Right colonic perforation in an Asian population: predictors of morbidity and mortality.
ABSTRACT Perforation of the colon is associated with significant morbidity and mortality. Pathologies arising from the right colon differ greatly between Asians and the Western population. The aims of our study were to evaluate the implications of perforated right colon in an Asian population and to identify factors that could predict the perioperative outcome.
A retrospective review of all patients who underwent operative intervention for peritonitis from right colonic perforation from July 2003 to April 2008 was performed. Patients were identified from the hospital's diagnostic index and operating records. The severity of abdominal sepsis for all patients was graded using the Mannheim peritonitis index (MPI). All the complications were graded according to the classification proposed by Clavian and colleagues.
Fifty-one patients with a median age of 60 years (range, 22-93 years) formed the study group. Diverticulitis (47.1%) and malignancy (37.3%) accounted for the majority of the pathologies. Right hemicolectomy without diverting stoma (n = 34, 66.7%) was performed most commonly. Of our patients, 74.5% had perioperative morbidity with 19 (37.3%) patients having grade III or worse complications. In our series, five (9.8%) patients died. On univariate analysis, American Society of Anesthesiologists (ASA) score >or=3, >or=2 premorbid conditions, raised MPI, raised creatinine, and stoma creation were related to more severe complications (grade III/IV). The following variables were correlated with in-hospital mortality: ASA score >or=3, raised MPI, hematocrit <33%, raised creatinine, malignant perforation, and stoma creation. On multivariate analysis, a higher ASA score >or=3 was predictive of significant morbidity, while both malignant perforation and stoma creation were associated with mortality.
Diverticulitis is the commonest cause of right colonic perforation in Asians. Patients with higher ASA score and malignant perforation are at risk of higher morbidity and mortality. Resection with primary anastomosis is safe and patients who require stomas are more likely to do worse.
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ABSTRACT: To prospectively audit stomas and to determine the nature and rate of complications and their relationship with various risk factors and their management. The study was performed prospectively on 97 consecutive patients who had stomas formed between January 2000 to August 2000. Patients were followed up for one year. Risk factors including age, body mass index (BMI), preoperative siting, contour of the abdominal wall, smoking, grade of operating surgeon, emergency or elective procedure, diabetes, type of stoma and suture material used were noted. The type of surgery, and indications for surgery were also recorded. The complications were documented by two qualified stoma nurses and a photographic record taken. Statistical analysis comprising both univariate and multivariate methods, was performed by SPSS 10. The mean age was 65 years (standard deviation 16.01, range 16-99) and mean body mass index was 24.5 (standard deviation 4.66, range 15-37). Forty-nine of 97 (50.5%) stomas developed one or more complications. Twenty-three patients experienced retraction, 18 had stomas sited in a skin crease, 16 had early and 12 had late skin excoriation, 12 had detachments and a further 12 had parastomal hernia. Eleven further stoma complications were noted including prolapse, necrosis, ischaemia and sloughing. None of the risk factors achieved statistical significance when analysed against the overall complication rate. However, when the risk factors were analysed against individual complications using univariate logistic regression, a high body mass index was associated with more retractions (P = 0.003), early skin excoriation (P = 0.036) and poor siting (stoma in crease) occurred more commonly in emergencies (P = 0.022). Diabetes was associated with late skin excoriation (P = 0.02). Multivariate logistic regressions confirmed an independent association of body mass index, diabetes and emergency surgery with complications. Forty-five of 49 patients who had complications needed some conservative management such as a convexity appliance. Four patients needed refashioning. Body mass index, diabetes and emergency surgery were the significant risk factors identified in our study. Overall complications compare favourably with other series. We found that preoperative siting by stoma nurses and the grade of operating surgeon did not affect the outcome.Colorectal Disease 02/2003; 5(1):49-52. · 2.08 Impact Factor
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ABSTRACT: Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis. A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated. The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn's disease (OR = 3.3), rectal cancer < or =12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01). Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision-making regarding defunctioning stoma formation.ANZ Journal of Surgery 08/2006; 76(7):579-85. · 1.50 Impact Factor
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ABSTRACT: Because the choice of surgical procedure for colonic perforation is still matter of debate, we retrospectively studied peritonitis caused by spontaneous colonic perforation to assess predictors of mortality and the safety of primary resection and anastomosis. Case series. We investigated one hundred thirty-six consecutive patients with peritonitis due to colonic perforation who were surgically treated in an emergency surgery department. Eighty-one patients underwent primary resection and anastomosis, thirty-three underwent the Hartmann procedure, and twenty-two had simple colostomy. The seriousness of peritonitis was assessed in terms of Hinchey stage, the Mannheim Peritonitis Index (MPI), and the acute physiology and chronic health evaluation (APACHE) II score. The overall mortality rate was 20%. The APACHE II scores and MPIs were lower for survivors than for nonsurvivors. The mortality rate was 6% for primary resection and anastomosis, 30% for the Hartmann procedure, and 59% for simple colostomy, but the severity scores were significantly lower in patients who underwent primary resection than those of patients who had the Hartmann procedure and colostomy, respectively. Since primary resection and anastomosis has been shown to be safe, we suggest that is is proper, even in the presence of peritonitis. In spite of this, we conclude that the surgical procedure does not influence outcome but that the mortality rate is related to the severity of peritonitis, accurately measured by APACHE II score and MPI.Archives of Surgery 08/1993; 128(7):814-8. · 4.10 Impact Factor