Abstract
Background
Colonic perforation is associated with abysmal outcome. The aims of our study were to review the surgical outcome of patients with perforated colon and to identify factors predicting peri-operative complications.
Methods
A retrospective review of all patients who underwent surgery for colonic perforation from January 2003 to August 2008 was performed. Patients with iatrogenic or traumatic perforation were excluded. The severity of abdominal sepsis was graded using the Mannheim peritonitis index (MPI).
Results
A total of 129 patients, with median age of 65 years (22–97 years), formed the study group. While 29.5% had severe peritoneal contamination, 56.6% had an American Society of Anesthesiologists (ASA) score ≥3. Sigmoid colon (47.3%) and caecum (24.8%) were the most common sites of perforation. Diverticulitis and malignancy were the diagnoses in 51.9% and 34.9%, respectively. Hartmann’s procedure and right hemicolectomy were performed in 43.4% and 34.1% of the patients, respectively. Stoma was created in 59.7%. The in-hospital mortality rate in our series was 15.5%. After multivariate analysis, the independent variables associated with worse peri-operative complications were ASA score ≥3, MPI >26 and creation of stoma. Malignant perforation was associated with higher ASA score and lower haematocrit level compared to diverticular perforation. Stoma was created more frequently in patients with MPI >26 and left-sided perforation, and was associated with worse complications.
Conclusions
Surgery for colonic perforation is associated with high morbidity and mortality rates. Short-term outcome is determined by ASA score and severity of peritonitis. A lower haematocrit level must alert the possibility of malignancy.
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References
Biondo S, Parés D, Martí Ragué J, De Oca J, Toral D, Borobia FG, Jaurrieta E. Emergency operations for nondiverticular perforation of the left colon. Am J Surg. 2002;183(3): 256–60.
Biondo S, Ramos E, Deiros M, Ragué JM, De Oca J, Moreno P, Farran L, Jaurrieta E. Prognostic factors for mortality in left colonic peritonitis: a new scoring system. J Am Coll Surg. 2000; 191(6): 635–42.
Bielecki K, Kamiński P, Klukowski M. Large bowel perforation: morbidity and mortality. Tech Coloproctol. 2002; 6(3): 177–82.
Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis. 1994; 9(3): 158–62.
Wu X, Chen VW, Martin J, Roffers S, Groves FD, Correa CN, Hamilton-Byrd E, Jemal A. Subsite-specific colorectal cancer incidence rates and stage distributions among Asians and Pacific Islanders in the United States, 1995–1999. Cancer Epidemiol Biomarkers Prev. 2004; 13(7): 1215–22.
Koo JH, Kin S, Wong C, Jalaludin B, Kneebone A, Connor SJ, Leong RW. Clinical and pathologic outcomes of colorectal cancer in a multi-ethnic population. Clin Gastroenterol Hepatol. 2008; 6(9): 1016–21.
Law WL, Lo CY, Chu KW. Emergency surgery for colonic diverticulitis: differences between right-sided and left-sided lesions. Int J Colorectal Dis. 2001; 16(5): 280–4.
Lee YS. Diverticular disease of the large bowel in Singapore. An autopsy survey. Dis Colon Rectum. 1986; 29(5): 330–5.
Tan KK, Zhang J, Liu JZ, Shen SF, Earnest A, Sim R. Right colonic perforation in an asian population: predictors of morbidity and mortality. J Gastrointest Surg. 2009; 13(12): 2252–9.
Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation. Arch Surg. 1993; 128(7): 814–8.
Breitenstein S, Kraus A, Hahnloser D, Decurtins M, Clavien PA, Demartines N. Emergency left colon resection for acute perforation: primary anastomosis or Hartmann’s procedure? A case-matched control study. World J Surg. 2007; 31(11): 2117–24.
Zorcolo L, Covotta L, Carlomagno N, Bartolo DC. Safety of primary anastomosis in emergency colo-rectal surgery. Colorectal Dis. 2003 May; 5(3): 262–9.
Kressner U, Antonsson J, Ejerblad S, Gerdin B, Påhlman L. Intraoperative colonic lavage and primary anastomosis-an alternative to Hartmann procedure in emergency surgery of the left colon. Eur J Surg. 1994 May; 160(5): 287–92.
Mealy K, Salman A, Arthur G. Definitive one-stage emergency large bowel surgery. Br J Surg. 1988; 75(12): 1216–9.
Regenet N, Pessaux P, Hennekinne S, Lermite E, Tuech JJ, Brehant O, Arnaud JP. Primary anastomosis after intraoperative colonic lavage vs. Hartmann’s procedure in generalized peritonitis complicating diverticular disease of the colon. Int J Colorectal Dis. 2003; 18(6): 503–7.
Billing A, Fröhlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Peritonitis Study Group. Br J Surg. 1994; 81(2): 209–13.
Astler VB, Coller FA. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg. 1954; 139(6): 846–52.
Clavien PA, Sanabria JR, Mentha G, Borst F, Buhler L, Roche B, Cywes R, Tibshirani R, Rohner A, Strasberg SM Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. Ann Surg. 1992; 216(6): 618–26.
Clavien PA, Camargo CA Jr, Croxford R, Langer B, Levy GA, Greig PD. Definition and classification of negative outcomes in solid organ transplantation. Application in liver transplantation. Ann Surg. 1994; 220(2): 109–20.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2): 205–13.
Schwesinger WH, Page CP, Gaskill HV 3rd, Steward RM, Chopra S, Strodel WE, Sirinek KR. Operative management of diverticular emergencies: strategies and outcomes. Arch Surg. 2000; 135(5): 558–62
Wong SK, Ho YH, Leong AP, Seow-Choen F.Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum. 1997; 40(3): 344–8.
McConnell EJ, Tessier DJ, Wolff BG.Population-based incidence of complicated diverticular disease of the sigmoid colon based on gender and age. Dis Colon Rectum. 2003; 46(8): 1110–4.
Stermer E, Lavy A, Rainis T, Goldstein O, Keren D, Zeina AR. Incidental colorectal computed tomography abnormalities: would you send every patient for a colonoscopy? Can J Gastroenterol. 2008; 22(9): 758–60.
Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol. 2000; 174(5): 1397–402.
Werner A, Diehl SJ, Farag-Soliman M, Düber C. Multi-slice spiral CT in routine diagnosis of suspected acute left-sided colonic diverticulitis: a prospective study of 120 patients. Eur Radiol. 2003; 13(12): 2596–603.
Chintapalli KN, Chopra S, Ghiatas AA, Esola CC, Fields SF, Dodd GD 3 rd. Diverticulitis versus colon cancer: differentiation with helical CT findings. Radiology. 1999; 210(2): 429–35.
Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery. 2000; 127(4): 370–6.
Anwar MA, D'Souza F, Coulter R, Memon B, Khan IM, Memon MA. Outcome of acutely perforated colorectal cancers: experience of a single district general hospital. Surg Oncol. 2006; 15(2): 91–6.
Tan KK, Bang SL, Sim R. Surgery for Small Bowel Perforation in an Asian Population: Predictors of Morbidity and Mortality. J Gastrointest Surg. 2010; 14(3): 493–9
Biondo S, Ramos E, Fraccalvieri D, Kreisler E, Ragué JM, Jaurrieta E. Comparative study of left colonic Peritonitis Severity Score and Mannheim Peritonitis Index. Br J Surg. 2006; 93(5): 616–22.
Kologlu M, Elker D, Altun H, Sayek I. Validation of MPI and PIA II in two different groups of patients with secondary peritonitis. Hepatogastroenterology. 2001; 48(37):147–51.
Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 2004; 13(2–3): 149–57
Arnaud JP, Bergamaschi R. Emergency subtotal/total colectomy with anastomosis for acutely obstructed carcinoma of the left colon. Dis Colon Rectum. 1994; 37(7): 685–8.
Constantinides VA, Heriot A, Remzi F, Darzi A, Senapati A, Fazio VW, Tekkis PP. Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg. 2007; 245(1): 94–103.
Vermeulen J, Coene PP, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GH, Weidema WF, Lange JF. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one-stage procedure? Colorectal Dis. 2009; 11(6): 619–24.
Leong QM, Koh DC, Ho CK. Emergency Hartmann’s procedure: morbidity, mortality and reversal rates among Asians. Tech Coloproctol. 2008; 12(1): 21–5.
David GG, Al-Sarira AA, Willmott S, Cade D, Corless DJ, Slavin JP. Use of Hartmann’s procedure in England. Colorectal Dis. 2009; 11(3): 308–12.
Aydin HN, Remzi FH, Tekkis PP, Fazio VW. Hartmann’s reversal is associated with high postoperative adverse events. Dis Colon Rectum. 2005; 48(11): 2117–26.
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Tan, KK., Hong, CC., Zhang, J. et al. Predictors of Outcome Following Surgery in Colonic Perforation: An Institution’s Experience Over 6 Years. J Gastrointest Surg 15, 277–284 (2011). https://doi.org/10.1007/s11605-010-1330-8
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DOI: https://doi.org/10.1007/s11605-010-1330-8