Colorectal resection in emergency general surgery: An EAST multicenter trial

Abstract

Objective: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients.

Methods: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality.

Results: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality.

Conclusion: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality.

Level of evidence: Therapeutic study, level IV.

Figure 1.

Twenty-one medical centers enrolled patients. Enrolling centers included the following: Cooper University Hospital, George Washington University Hospital, Loma Linda University Medical Center, Los Angeles County + University of Southern California Medical Center, Marshfield Clinic, Massachusetts General Hospital, Mayo Clinic Rochester, Medical City Plano, Methodist Dallas Medical Center, Northwestern Memorial Hospital, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, Reading Hospital, Rutgers Robert Wood Johnson, Southside Hospital—Northwell Health, Tufts Medical Center, UCHealth—Memorial Hospital, UCHealth—University of Colorado Hospital, University of California—Irvine, University of Miami/Ryder Trauma Center, University of Texas Southwestern Medical Center/Parkland Hospital, and West Virginia University Hospital (listed alphabetically).