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Right Colonic Perforation in an Asian Population: Predictors of Morbidity and Mortality

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

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.

Methods

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.

Results

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 ≥3, ≥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 ≥3, raised MPI, hematocrit <33%, raised creatinine, malignant perforation, and stoma creation. On multivariate analysis, a higher ASA score ≥3 was predictive of significant morbidity, while both malignant perforation and stoma creation were associated with mortality.

Conclusion

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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References

  1. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation. Arch Surg 1993;128(7):814–818.

    CAS  PubMed  Google Scholar 

  2. Bielecki K, Kamiński P, Klukowski M. Large bowel perforation: morbidity and mortality. Tech Coloproctol 2002;6(3):177–182.

    Article  CAS  PubMed  Google Scholar 

  3. 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):2117–2124.

    Article  PubMed  Google Scholar 

  4. Lee YS. Diverticular disease of the large bowel in Singapore: an autopsy survey. Dis Colon Rectum. 1986;29(5):330–335.

    Article  CAS  PubMed  Google Scholar 

  5. Sugihara K, Muto T, Morioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum. 1984;27(8):531–537.

    Article  CAS  PubMed  Google Scholar 

  6. Schoetz DJ Jr. Diverticular disease of the colon: a century-old problem. Dis Colon Rectum. 1999;42:703–709.

    Article  PubMed  Google Scholar 

  7. 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 to 1999. Cancer Epidemiol Biomarkers Prev. 2004;13(7):1215–1222.

    PubMed  Google Scholar 

  8. 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):209–213.

    Article  CAS  PubMed  Google Scholar 

  9. Hinchey EJ, Schaal PGH, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85–109.

    CAS  PubMed  Google Scholar 

  10. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. Berlin: Springer, 2002.

    Google Scholar 

  11. 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):618–626.

    Article  CAS  PubMed  Google Scholar 

  12. 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):109–120.

    Article  CAS  PubMed  Google Scholar 

  13. 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):205–213.

    Article  PubMed  Google Scholar 

  14. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis. 1994;9(3):158–162.

    Article  CAS  PubMed  Google Scholar 

  15. Antolovic D, Reissfelder C, Koch M, Mertens B, Schmidt J, Büchler MW, Weitz J. Surgical treatment of sigmoid diverticulitis—analysis of predictive risk factors for postoperative infections, surgical complications, and mortality. Int J Colorectal Dis. 2009;24(5):577–584.

    Article  CAS  PubMed  Google Scholar 

  16. 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.

    Article  PubMed  Google Scholar 

  17. Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum. 2004;47(11):1953–1964.

    Article  PubMed  Google Scholar 

  18. Carraro PG, Segala M, Orlotti C, Tiberio G. Outcome of large-bowel perforation in patients with colorectal cancer. Dis Colon Rectum. 1998;41(11):1421–1426.

    Article  CAS  PubMed  Google Scholar 

  19. Khan S, Pawlak SE, Eggenberger JC, Lee CS, Szilagy EJ, Margolin DA. Acute colonic perforation associated with colorectal cancer. Am Surg. 2001;67(3):261–264.

    CAS  PubMed  Google Scholar 

  20. Runkel NS, Schlag P, Schwarz V, Herfarth C. Outcome after emergency surgery for cancer of the large intestine. Br J Surg. 1991;78(2):183–188.

    Article  CAS  PubMed  Google Scholar 

  21. Kriwanek S, Armbruster C, Dittrich K, Beckerhinn P. Perforated colorectal cancer. Dis Colon Rectum. 1996;39(12):1409–1414.

    Article  CAS  PubMed  Google Scholar 

  22. Willett C, Tepper JE, Cohen A, Orlow E, Welch C. Obstructive and perforative colonic carcinoma: patterns of failure. J Clin Oncol. 1985;3(3):379–384.

    CAS  PubMed  Google Scholar 

  23. Obrand DI, Gordon PH. Incidence and patterns of recurrence following curative resection for colorectal carcinoma. Dis Colon Rectum. 1997;40(1):15–24.

    Article  CAS  PubMed  Google Scholar 

  24. 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):635–642.

    Article  CAS  PubMed  Google Scholar 

  25. 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):91–96.

    Article  PubMed  Google Scholar 

  26. Longo WE, Virgo KS, Johnson FE, Oprian CA, Vernava AM, Wade TP, Phelan MA, Henderson WG, Daley J, Khuri SF. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum. 2000;43(1):83–91.

    Article  CAS  PubMed  Google Scholar 

  27. Gurevitch AJ, Davidovitch B, Kashtan H. Outcome of right colectomy for cancer in octogenarians. J Gastrointest Surg. 2009;13(1):100–104.

    Article  PubMed  Google Scholar 

  28. Basili G, Lorenzetti L, Biondi G, Preziuso E, Angrisano C, Carnesecchi P, Roberto E, Goletti O. Colorectal cancer in the elderly. Is there a role for safe and curative surgery? ANZ J Surg. 2008;78(6):466–470.

    Article  PubMed  Google Scholar 

  29. 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):616–622.

    Article  CAS  PubMed  Google Scholar 

  30. 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):147–151.

    CAS  PubMed  Google Scholar 

  31. Shinkawa H, Yasuhara H, Naka S, Yanagie H, Nojiri T, Furuya Y, Ariki K, Niwa H. Factors affecting the early mortality of patients with nontraumatic colorectal perforation. Surg Today. 2003;33(1):13–17.

    Article  PubMed  Google Scholar 

  32. Miller FB, Nikolov NR, Garrison RN. Emergency right colon resection. Arch Surg. 1987;122:339–343.

    CAS  PubMed  Google Scholar 

  33. Wyrzykowski AD, Feliciano DV, George TA, Tremblay LN, Rozycki GS, Murphy TW, Dente CJ. Emergent right hemicolectomies. Am Surg. 2005;71(8):653–656.

    PubMed  Google Scholar 

  34. Lee YM, Law WL, Chu KW, Poon RT. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. J Am Coll Surg 2001;192(6):719–725.

    Article  CAS  PubMed  Google Scholar 

  35. Hsu TC. Comparison of one-stage resection and anastomosis of acute complete obstruction of left and right colon. Am J Surg. 2005;189(4):384–387.

    Article  PubMed  Google Scholar 

  36. Veyrie N, Ata T, Muscari F, Couchard AC, Msika S, Hay JM, Fingerhut A, Dziri C. Anastomotic leakage after elective right versus left colectomy for cancer: prevalence and independent risk factors. J Am Coll Surg. 2007;05(6):785–793.

    Article  Google Scholar 

  37. Konishi T, Watanabe T, Kishimoto J, Nagawa H. Risk factors for anastomotic leakage after surgery for colorectal cancer: results of prospective surveillance. J Am Coll Surg. 2006;202(3):439–444.

    Article  PubMed  Google Scholar 

  38. Lipska MA, Bissett IP, Parry BR, Merrie AE. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg. 2006;76(7):579–585.

    Article  PubMed  Google Scholar 

  39. Duchesne JC, Wang YZ, Weintraub SL, Boyle M, Hunt JP. Stoma complications: a multivariate analysis. Am Surg. 2002;68:961–966.

    PubMed  Google Scholar 

  40. Arumugam PJ, Bevan L, Macdonald L, Watkins AJ, Morgan AR, Beynon J, Carr ND. A prospective audit of stomas—analysis of risk factors and complications and their management. Colorectal Dis 2003;5(1):49–52.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore

    Ker-Kan Tan, Junren Zhang, Jody Zhiyang Liu, Sharon Fengli Shen & Richard Sim

  2. Clinical Research Unit, Tan Tock Seng Hospital, Singapore, Singapore

    Arul Earnest

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  1. Ker-Kan Tan
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Correspondence to Ker-Kan Tan.

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Tan, KK., Zhang, J., Liu, J.Z. et al. Right Colonic Perforation in an Asian Population: Predictors of Morbidity and Mortality. J Gastrointest Surg 13, 2252–2259 (2009). https://doi.org/10.1007/s11605-009-0986-4

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  • DOI: https://doi.org/10.1007/s11605-009-0986-4

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