Prognostic factors for mortality in left colonic peritonitis: a new scoring system.

BACKGROUND: Perforating lesions of the colon affect a heterogeneous group of patients, often elderly, and usually present as abdominal emergencies, with high morbidity and mortality. The aims of this study were to assess the prognostic value of specific factors in patients with left colonic peritonitis and to evaluate the utility of a scoring method that allows one to define groups of patients with different mortality risks. STUDY DESIGN: Between January 1994 and December 1999, 156 patients (77 men and 79 women), with a mean (SD) age of 63.2 years (15.5 years) (range 22 to 87 years), underwent emergency operation for a distal colonic perforation. Intraoperative colonic lavage was the first choice operation and it was performed in 74 patients (47.4%). There were three alternative procedures: the Hartmann operation was performed in 69 patients (44.2%), subtotal colectomy in 9, and colostomy in 4 patients. We analyzed specific variables for their possible relation to death including gender, age, American Society of Anesthesiologists (ASA) score, immunocompromised status, etiology, and degree of peritonitis, preoperative organ failure, time (hours) between hospital admission and surgical intervention, and degree of temperature elevation (38 degrees C). Univariate relations between predictors and outcomes (death) were analyzed using logistic regression. Multivariate logistic regression analysis was used to assess the prognostic value of combinations of the variables. Significant factors identified in univariate and multivariate logistic regression analyses were used to define a left colonic Peritonitis Severity Score (PSS). Factors that were significant only in univariate analysis scored 2 points if present and 1 if not. Variables significant in multivariate analysis were scored from 1 to 3 points. Patients were randomly split into two groups, one to calculate the scoring system and the other to validate it. RESULTS: Overall postoperative mortality rate was 22.4%. Septic-related mortality was observed in 24 patients (15.4%). Age, peritonitis grade, ASA score, immunocompromised status, and ischemic colitis were significant for postoperative death in univariate analysis. But only ASA score and preoperative organ failure were significantly associated with postoperative mortality in multivariate logistic regression analysis. The PSS, as defined in this study, was related to outcomes of patients. Mortality rate increased from 0%, when PSS was 6 points (minimum possible score), to 100% in patients with a PSS of 13 (maximum possible PSS = 14). CONCLUSIONS: Left colonic peritonitis continues to have a persistently high mortality in patients with septic complications. ASA score and preoperative organ failure are the only factors that are significantly associated with mortality in the multivariate analysis. The PSS classification may help uniformly define the mortality risk of patients with distal large bowel peritonitis, and may help to increase the comparability of studies carried out at different centers.

Resección y anastomosis primaria en pacientes con peritonitis por enfermedad del colon izquierdo / Resection and primary anastomosis in patients with peritonitis secondary to left-sided colonic disease

Introducción. Clásicamente, la presencia de un cuadro de peritonitis aguda localizada y sobre todo difusa se consideró una contraindicación para la anastomosis primaria en cirugía de colon urgente. El objetivo de este trabajo es definir qué lugar ocupa la cirugía en un tiempo (resección y anastomosis primaria tras lavado intraoperatorio de colon) en casos de peritonitis aguda localizada y difusa por enfermedad del colon izquierdo. Pacientes y método. Desde enero de 1994 hasta junio de 1999 fueron intervenidos de forma urgente 139 pacientes con peritonitis aguda por enfermedad del colon izquierdo. De éstos, 66 (47,5 por ciento) (41 con peritonitis localizada y 25 con peritonitis difusa) fueron tratados con resección, lavado intraoperatorio de colon y anastomosis primaria. Se analizaron los resultados con esta técnica, así como las diferencias entre los grupos con peritonitis localizada y difusa. Resultados. La incidencia de dehiscencia anastomótica fue del 3 por ciento (2 pacientes) y la morbilidad global fue del 42,4 por ciento, siendo la infección de herida quirúrgica la complicación más frecuente. La mortalidad fue del 3,1 por ciento (2 pacientes). No hubo diferencias estadísticamente significativas entre los resultados de los enfermos con peritonitis localizada y difusa. Conclusiones. La cirugía en un tiempo constituye un tratamiento seguro y eficaz en la terapia de pacientes con peritonitis purulenta localizada y difusa por enfermedad del colon izquierdo si se realiza una buena selección de los casos (AU)

Role of resection and primary anastomosis of the left colon in the presence of peritonitis.

BACKGROUND: Classically a primary colonic anastomosis is not performed in the presence of left colonic peritonitis. Recently there has been a trend towards resection and anastomosis in selected patients, but no prospective study concerning the safety of this approach has been published. The objective of this study was to define the role of intraoperative colonic lavage with resection and primary anastomosis (RPA) in left colonic peritonitis, and to evaluate the differences in outcome in patients with diffuse or localized peritonitis. METHODS: Between January 1994 and December 1998, 127 patients underwent emergency operation for a distal large bowel perforation. RPA was the operation of choice and was performed in 61 patients, 38 with localized and 23 with diffuse peritonitis. Septic shock, faecal peritonitis, immunocompromised status and American society of Anesthesiologists grade IV were contraindications to the one-stage procedure. Alternative operations used in high-risk patients were Hartmann's procedure in 55 patients, subtotal colectomy in eight and colostomy in three. RESULTS: There were two deaths (3 per cent) among 61 patients treated by RPA and one (2 per cent) case of clinical anastomotic dehiscence. Overall morbidity was 39 per cent and the overall mean(s.d.) hospital stay was 18(15) days. No statistical differences were observed between patients with localized and diffuse peritonitis treated by RPA. CONCLUSION: RPA may be the operation of choice in selected patients with left colonic diffuse peritonitis.