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Colorectal resection in emergency general surgery: An EAST multicenter trial
Brittany O Aicher1, Matthew C Hernandez, Alejandro Betancourt-Ramirez
1From the R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center (B.O.A., L.O.M., J.K., B.B.R.), Baltimore, Maryland; Department of Surgery, Mayo Clinic (M.C.H., M.D.Z.), Rochester, Minnesota; Department of Surgery, Southside Hospital, Northwell Health (A.B.R., M.D.G.), Bay Shore, NY; Department of Surgery, UCHealth Memorial Hospital Central Trauma Center (T.J.S., H.H.), Colorado Springs, Colorado; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital (N.K., H.M.A.K.), Boston, Massachusetts; Department of Surgery, West Virginia University Medicine (A.W., D.G.), Morgantown, West Virginia; Department of Surgery, Robert Wood Johnson University Hospital (M.S., G.P.), New Brunswick, NJ; Department of Surgery, University of Southern California (G.C., K.M.), Los Angeles, California; Department of Surgery, Marshfield Clinic (D.C.C., L.M.C.), Marshfield, Wisconsin; Department of Surgery, Northwestern Memorial Hospital (B.S., J.P.), Chicago, Illinois; Department of Surgery, Loma Linda University Medical Center (U.J.S., R.D.C.), Loma Linda, CA; Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital (G.V., D.D.Y.), Miami, Florida; Department of Surgery, Methodist Dallas Medical Center (V.A., M.S.T.) Dallas, Texas; Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital (M.P., L.D.), Dallas, Texas; Department of Surgery, Reading Hospital (A.M., A.W.O.), West Reading, Pennsylvania; Cooper University Health Care (J.L.S.R., N.B.), Camden, NJ; Department of Surgery, University of Colorado (O.F., C.G.V.), Denver, Colorado; George Washington University (C.H., J.M.E), Washington, District of Columbia; Department of Surgery, University of California, Irvine (S.G., J.N.), Irvine, California; Department of Surgery, Tufts University (K.J., N.B), Boston, Massachusetts; and Department of Surgery, Medical City Plano (V. P., M.M.C.), Plano, Texas.
Objective:
Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients.
Methods:
This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality.
Results:
A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality.
Conclusion:
This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality.
Level Of Evidence:
Therapeutic study, level IV.
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