A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development.

BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 -mg/-dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development

ABSTRACT BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 ­mg/­dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

Factores asociados a mal pronóstico en pacientes con sangrado digestivo bajo en un hospital público / Poor outcome factors associated to patients with lower digestive bleeding in a public hospital

Introducción: El sangrado digestivo bajo (SDB) es una entidad cuyas tasas de complicaciones y mortalidad se han incrementado en las últimas décadas. Si bien se han identificado algunos factores relacionados a mal pronóstico, aún quedan variables por evaluar. Objetivo: Identificar factores de mal pronóstico en pacientes que presentaron SDB en el Hospital Nacional Edgardo Rebagliati Martins de Lima, Perú. Materiales y métodos: Se realizó un estudio observacional analítico de tipo cohorte retrospectivo. Se realizó un censo de todos los pacientes que presentaron SDB agudo entre enero 2010 y diciembre 2013. Las variables principales a evaluar fueron frecuencia cardiaca ≥100/min, presión arterial sistólica <100 mmHg y hematocrito bajo (≤35%) al ingreso. Se definió mal pronóstico como cualquiera de los siguientes criterios: muerte durante la hospitalización, sangrado que requiera transfusión de ≥4 unidades de sangre, reingreso dentro del primer mes, o necesidad de cirugía de hemostasia. Resultados: Se incluyó un total de 341 pacientes con SDB, de los cuales el 27% tuvo mal pronóstico y 2% fallecieron. Se encontró como variables asociadas a mal pronóstico: frecuencia cardiaca ≥100/min al ingreso (RR: 1,75, IC 95% 1,23-2,50), presión arterial sistólica <100 mmHg al ingreso (RR: 2,18, IC 95% 1,49-3,19), hematocrito ≤35% al ingreso (RR: 1,98, IC 95% 1,23-3,18) y sangrado de origen no determinado (RR: 2,74, IC 95% 1,73-4,36). Conclusiones: Frecuencia cardiaca elevada al ingreso, hipotensión sistólica al ingreso, hematocrito bajo al ingreso y presentar un sangrado en el cual no se encuentra el punto de origen son factores que incrementan el riesgo de presentar mal pronóstico, por lo que se recomienda un monitoreo más estricto en estos pacientes

Background: Lower gastrointestinal bleeding (LGIB) is an event that has shown an increase in complications and mortality rates in the last decades. Although some factors associated with poor outcome have been identified, there are several yet to be evaluated. Objective: To identify risk factors for poor outcome in patients with LGIB in the Hospital Edgardo Rebagliati Martins of Lima, Peru. Material and methods: A prospective analytic observational cohort study was made, and a census was conducted with all patients with acute LGIB between January 2010 and December 2013. The main variables were heart rate ≥100/min, systolic blood pressure <100 mmHg and low hematocrit (≤35%) at admission. Poor outcome was defined as any of the following: death during hospital stay, bleeding requiring transfusion of ≥4 blood packs, readmission within one month of hospital discharge, or the need for hemostatic surgery. Results: A total of 341 patients with LGIB were included, of which 27% developed poor outcome and 2% died. Variables found to be statistically related to poor outcome were: heart rate ≥ 100/min at admission (RR: 1.75, IC 95% 1.23-2.50), systolic blood pressure <100 mmHg at admission (RR: 2.18, IC 95% 1.49-3.19), hematocrit ≤35% at admission (RR: 1.98, IC 95% 1.23-3.18) and LGIB of unknown origin (RR: 2.74, IC 95% 1.73-4.36). Conclusions: Elevated heart rate at admission, systolic hypotension at admission, low hematocrit at admission and having a LGIB of unknown origin are factors that increase the risk of developing poor outcome, and these patients should be monitored closely due to their higher risk of complications

[Poor outcome factors associated to patients with lower digestive bleeding in a public hospital]. / Factores asociados a mal pronóstico en pacientes con sangrado digestivo bajo en un hospital público.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is an event that has shown an increase in complications and mortality rates in the last decades. Although some factors associated with poor outcome have been identified, there are several yet to be evaluated. OBJECTIVE: To identify risk factors for poor outcome in patients with LGIB in the Hospital Edgardo Rebagliati Martins of Lima, Peru. MATERIAL AND METHODS: A prospective analytic observational cohort study was made, and a census was conducted with all patients with acute LGIB between January 2010 and December 2013. The main variables were heart rate ≥100/min, systolic blood pressure <100 mmHg and low hematocrit (≤35%) at admission. Poor outcome was defined as any of the following: death during hospital stay, bleeding requiring transfusion of ≥4 blood packs, readmission within one month of hospital discharge, or the need for hemostatic surgery. RESULTS: A total of 341 patients with LGIB were included, of which 27% developed poor outcome and 2% died. Variables found to be statistically related to poor outcome were: heart rate ≥ 100/min at admission (RR: 1.75, IC 95% 1.23- 2.50), systolic blood pressure <100 mmHg at admission (RR: 2.18, IC 95% 1.49-3.19), hematocrit ≤35% at admission (RR: 1.98, IC 95% 1.23-3.18) and LGIB of unknown origin (RR: 2.74, IC 95% 1.73-4.36). CONCLUSIONS: Elevated heart rate at admission, systolic hypotension at admission, low hematocrit at admission and having a LGIB of unknown origin are factors that increase the risk of developing poor outcome, and these patients should be monitored closely due to their higher risk of complications.

Is a Colectomy Always Just a Colectomy? Additional Procedures as a Proxy for Operative Complexity.

BACKGROUND: Studies of surgical outcomes can be confounded by operative complexity. Complexity is difficult to assess from claims data due to the absence of established measures, but information on additional procedures is typically available. We hypothesized that analyzing same-day procedures (SDPs) would provide a useful step toward including operative complexity in risk adjustment. STUDY DESIGN: Colon resections were identified in California, Florida, and New York (2008 to 2011). Same-day procedures were categorized using 6 definitions. In-hospital mortality and postoperative complications were examined. For all outcomes, we developed multivariable logistic regression models to measure the association between the SDP category and outcomes. RESULTS: Rates of SDP were 74.9% total, 69.5% surgical, 31.6% nonsurgical, 36.6% colon, 51.4% abdomen, and 34.3% other for the 215,041 colon resections examined. Mortality was associated with the inclusion of any SDP category in univariate (6.2% vs 1.7%; p < 0.001) and multivariable (odds ratio [OR] = 2.14; 95% CI, 1.99-2.30; p < 0.001) analysis. The association with mortality was high for nonsurgical (OR = 2.36; 95% CI, 2.26-2.46) and other (OR = 2.33; 95% CI, 2.23-2.43) procedures and moderate for surgical (OR = 1.45; 95% CI, 1.37-1.54) and colon (OR = 1.51; 95% CI, 1.44-1.57) procedures, but abdominal procedures were not independently associated with mortality (OR = 1.01; 95% CI, 0.97-1.06). The total number of SDPs was also associated with higher complication rates. CONCLUSIONS: The risk of complications and mortality associated with colectomy was increased among patients with SDPs and the magnitude of the association was dependent on the type and quantity of additional procedures. Information on SDPs might reflect a component of operative risk not typically captured and should be considered as a candidate variable for risk adjustment when using claims to compare outcomes across large cohorts.

La operación de Hartmann en hospital público: aún una opción / Hartmann's surgery in a public institution: still an option

ANTECEDENTES: La operación de Hartmann continúa siendo una alternativa válida en el tratamiento de la patología colónica de urgencia. Su atractivo se debe a la aparente simplicidad de su técnica, pero sin embargo. no está exenta de complicaciones, y entre el 20% al 70% de los casos, nunca llega a reconstruirse el tránsito intestinal. Hipótesis: La operación de Hartmann está sobreindicada en pacientes sin repercusión sistémica y con hallazgos quirúrgicos favorables. LUGAR DE APLlCACION: Hospital público de la Ciudad de Buenos Aires. DISEÑO: Retrospectivo, observacional. POBLACION: Todos los pacientes a los que se efectuó una operación de Hartmann entre enero del 2000 a marzo del 2009. METODO: Revisión de historias clínicas y de base de datos del servicio. Se utilizó el Mannheim Peritonitis Index (MPI) para clasificar los pacientes según los hallazgos intraoperatorios y la repercusión sistémica. RESULTADOS: 44 pacientes. 24 varones (45%) y 20 mujeres (65%). La edad promedio fue 44 años. 34 (77%1) cirugías de urgencia y 10 (23%) programadas. Según el MPI, 30 pacientes (68%) tuvieron un score = a 21; 12 pacientes (27%) entre 22 y 28 y 2 pacientes (5%) un score mayor a 28. En ocho pacientes (25%) se reconstruyó el tránsito intestinal en un tiempo medio de 284 días La morbilidad fue de 32% y la mortalidad de 27%. CONCLUSIONES: La operación de Hartmann está asociada a una alta morbi-mortalidad. Sólo un 25% de nuestra serie se reconstruyó el tránsito intestinal. Si analizamos a los pacientes según el MPI, el 68% tuvieron un puntaje = 21, por lo que concluimos que la operación de Hartmann está sobreindicada en nuestro medio.

BACKGROUND: Hartmann's procedure is widely used for treatment of acute colonic dísease. It's apparent simplicity is what makes it attractive, however, there are many postoperative complications and Hartmann's reversal is done in 20% to 70%. Hypothesis: Hartmann' s procedure is too often performed in patients without systemic disease and with a favorable surgical outcome. METHODS: Retrospective reviews of all patients who underwent Hartmann's procedure from January 2000 to January 2009. Patients were classified into three groups according to the general status and intraoperative findings using the Mannheim Peritonitis Index (MPI). RESULTS: 44 patients underwent Hartmann's procedure (24 men and 20 women). The mean age was 44 years. Ten out of 44 surgeries were elective. Nineteen patients (43%) had cancer, while 25 patients (57%) had a benign disease. Thirty patients (68%) had an MPI = 21; 12 patients (27%) had an MPI between 22 and 28 (25%), and 2 patients an MPI > 28. Twenty five percent underwent Hartmann' s reversal in a mean period of 284 days (Range 79-419 days). The morbidity was 32% and mortality 27%. CONCLUSION: Hartmann's procedure is associated with high morbidity and mortality. Only 25% underwent Hartmann's reversal. According to the Mannheim Peritonitis Index, 68% had scored less or equal to 21, so we can conclude that Hartmann's procedure is often unnecessarily performed in our Hospital.

Vólvulos de colon. Estudio de cuatro años

Actualmente los vólvulos de colon son considerados una causa poco común de obstrucción intestinal en los países de habla inglesa; mientras que en otro como Rusia, Irán, África, constituye la causa más frecuente de esta entidad. Para determinar el comportamiento de esta enfermedad en nuestro medio analizamos los pacientes intervenidos por la misma en el periodo comprendido entre los meses de octubre del año 2000 a octubre del 2004 en el Hospital Universitario “Arnaldo Milian Castro” de Villa Clara. Comprobamos la existencia de un predominio del sexo femenino con relación al masculino con predominio de esta afección en las edades comprendidas entre 61 80 años. La totalidad de los pacientes presentaron como síntoma principal el dolor abdominal, el cual se corroboró al examen físico y se acompañó de distensión abdominal y constipación. Mediante el tratamiento quirúrgico se corroboró el diagnóstico de Vólvulo de sigmoides en el 33.3 por ciento del los pacientes, con un 91.7 por ciento de localización a nivel del colon sigmoides. La mortalidad encontrada fue de un 33.3 por ciento y las complicaciones respiratorias fueron las que mayormente aparecieron en el postoperatorio de estos enfermos. La mayoría de los pacientes presentaron una estadía hospitalaria inferior a los 14 días(AU)

Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use?

BACKGROUND: Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed. STUDY DESIGN: The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup. RESULTS: A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence. CONCLUSIONS: We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used.

Laparoscopic colorectal procedures: a multicenter Brazilian experience.

An evaluation of the results of the Brazilian experience in colorectal laparoscopic procedures in a multicenter prospective protocol done by the Brazilian Society of Colo-Proctology is presented. From December 1991 to August 1998, 1,161 patients (583 men and 578 women; mean age, 49.8 years), were operated on laparoscopically. Most of the procedures (40.5%) were for cancer, and the most common procedure was anterior resection (22.5%). The mean operative time was 189 minutes (3.1 hours). There were 42 (3.6%) perioperative complications; visceral injuries were the most common (1.4%). Conversions occurred in 122 (10.5%) cases. There were 148 (12.7%) postoperative complications; wound infections were the most common (5.2%). A liquid diet was started at a mean time of 1.4 days after the operation, and the mean hospitalization period was 6.4 days.

[An index of the severity of intestinal gangrene due to colonic volvulus]. / Puntaje de severidad de la gangrena intestinal por vólvulo de colon.

This retrospective analysis evaluated 50 patients with gangrenous colonic volvulus two cases with ileocecal volvulus, one case with volvulus of the colon transverse and 47 cases with sigmoid volvulus- who were managed by primary resection with anastomosis (n = 21) or resection plus colostomy (n = 29) at Belén Hospital, Trujillo, Perú, from January 1, 1967 to July 31, 1993. The principal aim of the study was to identify by univariate analysis the combination of predictive risk factors for postoperative mortality. The following factors were associated with increased mortality: mean arterial pressure lower than 70 mmHg (p = 0.004), presence of purulent or fecaloid peritoneal fluid (p = 0.013) or evidence of macroscopic bowel perforation (p < 0.001). A method of quantifying the risk of mortality following gangrene of the loop using these factors was described. Each factor was given a weight value ranging from 0 a 2 (0 = major, 1 = moderate, 2 = minor) according to the severity of injury estimate. The sum of the individual factor scores comprised the final score of the Severity of Gangrenous Colon by Volvulus (S.S.G.C.). In this series the 30-day mortality rate was of 30%. A S.S.G.C. resulted greater than 4 in 34 (68%) of the patients. This was associated with a 9% mortality rate and contrasted to a 75% when the S.S.G.C. was equal to or less than 4. Mortality developed in 33% of the patients operated on using an immediate anastomosis (S.S.G.C., 4.2 +/- 0.99) and it was of 28% in those whose operation was resection plus colostomy (S.S.G.C., 3 +/- 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)