-sectional study of 152 consecutive, nonselected, nontraumatic patients operated on by splenectomy between 1996 and 2010 was carried out. Clinical, laboratory, and surgical data, histological findings, perioperative mortality, and postoperative complications according to Clavien-Dindo classification, were recorded. Factors related to morbidity and mortality were analyzed. RESULTS: Of the 152 patients (89 male and 63 female; mean age 49.8 ± 17.8 years), 74 (48.7%) were operated on for malignant hematologic disorders, 44 for benign hematologic process, and 34 for other nonhematologic disorders. The spleen was enlarged in 95 patients (62.5%) and 78 patients (51.3%) had hypersplenism. The overall complications rate was 40.1%: Grades I and II in 27 cases (17.7%), and Grades III and IV in 23 patients (15.1%). Perioperative mortality was 7.2% (11 patients). In univariate analysis, significant negative predictors for morbidity were age (p = 0.004), anemia (p = 0.03), leukocytosis (p = 0.016), and blood transfusions (p < 0.001). In the multivariate analysis, only the need for blood transfusion remained as an independent prognostic factor (p = 0.001). Related to mortality, negative prognostic factors were age (p = 0.003), leukocytosis (p = 0.048), American Society of Anesthesiologists (ASA) score (p < 0.001), blood transfusion (p < 0.001), pleural effusion (p = 0.031), and pneumonia (p = 0.001). Pneumonia remained an independent prognostic factor of mortality (p = 0.024). CONCLUSION: Blood loss is the most important prognostic factor for postoperative complications after nontraumatic splenectomies. Pneumonia is the main prognosis factor for perioperative mortality.

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.

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.