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Pajola M, Fugazzola P, Cobianchi L, Frassini S, Ghaly A, Bianchi C, Ansaloni L. Surgical Emergencies in Rectal Cancer: A Narrative Review. J Clin Med 2024; 14:126. [PMID: 39797209 PMCID: PMC11721366 DOI: 10.3390/jcm14010126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Revised: 12/14/2024] [Accepted: 12/19/2024] [Indexed: 01/13/2025] Open
Abstract
Colorectal cancer (CRC) is the third most diagnosed cancer worldwide and the second most common cause of cancer death. About 20% of patients diagnosed with rectal cancer present with emergency symptoms. Typical symptoms include acute bleeding, obstruction, and perforation. These emergency situations can be life-threatening and may lead to decreased life expectancy and quality of life. Bowel perforation is the most common cause of emergency presentation, followed by obstruction and acute bleeding. This narrative review analyzes the existing literature regarding the acute presentation of rectal cancer, producing three flow charts for the management of the main rectal emergencies. The treatment of acute bleeding differs based on the hemodynamic status. Treatment for bowel perforation or occlusion differs depending on whether the lesion is intraperitoneal or extraperitoneal. Emergency presentations seem to be strongly associated with several poor prognostic factors, including lymphovascular invasion, perineural invasion, and high-grade or poorly differentiated tumors. An association between emergency presentation and larger tumor size, advanced tumor stage, node-positive disease, and metastatic disease is reported in the literature. The difference between colon and rectal cancer, both in terms of treatment and prognosis, has been widely acknowledged. Thus, comprehensive studies and dedicated guidelines are needed, considering the lack of literature published about rectal cancer in an emergency setting.
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Affiliation(s)
- Maria Pajola
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
| | - Paola Fugazzola
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
- PhD in Experimental Medicine, Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy
| | - Lorenzo Cobianchi
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Simone Frassini
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
| | - Ahmed Ghaly
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
| | - Carlo Bianchi
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Luca Ansaloni
- General Surgery Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (M.P.); (L.C.); (S.F.); (A.G.); (C.B.); (L.A.)
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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Brunner M, Gärtner L, Weiß A, Weber K, Denz A, Krautz C, Weber GF, Grützmann R. Risk Factors for Postoperative Major Morbidity, Anastomotic Leakage, Re-Surgery and Mortality in Patients with Colonic Perforation. J Clin Med 2024; 13:5220. [PMID: 39274433 PMCID: PMC11396422 DOI: 10.3390/jcm13175220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/25/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objectives: This study aimed to determine the risk factors associated with postoperative major morbidity, anastomotic/suture leakage, re-surgery and mortality in patients undergoing emergency surgery for colonic perforation. Methods: A total of 204 adult patients treated surgically for colonic perforation from 2016 to 2021 at the University Hospital Erlangen were included in a retrospective analysis. Patient demographics and pre-, intra- and postoperative parameters were obtained and evaluated among various outcome groups (in-hospital major morbidity, anastomotic/suture leakage, re-surgery and 90-day mortality). Results: Postoperative in-hospital major morbidity, anastomotic/suture leakage, need of re-surgery and 90-day mortality occurred in 45%, 12%, 25% and 12% of the included patients, respectively. Independent risk factors for in-hospital major morbidity were identified and included the presence of any comorbidity, a significantly reduced preoperative general condition, the localization of perforation in the right hemicolon and the need for an intraoperative blood transfusion. The only independent risk factor for anastomotic/suture leakage was the presence of any comorbidity, whereas no independent risk factors for re-surgery were found. An age > 65 years, a significantly reduced preoperative general condition and the need for an intraoperative blood transfusion were independent risk factors for 90-day mortality. Conclusions: Our study identified risk factors impacting postoperative outcomes in patients undergoing emergency surgery for colonic perforation. These patients should receive enhanced postoperative care and may benefit from individualized and targeted therapeutic approaches.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Lara Gärtner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Andreas Weiß
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Klaus Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054 Erlangen, Germany
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Suda K, Shimizu T, Ishizuka M, Miyashita S, Niki M, Shibuya N, Hachiya H, Shiraki T, Matsumoto T, Sakuraoka Y, Mori S, Iso Y, Takagi K, Aoki T, Kubota K. Total Steroid Intake is Associated With Hospital Mortality in Patients With Pan-Peritonitis due to Colorectal Perforation. Am Surg 2023; 89:4764-4771. [PMID: 36301856 DOI: 10.1177/00031348221136576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Patients with pan-peritonitis (PP) due to colorectal perforation have high mortality rate because colorectal perforation causes septic shock. The association between total steroid intake (TSI) and hospital mortality of such patients is not clear. METHODS One hundred forty-two patients who underwent surgery for PP due to colorectal perforation were reviewed. Patients were divided into two groups by 8000 mg of TSI. The cut-off value of TSI was determined using a receiver operating characteristic curve for hospital mortality. RESULTS The cut-off value of TSI for hospital mortality was 8000 mg. Patients with TSI>8000 mg had high rate of hemodialysis, hospital mortality, and elevated neutrophil ratio (>95%) compared with those with TSI≤8000 mg. Multivariate analyses revealed that TSI (>8000/≤8000, mg) (OR, 9.669; 95% CI, 1.011-92.49; P = .049) was significantly associated with hospital mortality as well as bleeding volume (>1000/≤1000, mL) (OR, 26.08; 95% CI, 3.566-190.4; P = .001), lymphocyte ratio (≤4/>4, %) (OR, 7.988; 95% CI, 1.498-42.58; P = .015) and C-reactive protein (≤7.5/>7.5, mg/dL) (OR, 41.66; 95% CI, 4.784-33.33; P = .001). DISCUSSION There was a significant association between TSI and hospital mortality in patients with PP due to colorectal perforation as well as intraoperative bleeding and systemic inflammatory markers.
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Affiliation(s)
- Kotaro Suda
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shimizu
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Mitsuru Ishizuka
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Shotaro Miyashita
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Maiko Niki
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Norisuke Shibuya
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Hiroyuki Hachiya
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shiraki
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | | | - Yuhki Sakuraoka
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Shozo Mori
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yukihiro Iso
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Kazutoshi Takagi
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Taku Aoki
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Keiichi Kubota
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
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Lee DB, Shin S, Yang CS. Patient outcomes and prognostic factors associated with colonic perforation surgery: a retrospective study. Yeungnam Univ J Med 2021; 39:133-140. [PMID: 34710320 PMCID: PMC8913914 DOI: 10.12701/yujm.2021.01445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background Despite advances in surgery and intensive perioperative care, fecal peritonitis secondary to colonic perforation is associated with high rates of morbidity and mortality. This study was performed to review the outcomes of patients who underwent colonic perforation surgery and to evaluate the prognostic factors associated with mortality. Methods A retrospective analysis was performed on 224 consecutive patients who underwent emergency colonic perforation surgery between January 2008 and May 2019. We divided the patients into survivor and non-survivor groups and compared their surgical outcomes. Results The most common cause of colon perforation was malignancy in 54 patients (24.1%), followed by iatrogenic perforation in 41 (18.3%), stercoral perforation in 39 (17.4%), and diverticulitis in 37 (16.5%). The sigmoid colon (n=124, 55.4%) was the most common location of perforation, followed by the ascending colon, rectum, and cecum. Forty-five patients (20.1%) died within 1 month after surgery. Comparing the 179 survivors with the 45 non-survivors, the patient characteristics associated with mortality were advanced age, low systolic blood pressure, tachycardia, organ failure, high C-reactive protein, high creatinine, prolonged prothrombin time, and high lactate level. The presence of free or feculent fluid, diffuse peritonitis, and right-sided perforation were associated with mortality. In multivariate analysis, advanced age, organ failure, right-sided perforation, and diffuse peritonitis independently predicted mortality within 1 month after surgery. Conclusion Age and organ failure were prognostic factors for mortality associated with colon perforation. Furthermore, right-sided perforation and diffuse peritonitis demonstrated a significant association with patient mortality.
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Affiliation(s)
- Do-Bin Lee
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Seonhui Shin
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chun-Seok Yang
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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Perioperative clinical parameters associated with short-term mortality after colorectal perforation. Eur J Trauma Emerg Surg 2021; 48:3017-3024. [PMID: 34081159 PMCID: PMC8172362 DOI: 10.1007/s00068-021-01719-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 05/27/2021] [Indexed: 11/24/2022]
Abstract
Purpose Although early prediction of mortality is useful for the management of patients with colorectal perforations, no significant perioperative predictive factors have been identified. The purpose of this study was to identify useful prognostic factors for patients with colorectal perforation. Methods This single-center retrospective study included consecutive patients undergoing emergency surgery for colorectal perforation from January 2012 to December 2019. The primary outcome was combined 30 day and in-hospital mortality. Patient- and disease-related factors obtained perioperatively were evaluated for mortality prediction. A scoring system was developed to enhance clinical utility. Results Overall, 146 patients were included and 20 (14%) died after surgery. Multivariate logistic regression identified five predictive factors: age, hemodialysis, uncommon perforation etiology, plasma albumin level, and decreased platelet count. The area under the receiver operating curve for the scoring system using these parameters was 0.894 (95% CI 0.835–0.952). Patients at high-risk of mortality were classified by the proposed score with a sensitivity of 90.0% and negative predictive value of 98.0%. Conclusion This study identified five perioperative factors significantly associated with mortality of patients with colorectal perforation. Although these parameters predict mortality of patients with colorectal perforation using a score with high discrimination, further study is required to confirm these findings. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01719-8.
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Peacock O, Yanni F, Kuryba A, Cromwell D, Lockwood S, Anderson I, Vohra RS. Failure to rescue patients after emergency laparotomy for large bowel perforation: analysis of the National Emergency Laparotomy Audit (NELA). BJS Open 2021; 5:zraa060. [PMID: 33609399 PMCID: PMC7896807 DOI: 10.1093/bjsopen/zraa060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/01/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability. METHODS Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality. RESULTS Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770). CONCLUSION Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.
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Affiliation(s)
- O Peacock
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Yanni
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - I Anderson
- University of Manchester School of Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - R S Vohra
- Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Konno-Kumagai T, Sakurai T, Taniyama Y, Sato C, Takaya K, Ito K, Kamei T. Transverse colon perforation in the mediastinum after esophagectomy: a case report. Surg Case Rep 2020; 6:114. [PMID: 32451644 PMCID: PMC7247284 DOI: 10.1186/s40792-020-00862-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background While anastomotic leakage, recurrent laryngeal nerve paralysis, and pneumonia are well-known complications of esophagectomy, the incidence of hiatal hernia after esophagectomy for carcinoma has been reported to only be between 0.6 and 10%. We report a very rare case of hiatal hernia with transverse colon rupture in the mediastinum after esophagectomy in a 65-year-old woman. Case presentation The patient underwent definitive chemoradiotherapy for clinical stage IIA esophageal squamous cell carcinoma and salvage esophagectomy with gastric tube reconstruction through a posterior mediastinum route for residual carcinoma. Three years after the initial surgery, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT and were treated with oral anticancer drugs. After 6 months, the patient was readmitted for anorexia. Upon admission, computed tomography revealed an ileus caused by a hiatal hernia. Emergent operative repair was performed; an incarcerated herniation of the transverse colon was perforated in the mediastinum, and partial transverse colon resection and colostomy were performed. Intensive care was required to control septic shock after surgery, and the patient was discharged on the 53rd postoperative day. Conclusions Cases of hiatal hernia with digestive tract prolapsing into the mediastinum after esophagectomy with reconstruction through posterior mediastinum are rare but potentially life-threatening complications.
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Affiliation(s)
- Takuro Konno-Kumagai
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Tadashi Sakurai
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yusuke Taniyama
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kai Takaya
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Ken Ito
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takashi Kamei
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, University of Tohoku, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Pouli S, Kozana A, Papakitsou I, Daskalogiannaki M, Raissaki M. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. Insights Imaging 2020; 11:31. [PMID: 32086627 PMCID: PMC7035412 DOI: 10.1186/s13244-019-0823-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/29/2019] [Indexed: 12/11/2022] Open
Abstract
Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis. Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations. The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.
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Affiliation(s)
- Styliani Pouli
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Androniki Kozana
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Ioanna Papakitsou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - Maria Daskalogiannaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece.
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Colorectal Perforation in Patients with Connective Tissue Disease. Emerg Med Int 2019; 2019:5852438. [PMID: 31321099 PMCID: PMC6607726 DOI: 10.1155/2019/5852438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose The goal of this retrospective study was to identify prognostic factors associated with mortality after surgery for colorectal perforation among patients with connective tissue disease (CTD) and to review postoperative outcomes based on these prognostic factors. Methods The subjects were 105 patients (CTD group: n=26, 24.8%; non-CTD group: n=79, 75.2%) who underwent surgery for colorectal perforation at our department. Cases with iatrogenic perforation due to colonoscopic examination were excluded from the study. We retrospectively investigated perioperative clinicopathological factors in patients undergoing surgery for colorectal perforation. Results There were 7 patients (6.7%) who died within 28 days after surgery in all patients. In multivariate analysis, CTD and fecal peritonitis emerged as significant independent prognostic factors (p=0.005, odds ratio=12.39; p=0.04, odds ratio=7.10, respectively). There were 5 patients (19.2%) who died within 28 days after surgery in the CTD group. In multivariate analysis, fecal peritonitis emerged as a significant independent prognostic factor in the CTD group (p=0.03, odds ratio=31.96). The cumulative survival curve in the CTD group was significantly worse than that in the non-CTD group (p=0.006). An analysis based on the presence of fecal peritonitis indicated no significant difference in cumulative survival curves for patients without fecal peritonitis in the CTD and non-CTD groups (p=0.55) but a significant difference in these curves for patients with fecal peritonitis in the two groups (p<0.0001). Conclusions This study demonstrated that cumulative survival in patients with CTD is significantly worse than that in patients without CTD after surgery for colorectal perforation.
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Diagnostic effectiveness of preoperative water-soluble contrast enema in colorectal perforation. Asian J Surg 2019; 42:696-701. [PMID: 31104697 DOI: 10.1016/j.asjsur.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. METHODS We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV. RESULTS WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively. CONCLUSIONS This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.
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The Association between Absence of Abdominal Pain and Mortality in Lower Intestinal Perforation in Patients with Autoimmune Rheumatic Diseases. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5381453. [PMID: 30906775 PMCID: PMC6398054 DOI: 10.1155/2019/5381453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 01/28/2019] [Indexed: 01/13/2023]
Abstract
Objective To determine mortality and predictive factors for lower intestinal perforation (LIP) among patients with autoimmune rheumatic diseases. Methods This retrospective, single-center, observational study analyzed mortality rates in 31 autoimmune rheumatic disease patients with LIP who were admitted to our hospital from January 2002 to June 2017. The primary outcome was the mortality rate during hospitalization. Results The median age at the time of LIP was 61 years, and the survival rate at discharge was 64.5%. Eleven patients died of sepsis during hospitalization. Cox univariable analysis for mortality during hospitalization showed that absence of abdominal pain (hazard ratio (HR) 5.61, 95% confidence interval (CI) 1.38–22.9), higher age (HR 1.06, 95% CI 1.01–1.11), chronic kidney disease (HR 6.89, 95% CI 1.85–25.7), systemic vasculitis (HR 3.95, 95% CI 1.14–13.6), higher blood urea nitrogen (HR 1.02, 95% CI 1.01–1.04), higher serum creatinine (HR 1.41, 95% CI 1.06–1.87), and LIP due to malignancy (HR 14.3, 95% CI 1.95–105.1) significantly increased mortality. Conclusion Abdominal pain was absent in 16% of LIP patients with autoimmune rheumatic diseases, and this absence was a poor prognostic factor in this cohort. Moreover, higher age, chronic kidney disease, systemic vasculitis, and LIP due to malignancy were associated with significantly increased mortality. Physicians should be aware of LIP in autoimmune disease patients with higher age, chronic kidney diseases, or systemic vasculitis even if patients reveal mild abdominal symptoms.
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Tsuchiya A, Yasunaga H, Tsutsumi Y, Matsui H, Fushimi K. Mortality and Morbidity After Hartmann's Procedure Versus Primary Anastomosis Without a Diverting Stoma for Colorectal Perforation: A Nationwide Observational Study. World J Surg 2018; 42:866-875. [PMID: 28871326 DOI: 10.1007/s00268-017-4193-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The benefit of primary anastomosis (PA) without a diverting stoma over Hartmann's procedure (HP) for colorectal perforation remains controversial. We compared postoperative mortality and morbidity between HP and PA without a diverting stoma for colorectal perforation of various etiologies. METHODS Using the Japanese Diagnosis Procedure Combination database, we extracted data on patients who underwent emergency open laparotomy for colorectal perforation of various etiologies from July 1, 2010 to March 31, 2014. We compared 30-day mortality, postoperative complication rates, and postoperative critical care interventions between HP and PA groups using propensity score matching, inverse probability of treatment weighting, and instrumental variable analyses to adjust for measured and unmeasured confounding factors. RESULTS We identified 8500 eligible patients (5455 HP and 3045 PA). In the propensity score-matched model, a significant difference between the HP and PA groups was detected in 30-day mortality (7.7% vs. 9.6%; risk difference, 1.9%; 95% confidence interval [CI], 0.5-3.4). The inverse probability of treatment weighting showed similar results (8.8% vs. 10.7%; risk difference, 1.9%; 95% CI, 1.0-2.8). In the instrumental variable analysis, the point estimate suggested similar direction to that of the propensity score analyses (risk difference, 4.4%; 95% CI, -3.3 to 12.1). The PA group had significantly higher rates of secondary surgery for complications (4.6% vs. 8.4%; risk difference, 3.8%; 95% CI, 2.5-4.1) and slightly longer duration of postoperative critical care interventions. CONCLUSIONS This study revealed a significant difference in 30-day mortality between HP and PA without a diverting stoma.
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Affiliation(s)
- Asuka Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan. .,Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, 280, Sakuranosato, Ibarakimachi, Higahi-Ibarakigun, Ibaraki, 3113193, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, 280, Sakuranosato, Ibarakimachi, Higahi-Ibarakigun, Ibaraki, 3113193, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138510, Japan
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13
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Otani K, Kawai K, Hata K, Tanaka T, Nishikawa T, Sasaki K, Kaneko M, Murono K, Emoto S, Nozawa H. Colon cancer with perforation. Surg Today 2018; 49:15-20. [PMID: 29691659 DOI: 10.1007/s00595-018-1661-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/30/2018] [Indexed: 02/04/2023]
Abstract
Perforation of the colon is a rare complication for patients with colon cancer and usually requires emergent surgery. The characteristics of perforation differ based on the site of perforation, presenting as either perforation at the cancer site or perforation proximal to the cancer site. Peritonitis due to perforation tends to be more severe in cases of perforation proximal to the cancer site; however, the difference in the outcome between the two types remains unclear. Surgical treatment of colon cancer with perforation has changed over time. Recently, many reports have shown the safety and effectiveness of single-stage operation consisting of resection and primary anastomosis with intraoperative colonic lavage. Under certain conditions, laparoscopic surgery can be feasible and help minimize the invasion. However, emergent surgery for colon cancer with perforation is associated with a high rate of mortality and morbidity. The long-term prognosis seems to have no association with the existence of perforation. Oncologically curative resection may be warranted for perforated colon cancer. In this report, we perform a literature review and investigate the characteristics and surgical strategy for colon cancer with perforation.
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Affiliation(s)
- Kensuke Otani
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
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14
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Jeong DS, Kim YH, Kim KJ. Surgical Outcomes and Risk Factors in Patients Who Underwent Emergency Colorectal Surgery. Ann Coloproctol 2017; 33:239-244. [PMID: 29354607 PMCID: PMC5768479 DOI: 10.3393/ac.2017.33.6.239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/02/2017] [Indexed: 12/02/2022] Open
Abstract
Purpose Emergency colorectal surgery has high rates of complications and mortality because of incomplete bowel preparation and bacterial contamination. The authors aimed to evaluate the surgical outcomes and the risk factors for the mortality and the complication rates of patients who underwent emergency surgery to treat colorectal diseases. Methods This is a prospective study from January 2014 to April 2016, and the results are based on a retrospective analysis of the clinical results for patients who underwent emergency colorectal surgery at Chosun University Hospital. Results A total of 99 patients underwent emergency colorectal surgery during the study period. The most frequent indication of surgery was perforation (75.8%). The causes of disease were colorectal cancer (19.2%), complicated diverticulitis (21.2%), and ischemia (27.2%). There were 27 mortalities (27.3%). The major morbidity was 39.5%. Preoperative hypotension and perioperative blood transfusion were independent risk factors for both morbidity and mortality. Conclusion These results revealed that emergency colorectal surgeries are associated with significant morbidity and mortality. Furthermore, the independent risk factors for both morbidity and mortality in such patiients were preoperative hypotension and perioperative transfusion.
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Affiliation(s)
- Dai Sik Jeong
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
| | - Young Hun Kim
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
| | - Kyung Jong Kim
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
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15
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Büyükaşık K, Gürbulak B, Özoran E, Düzköylü Y, Kabul Gürbulak E, Arı A, Bektaş H. Ostomy in Nontraumatic Conditions: Our Experience and Review of the Literature. Indian J Surg 2017; 78:471-476. [PMID: 28100944 DOI: 10.1007/s12262-015-1413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 11/17/2015] [Indexed: 11/27/2022] Open
Abstract
A number of nontraumatic acute abdomen can result in peritonitis leading to sepsis. In emergent conditions, various procedures like segmentary colectomy and/or subtotal colectomy with anastomosis, Hartmann's procedure, transverse colectomy, and/or expandable metallic stent (SEMS) placement can be performed, considering the status of the patient and the facilitaties of the institution. In our study, we examined the cases diagnosed as acute abdomen without the history of trauma, which had lead to a procedure requiring colostomy. We retrospectively analysed 105 cases of nontraumatic acute abdomen, resulted in a procedure requiring colostomy. American Society of Anesthesiologists (ASA) scoring and Mannheim Peritonitis Index (MPI) were used in the evaluation of the risk of mortality and morbidity. There were colonic perforations of rectosigmoid tumor in 66 cases (62.8 %), sigmoid volvulus in 10 cases (9.5 %), colonic anastomotic leakage in 9 cases (8.5 %), intestinal adhesions in 8 cases (7.6 %), mesenteric ischemia in 5 cases (4.7 %), gynecological diseases in 3 cases (2.85 %), strangulated hernias in 3 (2.85 %), and Ogilvie syndrome in 1 case (0.95 %). Rate of morbidity was found to be 25.7 %, while mortality occurred in 2.8 % of the cases. Cases with mortality and morbidity had ASA scores above two and MPI scores above 23. Anastomotic leakage was the only reason of mortality. In nontraumatic occasions, the management and prognosis of cases with peritonitis, general status of the patients play major roles. The prognosis rates of morbidity and mortality can be highly predicted when ASA and MPI scores are evaluated together.
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Affiliation(s)
- Kenan Büyükaşık
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Bünyamin Gürbulak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey ; Istanbul Eğitim ve Araştırma Hastanesi, Kasap Ilyas mah. Org. Abdurrahman Nafiz Gürman Cd, Zip Code 34098 Fatih, Istanbul Turkey ; Sakarya mah, Silahtaraga cad. No 150/10, Zip Code 34050 Eyup, Istanbul Turkey
| | - Emre Özoran
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yiğit Düzköylü
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Esin Kabul Gürbulak
- Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Aziz Arı
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Hasan Bektaş
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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16
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Shin R, Lee SM, Sohn B, Lee DW, Song I, Chai YJ, Lee HW, Ahn HS, Jung IM, Chung JK, Heo SC. Predictors of Morbidity and Mortality After Surgery for Intestinal Perforation. Ann Coloproctol 2016; 32:221-227. [PMID: 28119865 PMCID: PMC5256250 DOI: 10.3393/ac.2016.32.6.221] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/23/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose An intestinal perforation is a rare condition, but has a high mortality rate, even after immediate surgical intervention. The clinical predictors of postoperative morbidity and mortality are still not well established, so this study attempted to identify risk factors for postoperative morbidity and mortality after surgery for an intestinal perforation. Methods We retrospectively analyzed the cases of 117 patients who underwent surgery for an intestinal perforation at a single institution in Korea from November 2008 to June 2014. Factors related with postoperative mortality at 1 month and other postoperative complications were investigated. Results The mean age of enrolled patients was 66.0 ± 15.8 years and 66% of the patients were male. Fifteen patients (13%) died within 1 month after surgical treatment. Univariate analysis indicated that patient-related factors associated with mortality were low systolic and diastolic blood pressure, low serum albumin, low serum protein, low total cholesterol, and high blood urea nitrogen; the surgery-related factor associated with mortality was feculent ascites. Multivariate analysis using a logistic regression indicated that low systolic blood pressure and feculent ascites independently increased the risk for mortality; postoperative complications were more likely in both females and those with low estimated glomerular filtration rates and elevated serum C-reactive protein levels. Conclusion Various factors were associated with postoperative clinical outcomes of patients with an intestinal perforation. Morbidity and mortality following an intestinal perforation were greater in patients with unstable initial vital signs, poor nutritional status, and feculent ascites.
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Affiliation(s)
- Rumi Shin
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang Mok Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Beonghoon Sohn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Dong Woon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Song
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hye Seong Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung Kee Chung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung Chul Heo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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17
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Han EC, Ryoo SB, Park BK, Park JW, Lee SY, Oh HK, Ha HK, Choe EK, Moon SH, Jeong SY, Park KJ. Surgical outcomes and prognostic factors of emergency surgery for colonic perforation: would fecal contamination increase morbidity and mortality? Int J Colorectal Dis 2015; 30:1495-504. [PMID: 26156966 DOI: 10.1007/s00384-015-2315-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Complications resulting from colonic perforation are related to secondary peritonitis due to bacterial or fecal contamination. We investigated outcomes of emergency surgery for colonic perforation associated with fecal contamination with regard to early and late postoperative complication rates and mortality rates, and investigated prognostic factors influencing those outcomes. METHODS A retrospective analysis of prospectively collected data on factors influencing complications and mortality rates was conducted on data from 152 patients who had undergone emergent operations for colonic perforation between January 2005 and December 2011. Patients were categorized into two groups: those with and without gross fecal contamination at the time of operation. RESULTS Forty-one (26.9 %) patients had gross fecal contamination. Patients who had fetal contamination had a higher Mannheim peritonitis index (31.3 ± 5.1 vs. 21.9 ± 7.2, p < 0.001), higher organ failure rate (53.7 vs. 24.3 %, p = 0.001), and longer operating time (168.8 ± 49.9 vs. 144.8 ± 66.1 min, p = 0.036) than patients without fecal contamination. Early complications (<30 days) occurred more frequently in the fecal contamination group (82.9 vs. 49.5 %, p = 0.001), although late complications (46.2 vs. 39.3 %, p = 0.942) and mortality (17.1 vs. 8.1 %, p = 0.110) did not differ. In multivariate analysis, fecal contamination significantly predicted early complications (odds ratio, 2.78; p = 0.037) but not late complications or mortality. CONCLUSIONS The frequency of early complications can increase if fecal contamination exists. However, when early complications are well managed, fecal contamination does not significantly influence occurrences late complications or mortality.
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Affiliation(s)
- Eon Chul Han
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea.
| | - Byung Kwan Park
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Soo Young Lee
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Heon-Kyun Ha
- Department of Surgery, Myongji Hospital, Goyang, Gyeonggi, Republic of Korea
| | - Eun Kyung Choe
- Seoul National University Hospital Gangnam Center, Seoul, Republic of Korea
| | - Sang Hui Moon
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, 101 Daehangno (28 Yongon-dong), Jongno-Gu, Seoul, 110-744, Republic of Korea
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18
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Yamamoto T, Kita R, Masui H, Kinoshita H, Sakamoto Y, Okada K, Komori J, Miki A, Uryuhara K, Kobayashi H, Hashida H, Kaihara S, Hosotani R. Prediction of mortality in patients with colorectal perforation based on routinely available parameters: a retrospective study. World J Emerg Surg 2015. [PMID: 26213564 PMCID: PMC4513392 DOI: 10.1186/s13017-015-0020-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Even after surgery and intensive postoperative management, the mortality rate associated with colorectal perforation is high. Identification of mortality markers using routinely available preoperative parameters is important. METHODS We enrolled consecutive patients with colorectal perforation who underwent operations from January 2010 to January 2015. We divided them into a mortality and survivor group and compared clinical characteristics between the two groups. Additionally, we compared the mortality rate between different etiologies: malignant versus benign and diverticular versus nondiverticular. We used the χ (2) and Mann-Whitney U tests and a logistic regression model to identify factors associated with mortality. RESULTS We enrolled 108 patients, and 52 (48 %) were male. The mean age at surgery was 71 ± 13 years. The postoperative mortality rate was 12 % (13 patients). Multivariate logistic regression analysis showed that a high patient age (odds ratio [OR], 1.09; 95 % confidence interval [CI], 1.020-1.181) and low preoperative systolic blood pressure (OR, 0.98; 95 % CI, 0.953-0.999) were independent risk factors for mortality in patients with colorectal perforation. In the subgroup analysis, there was no significant difference between the malignant and benign group (11.8 % vs. 23.9 %, respectively; p = 0.970), while the diverticular group had a significantly lower mortality rate than the nondiverticular group (2.6 % vs. 17.1 %, respectively; p = 0.027). CONCLUSIONS Older patients and patients with low preoperative blood pressure had a high risk of mortality associated with colorectal perforation. For such patients, operations and postoperative management should be performed carefully.
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Affiliation(s)
- Takehito Yamamoto
- Department of Surgery, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ogimachi, Kita-ku, Osaka, 530-8480 Japan
| | - Ryosuke Kita
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hideyuki Masui
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiromitsu Kinoshita
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Yusuke Sakamoto
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Kazuyuki Okada
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Junji Komori
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Akira Miki
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Kenji Uryuhara
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiroyuki Kobayashi
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Hiroki Hashida
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Satoshi Kaihara
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
| | - Ryo Hosotani
- Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuoku, Kobe 650-0047 Japan
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Seishima R, Okabayashi K, Hasegawa H, Tsuruta M, Hoshino H, Yamada T, Kitagawa Y. Computed tomography attenuation values of ascites are helpful to predict perforation site. World J Gastroenterol 2015; 21:1573-1579. [PMID: 25663776 PMCID: PMC4316099 DOI: 10.3748/wjg.v21.i5.1573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/27/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of computed tomography (CT) attenuation values of ascites on gastrointestinal (GI) perforation site prediction.
METHODS: The CT attenuation values of the ascites from 51 patients with GI perforations were measured by volume rendering to calculate the mean values. The effect of the CT attenuation values of the ascites on perforation site prediction and postoperative complications was evaluated.
RESULTS: Of 24 patients with colorectal perforations, the CT attenuation values of ascites were significantly higher than those in patients with perforations at other sites [22.5 Hounsfield units (HU) vs 16.5 HU, respectively, P = 0.006]. Colorectal perforation was significantly associated with postoperative complications (P = 0.038). The prediction rate of colorectal perforation using attenuation values as an auxiliary diagnosis improved by 9.8% compared to that of CT findings alone (92.2% vs 82.4%).
CONCLUSION: The CT attenuation values of ascites could facilitate the prediction of perforation sites and postoperative complications in GI perforations, particularly in cases in which the perforation sites are difficult to predict by CT findings alone.
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20
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Shimazaki J, Motohashi G, Nishida K, Ubukata H, Tabuchi T. Postoperative arterial blood lactate level as a mortality marker in patients with colorectal perforation. Int J Colorectal Dis 2014; 29:51-5. [PMID: 23846515 PMCID: PMC3898377 DOI: 10.1007/s00384-013-1738-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to assess the clinical relevance of postoperative arterial blood lactate (LAC) level as a prognostic factor in patients with colorectal perforation. METHODS Forty-two patients (22 males, 20 females; mean age, 70.8 years) underwent emergency surgery for colorectal perforation. The patients were divided into mortality and survivor groups. As a prognostic scoring system, Acute Physiological and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA), and Systemic Inflammatory Response Syndrome criteria were calculated. These scores, postoperative LAC level, and other data, including site and etiology of perforation, elapsed time from onset to surgery (eTIME), preoperative white blood cell (WBC) and platelet counts, preoperative C-reactive protein (CRP), and preoperative arterial blood base excess were assessed between the groups. RESULTS The total mortality rate was 33.3 %. On univariate analysis, the APACHE-II and SOFA scores were significantly higher, and eTIME was significantly longer in the mortality group than in the survivor group. The postoperative LAC level was significantly higher in the mortality group (43.1 ± 14.1 mg/dl) than in the survivor group (23.8 ± 12.7 mg/dl; p < 0.001), and the preoperative WBC was significantly lower in the mortality group than in the survivor group. Multivariate logistic regression analysis using the mortality risk factors determined by univariate analysis (eTIME, APACHE-II score, SOFA score, preoperative WBC count, and postoperative LAC) demonstrated that postoperative LAC level was an independent risk factor for mortality. CONCLUSIONS High postoperative LAC level was a useful factor for predicting high mortality rate in patients with colorectal perforation.
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Affiliation(s)
- Jiro Shimazaki
- Department of Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1, Chuo Ami-Machi, Inasiki-Gun, Ibaraki 300-0395 Japan
| | - Gyo Motohashi
- Department of Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1, Chuo Ami-Machi, Inasiki-Gun, Ibaraki 300-0395 Japan
| | - Kiyotaka Nishida
- Department of Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1, Chuo Ami-Machi, Inasiki-Gun, Ibaraki 300-0395 Japan
| | - Hideyuki Ubukata
- Department of Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1, Chuo Ami-Machi, Inasiki-Gun, Ibaraki 300-0395 Japan
| | - Takafumi Tabuchi
- Department of Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1, Chuo Ami-Machi, Inasiki-Gun, Ibaraki 300-0395 Japan
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21
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Gourgiotis S, Liakos N, Gemenetzis G, Seretis C, Aloizos S, Vougas V, Drakopoulos S. Less Common Nontraumatic Bowel Perforations: Diagnosis and Management through a Retrospective Study. Am Surg 2013. [DOI: 10.1177/000313481307900427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nontraumatic bowel perforation has always been a consideration because of associated morbidity and mortality. The aim of this study is to define etiologies, treatment, and outcomes as well as to highlight difficulties in the diagnosis and management of nontraumatic bowel perforation. We conducted a retrospective study of 35 patients with less common nontraumatic bowel perforations hospitalized during a six-year period. The most common cause was ulcerative colitis (34.3%). Abdominal pain was the constant symptom. Physical examination showed signs of peritoneal irritation in 29 cases. The abdominal radiograph failed to reveal abnormal findings in two patients; the abdominal computed tomography scan confirmed the diagnosis in all cases. Twenty patients (57.1%) were operated on within 24 hours of developing perforation, whereas seven patients (20%) were initially misdiagnosed. Most of the perforations were located only in the large intestine (60%). There was only one perforation in 25 patients (71.5%) and two or more perforations in 10 patients (28.5%). Many less common diseases are responsible for the spontaneous perforation of the bowel. Early diagnosis before the patient's general condition deteriorates decreases mortality and morbidity rates. Adequate resuscitation and emergency laparotomy followed by resection with or without anastomosis remains the treatment of choice.
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Affiliation(s)
- Stavros Gourgiotis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece; and the
| | - Nikolaos Liakos
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece; and the
| | - George Gemenetzis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece; and the
| | - Charalampos Seretis
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece; and the
| | - Stavros Aloizos
- Second Surgical Department, 401 General Army Hospital of Athens, Athens, Greece; and the
| | - Vasilis Vougas
- First Surgical Department, “Evangelismos” General Hospital of Athens, Athens, Greece
| | - Spyros Drakopoulos
- First Surgical Department, “Evangelismos” General Hospital of Athens, Athens, Greece
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Sugimoto K, Sato K, Maekawa H, Sakurada M, Orita H, Ito T, Sakamoto K. Analysis of the efficacy of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) according to the prognostic factors in patients with colorectal perforation. Surg Today 2012; 43:1031-8. [PMID: 23129028 DOI: 10.1007/s00595-012-0399-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 07/05/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been reported to improve the outcomes in patients with colorectal perforation. We retrospectively identified prognostic factors in patients with colorectal perforation and considered the efficacy of PMX-DHP based on these prognostic factors. METHODS One hundred and fifty-six patients who underwent surgery for colorectal perforation in our department between November 1995 and March 2011 were enrolled in this study. The clinicopathological factors were compared between the survivor and non-survivor groups. RESULTS There were 28 patients (17.9 %) who died within 28 days after surgery. According to the multivariate analysis, an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 or more was a significant independent prognostic factor (P = 0.002, odds ratio = 5.39). There was a significant difference in the survival rates between the patients with APACHE II scores of 16 or less and those with scores of 17 or more who had received the PMX-DHP (+) (P < 0.0001). CONCLUSION The APACHE II score is useful as a prognostic factor in patients with colorectal perforation, and the survival rate was 50 % or lower among the patients with APACHE II scores of 17 or higher. Therefore, PMX-DHP appears to have limited efficacy in serious cases.
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Affiliation(s)
- Kiichi Sugimoto
- Department of Surgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295, Japan.
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Martinez M, Last R, Agaba EI, Kassam H, Sun Y, Servilla KS, Murata GH, Tzamaloukas AH. Surgical Procedures before and after Starting Chronic Hemodialysis in a Predominantly Male Population with High Prevalence of Diabetes. Int J Artif Organs 2012; 35:648-654. [DOI: 10.1177/039139881203500904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Milagros Martinez
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine
| | - Reuben Last
- Department of Surgery, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
| | - Emmanuel I. Agaba
- Department of Medicine, Jos University Teaching Hospital, Jos - Nigeria
| | - Hussein Kassam
- Department of Surgery, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
| | - Yijuan Sun
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine
| | - Karen S. Servilla
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine
| | - Glen H. Murata
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine
| | - Antonios H. Tzamaloukas
- Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine
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Yadav D, Garg PK. Spectrum of perforation peritonitis in delhi: 77 cases experience. Indian J Surg 2012; 75:133-7. [PMID: 24426408 DOI: 10.1007/s12262-012-0609-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/06/2012] [Indexed: 12/18/2022] Open
Abstract
Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.
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Jiménez Fuertes M, Costa Navarro D. Resection and primary anastomosis without diverting ileostomy for left colon emergencies: is it a safe procedure? World J Surg 2012; 36:1148-1153. [PMID: 22402970 DOI: 10.1007/s00268-012-1513-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Large-bowel obstruction and perforation are still frequently occurring entities for the acute care surgeon. In these cases, Hartmann's procedure is the most commonly used surgical technique. However, recent papers demonstrate that colon resection and primary anastomosis (RPA) in the emergency setting is a safe and feasible procedure. We present our series of left colon resection and primary anastomosis procedures from Torrevieja Hospital (Alicante, Spain), performed without bowel irrigation or a diverting ileostomy. MATERIALS AND METHODS Thirty-two RPA procedures were performed in emergency settings for perforation or obstruction, or both, during an 18-month period. The following data were prospectively collected: age, gender, nationality, diagnoses, ASA score, body mass index (BMI), POSSUM score (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity), and the score according to the Hinchey classification. Furthermore, duration of the operation, length of postoperative hospital stay, and mortality and morbidity data were recorded. RESULTS Sixteen of these patients were diagnosed with acute diverticulitis, 14 patients with neoplasm (of which 9 cases had obstruction, 2 cases had perforation, and 3 cases had both), and foreign body perforation in the remaining 2 cases. The mean hospital stay was 7.8 (range, 4-10) days. The physiological POSSUM score was 24.4 (range, 15-39), and the surgical POSSUM score was 19.8 (range, 16-24). None of the patients died (0% mortality). Seven patients developed some kind of complication (21.9%), all of which were managed conservatively. CONCLUSIONS The results of this study suggest that RPA for left colon obstruction and perforation in emergency settings can be safely performed in certain surgical conditions.
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Affiliation(s)
- Montiel Jiménez Fuertes
- General and Digestive Tract Department, Marina Baja Medical Center, Alcalde En Jaume Botella Mayor 7, 03570, Villajoyosa, Alicante, Spain
| | - David Costa Navarro
- General and Digestive Tract Department, Marina Baja Medical Center, Alcalde En Jaume Botella Mayor 7, 03570, Villajoyosa, Alicante, Spain .
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Tsujimoto H, Yaguchi Y, Hiraki S, Sakamoto N, Kumano I, Matsumoto Y, Yoshida K, Sugasawa H, Ono S, Yamamoto J, Hase K. Peritoneal computed tomography attenuation values reflect the severity of peritonitis caused by gastrointestinal perforations. Am J Surg 2011; 202:455-60. [PMID: 21943948 DOI: 10.1016/j.amjsurg.2010.08.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Revised: 08/02/2010] [Accepted: 08/02/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the peritoneal computed tomography (CT) attenuation values and relate them to the severity of peritonitis in patients with gastrointestinal tract (GI) perforations. METHODS A total of 56 consecutive patients with GI perforations who underwent CT scan and emergency laparotomy in our hospital were enrolled in this study. The CT attenuation values of the peritoneum were measured on a workstation by 2 independent investigators, and were investigated in relation to the severity of illness and hospital mortality. RESULTS Peritoneal CT attenuation values in hospital nonsurvivors were significantly lower than those in survivors. There was significant negative correlation between peritoneal CT attenuation values and sequential organ failure assessment score, acute physiology and chronic health evaluation II score, and the Mannheim peritonitis index. CONCLUSIONS The evaluation of peritoneal CT attenuation values in patients with peritonitis is simple and can be used for objective assessment of the severity of peritonitis.
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Affiliation(s)
- Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan.
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Tan KK, Hong CC, Zhang J, Liu JZ, Sim R. Surgery for perforated colorectal malignancy in an Asian population: an institution's experience over 5 years. Int J Colorectal Dis 2010; 25:989-995. [PMID: 20390285 DOI: 10.1007/s00384-010-0945-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2010] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Perforated colorectal malignancy is associated with numerous peri-operative complications and dismal long-term survival. The study aimed to review the outcome and factors predicting peri-operative complications and long-term survival of patients who underwent surgery for perforated colorectal malignancy. METHODS A retrospective review of all patients who underwent operative intervention for perforated colorectal malignancy from February 2003 to April 2008 was performed. The severity of peritonitis was graded using the Mannheim peritonitis index (MPI). RESULTS Forty-five patients, median age 67 years (36-97 years), formed the study group. Sigmoid colon (37.8%) and cecum (28.9%) were the most common sites of perforation. Sixteen (35.6%) patients had stage IV disease, while 14 (31.1%) had severe peritoneal contamination (MPI >26). Hartmann's procedure and right hemicolectomy were performed most frequently in 17 (37.8%) and 15 (33.4%) patients, respectively. The mortality rate in our series was 17.8%, with another 26.7% requiring surgical intensive care unit care. The independent variables predicting worse perioperative complications were American Society of Anesthesiologists (ASA) score >or= 3 and MPI >26. Left-sided perforation was the only independent factor predicting stoma creation. The only factor predicting long-term survival was the stage of malignancy (p<0.001). The overall mean survival time for stage II, III, and IV disease were 63.7, 38.1, and 13.8 months, respectively. CONCLUSIONS Surgery for perforated colorectal malignancy is associated with high morbidity and mortality rates. Short-term outcome is determined by ASA score and severity of peritonitis, while long-term outcome is determined by staging of the cancer.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
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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; 13:2252-2259. [PMID: 19707836 DOI: 10.1007/s11605-009-0986-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 08/04/2009] [Indexed: 01/31/2023]
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 >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. 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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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore.
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Whiteoak S, Khan O, Allen SC. Perforated colonic diverticulum in old age: surgical or medical management? Br J Hosp Med (Lond) 2009; 70:699-703. [DOI: 10.12968/hmed.2009.70.12.45506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Simon Whiteoak
- The Royal Bournemouth Hospital, Bournemouth, Dorset BH7 7DW
| | - Omar Khan
- The Royal Bournemouth Hospital, Bournemouth, Dorset BH7 7DW
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30
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Índices pronósticos de mortalidad postoperatoria en la peritonitis del colon izquierdo. Cir Esp 2009; 86:272-7. [DOI: 10.1016/j.ciresp.2009.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 03/25/2009] [Indexed: 01/15/2023]
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Afridi SP, Malik F, Ur-Rahman S, Shamim S, Samo KA. Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience. World J Emerg Surg 2008; 3:31. [PMID: 18992164 PMCID: PMC2614978 DOI: 10.1186/1749-7922-3-31] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 11/08/2008] [Indexed: 03/05/2023] Open
Abstract
Background Perforation peritonitis is the most common surgical emergency encountered by the surgeons all over the world as well in Pakistan. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counter part. This study was conducted at Dow University of health sciences and Civil Hospital Karachi (DUHS & CHK) Pakistan, designed to highlight the spectrum of perforation peritonitis in the East and to improve its outcome. Methods A prospective study includes three hundred consecutive patients of perforation peritonitis studied in terms of clinical presentations, Causes, site of perforation, surgical treatment, post operative complications and mortality, at (DUHS&CHK) Pakistan, from 1st September 2005 – 1st March 2008, over a period of two and half years. All patients were resuscitated underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. Results The most common cause of perforation peritonitis noticed in our series was acid peptic disease 45%, perforated duodenal ulcer (43.6%) and gastric ulcer 1.3%. followed by small bowel tuberculosis (21%) and typhoid (17%). large bowel perforation due to tuberculosis 5%, malignancy 2.6% and volvulus 0.3%. Perforation due to acute appendicitis (5%). Highest number of perforations has seen in the duodenum 43.6%, ileum37.6%, and colon 8%, appendix 5%, jejunum 3.3%, and stomach 2.3%. Overall mortality was (10.6%). Conclusion The spectrum of perforation peritonitis in Pakistan continuously differs from western country. Highest number of perforations noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. Most common cause of perforation peritonitis is perforated duodenal ulcer, followed by small bowel tuberculosis and typhoid perforation. Majority of the large bowel perforations are also tubercular. Malignant perforations are least common in our setup.
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Affiliation(s)
- Shahida Parveen Afridi
- Department of General Surgery, Dow University of Health Sciences and Civil Hospital, Karachi, Pakistan.
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Kabre R, Katz BZ. Bowel ischemia following pneumonia in compromised children. Clin Pediatr (Phila) 2008; 47:598-601. [PMID: 18566355 DOI: 10.1177/0009922808315660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Two severely compromised children developed bowel necrosis in the context of severe pneumonia, presumably secondary to ischemia. No other obvious etiology for the abdominal pathology could be ascertained.
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Affiliation(s)
- Rashmi Kabre
- Department of Surgery, Rush University Medical Center
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Horiuchi A, Watanabe Y, Doi T, Sato K, Yukumi S, Yoshida M, Yamamoto Y, Sugishita H, Kawachi K. Evaluation of prognostic factors and scoring system in colonic perforation. World J Gastroenterol 2007; 13:3228-31. [PMID: 17589902 PMCID: PMC4436609 DOI: 10.3748/wjg.v13.i23.3228] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the significance of scoring systems assessing severity and prognostic factors in patients with colonic perforation.
METHODS: A total of 26 patients (9 men, 17 women; mean age 72.7 ± 11.6 years) underwent emergency operation for colorectal perforation in our institution between 1993 and 2005. Several clinical factors were measured preoperatively and 24 h postoperatively. Acute physiology and chronic health evaluation II (APACHE II), Mannheim peritonitis index (MPI) and peritonitis index of Altona (PIA II) scores were calculated preoperatively.
RESULTS: Overall postoperative mortality rate was 23.1% (6 patients). Compared with survivors, non-survivors displayed low blood pressure, low serum protein and high serum creatinine preoperatively, and low blood pressure, low white blood cell count, low pH, low PaO2/FiO2, and high serum creatinine postoperatively. APACHE II score was significantly lower in survivors than in non-survivors (10.4 ± 3.84 vs 19.3 ± 2.87, P = 0.00003). Non-survivors tended to display high MPI score and low PIA II score, but no significant difference was identified.
CONCLUSION: Pre- and postoperative blood pressure and serum creatinine level appear related to prognosis of colonic perforation. APACHE II score is most associated with prognosis and scores ≥ 20 are associated with significantly increased mortality rate.
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Affiliation(s)
- Atsushi Horiuchi
- Department of Surgery 2, Ehime University School of Medicine, Shitsukawa, Toon-city, Ehime 791-0295, Japan.
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Hynninen M, Wennervirta J, Leppäniemi A, Pettilä V. Organ dysfunction and long term outcome in secondary peritonitis. Langenbecks Arch Surg 2007; 393:81-6. [PMID: 17372753 DOI: 10.1007/s00423-007-0160-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Accepted: 01/24/2007] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. PATIENTS AND METHODS 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. RESULTS Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). CONCLUSION Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis.
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Affiliation(s)
- M Hynninen
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, PO Box 340, Haartmaninkatu 4, 00029 HUS Helsinki, Finland.
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Alam I, Shanoon D, Alhamdani A, Boyd A, Griffiths AP, Baxter JN. Severe proctitis, perforation, and fatal rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case. Surg Today 2007; 37:66-9. [PMID: 17186350 PMCID: PMC7102328 DOI: 10.1007/s00595-006-3335-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 07/25/2006] [Indexed: 01/30/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor-Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.
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Affiliation(s)
- Imran Alam
- Department of Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
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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; 15:91-6. [PMID: 17049848 DOI: 10.1016/j.suronc.2006.09.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Perforation of colorectal cancer (CRC) is rare and is associated with a significantly high mortality and morbidity. The aim of the current study was to evaluate various factors influencing the outcome in these patients. MATERIAL AND METHODS A retrospective analysis of 42 patients with perforated CRC between 1999 and 2003 was performed. A number of variables including age, sex, site of perforation, presence of faecal peritonitis, grade of surgeon, presence of metastasis, stage of tumour, type of surgery, ASA grade and CR POSSUM score were analysed for their influence on the outcome in these patients using MS Excel, MS Access and Stata. RESULTS Of the 42 patients 19 were female and 23 were male. The mean age of the patients was 70.5 (range 44-96yr). Thirty patients had perforation at the tumour, 10 proximal to the tumour, and one distal to the primary tumour. The perforation was localised in 25 patients. However, 17 patients had free perforation with frank faecal peritonitis. Twenty-one patients had resection and anastomosis, 18 patients had resection without restoration of bowel continuity and 3 had palliative colostomy. The in-hospital mortality (within 30d) was 40.5% (n=17) with only 15 patients being alive at the end of 2yr with an overall mortality of 64.3% (n=27). The outcome was not altered by variables such as sex, surgeon's grade, surgical procedure, Dukes' staging or the site of perforation (p>0.5). Univariate analysis showed that advanced age (p<0.01), higher ASA grade (p<0.001), higher CR POSSUM score (p<0.001) and degree of peritonitis (p<0.01) were strongly associated with adverse outcomes. However, in stepwise multivariate logistic regression analysis ASA grade (p=0.01) and CR POSSUM score (p=0.01) were the only significant predictors of in-hospital mortality. CONCLUSION The outcome of perforated colonic cancer continues to be poor. ASA score and CR POSSUM score are good predictors of the short-term outcome.
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Affiliation(s)
- Muzaffar Ali Anwar
- Department of Surgery, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, UK
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Komatsu S, Shimomatsuya T, Nakajima M, Ono S, Maruhashi K. Severity Scoring Systems for Prognosis and Efficacy of Polymyxin B-Immobilized Fiber Treatment for Colonic Perforation. Surg Today 2006; 36:807-10. [PMID: 16937285 DOI: 10.1007/s00595-006-3256-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 03/14/2006] [Indexed: 01/31/2023]
Abstract
PURPOSE There is no established system for predicting prognosis and evaluating the efficacy of antiseptic treatments such as polymyxin B-immobilized fiber (PMX) according to the severity of peritonitis in patients with colonic perforation. We investigated the predictive value of various severity scoring systems for survival and for the efficacy of antiseptic treatments, to identify high-risk patients. METHODS We reviewed 26 consecutive patients who underwent emergency operations between 1996 and 2003 for colorectal perforation not caused by trauma or iatrogenic disease. Several severity scores, i.e., Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Mannheim Peritonitis Index (MPI), and Multiple Organ Failure (MOF) were calculated and analyzed as predictive scoring systems for prognosis, survival and efficacy of PMX treatment. RESULTS An APACHE II score of 19, a SOFA score of 8, an MPI score of 30, and an MOF score of 7 or more were significantly related to a poor prognosis. With or without PMX treatment, an APACHE II score of 15 or less, a SOFA score of 7 or less, an MPI score of 27 or less, and an MOF score of 7 or less were all related to a good prognosis. Conversely, all patients died when the severity scoring points were higher than 20 in APACHE II, higher than 12 in SOFA, and higher than 39 in MPI. When PMX treatment was given to patients with an intermediate score, no correlation between survival and its efficacy was found, except in the MOF scoring system. CONCLUSION These severity scoring systems can assist with the prediction of prognosis. They may also be useful for determining if PMX treatment would be unnecessary or ineffective in certain patients. However, the optimal application of PMX treatment in selected patients according to the severity scoring systems needs further investigation.
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Affiliation(s)
- Shuhei Komatsu
- Department of Surgery, Nagahama Red Cross Hospital, Nagahama, Shiga, Japan
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Yoo PS, Mulkeen AL, Frattini JC, Longo WE, Cha CH. Assessing risk factors for adverse outcomes in emergent colorectal surgery. Surg Oncol 2006; 15:85-9. [PMID: 17074478 DOI: 10.1016/j.suronc.2006.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 08/27/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND A variety of factors influence the increased morbidity and mortality seen in patients undergoing emergent colon surgery. Understanding comorbid conditions and variations in preoperative laboratory values that effect both morbidity and mortality can influence clinical decision making. METHODS During a 5-year period 185 patients underwent colon surgery at the Veterans Administration Hospital in West Haven, CT. Through a retrospective chart review patients were classified as having either emergent or elective surgery. Patient characteristics and postoperative outcomes were analyzed using Chi Square and logistic regression models. RESULTS Differences existed in preoperative variables as well as postoperative outcomes when comparing emergent and elective paitents. In those patients undergoing emergent colorectal surgery, both morbidity and mortality were increased and overall survival decresed when compared to a non-emergent population. CONCLUSIONS Through identification of preoperative variables such as a hematocrit <30, the use of steroids, an albumin <3.5, and a creatinine of >1.4, those patients at risk for postoperative morbidity and mortality can be identified and clinical decision making can be appropriately adjusted.
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Affiliation(s)
- Peter S Yoo
- VA Connecticut Healthcare, Yale University School of Medicine, Department of Surgery, 330 Cedar Street, LH 118, P.O. Box 208062, New Haven, CT 06520-8062, USA
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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; 93:616-22. [PMID: 16607684 DOI: 10.1002/bjs.5326] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prognostic evaluation of patients with left colonic perforation is useful in predicting mortality. The aims of this prospective study were to determine the prognostic value of the left colonic Peritonitis Severity Score (PSS) and to compare it with the Mannheim Peritonitis Index (MPI). METHODS One-hundred and fifty-six patients underwent emergency operation for distal colonic peritonitis. The PSS and MPI were calculated for each patient. The Spearman rank correlation coefficient was used to measure the association between the two scores. The predictive power of the two scoring systems and their differences were studied using the area under the receiver-operator characteristic (ROC) curve. RESULTS Forty-one patients died (26.3 per cent). The relationship between scores and mortality was statistically significant for each scoring system (P < 0.001). The Spearman rank correlation coefficient for the correlation between the MPI and PSS was 0.55 (P < 0.001). There was no difference between areas under the ROC curves for the two systems. CONCLUSION The PSS and MPI are both well validated scoring systems for left colonic peritonitis. Their routine use might allow stratification of patients according to mortality risk.
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Affiliation(s)
- S Biondo
- Department of Surgery, Colorectal Unit, Hospital Universitario de Bellvitge, University of Barcelona, C/Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
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Gupta S, Kaushik R. Peritonitis - the Eastern experience. World J Emerg Surg 2006; 1:13. [PMID: 16759427 PMCID: PMC1475566 DOI: 10.1186/1749-7922-1-13] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 04/26/2006] [Indexed: 02/07/2023] Open
Abstract
Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6–27%.
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Affiliation(s)
- Sanjay Gupta
- Department of Surgery Government Medical College and Hospital Chandigarh, India
| | - Robin Kaushik
- Department of Surgery Government Medical College and Hospital Chandigarh, India
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Edremitlioğlu M, Kiliç D, Oter S, Kisa U, Korkmaz A, Coşkun O, Bedir O. The Effect of Hyperbaric Oxygen Treatment on the Renal Functions in Septic Rats: Relation to Oxidative Damage. Surg Today 2005; 35:653-61. [PMID: 16034546 DOI: 10.1007/s00595-004-3000-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Accepted: 11/16/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate the effects of hyperbaric oxygen (HBO) treatment on renal functions and damage in septic rats. METHODS The animals were divided into four groups, each containing ten animals: control, hyperbaric oxygen, sepsis, and sepsis/hyperbaric oxygen. One milliliter of saline containing live Escherichia coli cells (2.1 x 10(9)) was injected intraperitoneally to induce sepsis. The groups treated with HBO were given five sessions of 2 atmospheres absolute of 100% oxygen at intervals of 6 h. Blood, urine, and tissue samples were then collected, and the functional renal parameters, malondialdehyde (MDA) levels, and superoxide dismutase (SOD) and catalase activities were examined. RESULTS The reduced glomerular filtration rate and urine flow returned to normal levels after HBO treatment; however, the increase in fractionated sodium excretion continued. The increased MDA levels in the renal cortex and medulla also decreased to the level of the control group. In the sepsis group, both the SOD and catalase activities decreased in the renal cortex, while a reduction was observed only in the catalase activity in the medulla. The reduced enzyme activities significantly increased in the sepsis/hyperbaric oxygen group. CONCLUSION HBO treatment has a beneficial effect on renal dysfunction in sepsis. The probable reason for this effect is the reduction in oxidative damage because of the increase in antioxidative capacity.
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Affiliation(s)
- Mustafa Edremitlioğlu
- Department of Physiology, Kirikkale University School of Medicine, 71100 Kirikkale, Turkey
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