Colorectal resection in Emergency General Surgery - An EAST multicenter trial.

Aicher, Brittany O; Hernandez, Matthew C; Betancourt-Ramirez, Alejandro; Grossman, Michael D; Heise, Holly; Schroeppel, Thomas J; Kongkaewpaisan, Napaporn; Kaafarani, Haytham M A; Wagner, Afton; Grabo, Daniel; Scott, Michael; Peck, Gregory; Chang, Gloria; Matsushima, Kazuhide; Cullinane, Daniel C; Cullinane, Laura M; Stocker, Benjamin; Posluszny, Joseph; Simonoski, Ursula J; Catalano, Richard D; Vasileiou, Georgia; Yeh, D Dante; Agrawal, Vaidehi; Truitt, Michael S; Pickett, MaryAnne; Dultz, Linda; Muller, Alison; Ong, Adrian W; San Roman, Janika L; Barth, Nadine; Fackelmayer, Oliver; Velopulos, Catherine G; Hendrix, Cheralyn; Estroff, Jordan M; Gambhir, Sahil; Nahmias, Jeffry; Jeyamurugan, Kokila; Bugaev, Nikolay; Portillo, Victor; Carrick, Matthew M; O'Meara, Lindsay; Kufera, Joseph; Zielinski, Martin D; Bruns, Brandon R

Evidence comparing stoma (STM) versus anastomosis (ANST) after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an EAST-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients over 11-months. Preoperative, intraoperative, and postoperative variables were recorded. Chi-square, Mann-Whitney U-test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS 439 patients were enrolled (184 ANST, 255 STM). Median (IQR) age was 62 (53-71) years and median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). STM group was older (64 vs. 58 years, p<0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively STM patients were more likely to be intubated (57 vs. 15, p<0.001), on vasopressors (61 vs. 13, p<0.001), have pneumoperitoneum (131 vs. 41, p<0.001) or fecal contamination (114 vs. 33, p<0.001), and had a higher incidence of elevated lactate (149 vs. 67, p<0.001). Overall mortality was 13%, which was higher in STM patients (18 vs. 8%, p=0.02). Surgical complications were more common in STM patients (35 vs. 25%, p=0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion and larger hospital size were associated with development of a surgical complication while CCI, preoperative vasopressor use, steroid use, open abdomen and intraoperative blood transfusion were independently associated with mortality. CONCLUSIONS This study highlights a tendency to perform fecal diversion in patients that are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level III.