Outcome analysis of patients undergoing colorectal resection for emergent and elective indications

Despite advances in perioperative care and operative techniques, urgent colorectal operations are associated with higher morbidity and mortality. To evaluate our rate of complications in elective and urgent colorectal operations, we performed retrospective chart review of 209 consecutive patients who underwent colorectal resection between 1998 and 2002 at Harbor-UCLA Medical Center. One hundred, forty-three (71%) patients underwent elective colorectal resection. A total of 19 (13.3%) complications occurred in the elective group, compared with 24 (38.1%) in the urgent group (P = 0.003). Both right-sided and left-sided operations were associated with higher incidence of complications when performed urgently. Wound infection occurred in 7.7 per cent of patients undergoing an elective operation and 14.3 per cent in an urgent setting (P = 0.21). Intra-abdominal abscess occurred in 1.4 per cent of patients undergoing elective operation, compared with 11.1 per cent in the urgent operation group. Four (1.9%) patients developed wound dehiscence, 1 in elective and 3 in the urgent group (P = 0.09). Anastomotic leak occurred in 1.9 per cent of patients, 2 in each group (P = 0.6). There were six deaths, 3 in elective and 3 in urgent cases (P = 0.4). Urgent operation of the colon and rectum is associated with higher incidence of complications. Both right- and left-sided resections have a higher complication rate when performed in a nonelective setting.     

Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection

BACKGROUND: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery. METHODS: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days. RESULTS: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not. CONCLUSION: MBP does not lower the complication rate and can be omitted before elective colonic resection. Registration number: ISRCTN28535118 (http://www.controlled-trials.com).     

Mechanical bowel preparation for elective colorectal surgery: a meta-analysis

HYPOTHESIS: There is little scientific evidence to support the routine practice of mechanical bowel preparation (MBP) before elective colorectal surgery in order to minimize the risk of postoperative septic complications. DATA SOURCES: Trials were retrieved using a MEDLINE search followed by a manual search of the bibliographic information in select articles. Languages were restricted to English, French, Spanish, Italian, and German. There was no date restriction. STUDY SELECTION: Only prospective randomized clinical trials (RCTs) evaluating MBP vs no MBP before elective colorectal surgery were included. DATA EXTRACTION: Outcomes evaluated were anastomotic leakage, intra-abdominal infection, wound infection, reoperation, and general and extra-abdominal morbidity and mortality rates. Data were extracted by 2 independent observers. DATA SYNTHESIS: Seven RCTs were retrieved. The total number of patients in these RCTs was 1297 (642 who had received MBP and 655 who had not). Among all the RCTs reviewed, anastomotic leak was significantly more frequent in the MBP group, 5.6% (36/642), compared with the no-MBP group, 2.8% (18/655) (odds ratio, 1.84; P = .03). Intra-abdominal infection (3.7% for the MBP group vs 2.0% for the no-MBP group), wound infection (7.5% for the MBP group vs 5.5% for the no-MBP group), and reoperation (5.2% for the MBP group vs 2.2% for the no-MBP group) rates were nonstatistically significantly higher in the MBP group. General morbidity and mortality rates were slightly higher in the MBP group. CONCLUSIONS: There is no evidence to support the use of MBP in patients undergoing elective colorectal surgery. Available data tend to suggest that MBP could be harmful with respect to the incidence of anastomotic leak and does not reduce the incidence of septic complications.     

Feasibility of colorectal surgery without colonic preparation. A prospective study

INTRODUCTION: Mechanical bowel preparation (MBP), aimed at reducing the infectious complications of colorectal surgery, was considered as indispensable. This benefit is actually disputed. The aim of this study was to report an experience of colorectal surgery without MBP. MATERIALS AND METHODS: Hundred ninety patients without MBP and without low residue diet, who underwent colorectal surgery with primary anastomosis not requiring a diverting stoma were included. The main outcome were the rate of mortality, anastomotic leak, wound infection and intra-abdominal abscess. Secondary outcomes were duration of intravenous perfusion, nasogastric aspiration, total hospitalisation stay and time to realimentation. RESULTS: The procedure was performed by laparotomy (n=142) or laparoscopy (n=48). Forty-eight patients underwent emergency surgery. Ninety-two patients were operated for malignancy. The rate of mortality was 6.3% in correlation with the scale of AFC. The rate of anastomotic leak was 3.7%. The rate of specific morbidity was independent of scale of AFC on the contrary to the frequency of non-specific complications. The mean duration of intravenous perfusion and nasogastric suction were 6 days and 0.3 day. The patient had normal diet to the 4th day (4+/-3 days). The mean hospital stay was 13.4 days. CONCLUSION: The colorectal surgery without MBP may be safely performed and could improve the quality of life of patients in the perioperatory period.     

Comparison of one dose versus three doses of prophylactic antibiotics, and the influence of blood transfusion, on infectious complications in acute and elective colorectal surgery

In a randomized prospective controlled trial involving 311 patients undergoing acute or elective colorectal surgery, the efficacy and safety of two different single dose and one triple dose regimen of antibiotic prophylaxis, as well as the influence of blood transfusion on postoperative infectious complications, were studied. Postoperative infectious complications occurred in a total of 59 patients (19.0 per cent). There were no major differences between the three treatment groups. Thirty-four patients (10.9 per cent) developed abdominal wound infection, 17 patients (5.5 per cent) intra-abdominal abscess and 16 patients (5.1 per cent) anastomotic leakage. Of 202 patients (65.0 per cent) requiring blood transfusion during hospitalization 57 (28.2 per cent; 95 per cent confidence limits of 23-36 per cent) developed infectious complications, whereas two non-transfused patients (1.8 per cent; 95 per cent confidence limits of 0.2 to 6 per cent; P less than 0.001) developed infectious complications. It is concluded that one single dose of antibiotic prophylaxis in acute and elective colorectal surgery is as protective as a triple dose regimen. The development of infectious complications despite antibiotic prophylaxis is strongly related to blood transfusion.     

Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection

BACKGROUND: The value of routine nasogastric tube (NGT) decompression after elective hepatic resection has not been investigated. METHODS: Of 200 patients who had elective hepatic resection, including 68 who had previously had colorectal surgery, 100 were randomized to NGT decompression, where the NGT was left in place after surgery until the passage of flatus or stool, and 100 to no decompression, where the NGT was removed at the end of the operation. RESULTS: There was no difference between patients who had NGT decompression and those who did not in terms of overall surgical complications (15.0 versus 19.0 per cent respectively; P = 0.451) medical morbidity (61.0 versus 55.0 per cent; P = 0.391), in-hospital mortality (3.0 versus 2.0 per cent; P = 0.640), duration of ileus (mean(s.d.) 4.3(1.5) versus 4.5(1.7) days; P = 0.400) or length of hospital stay (14.2(8.5) versus 15.8(10.8) days; P = 0.220). Twelve patients randomized to no NGT decompression required reinsertion of the tube 3.9(1.9) days after surgery. Previous abdominal surgery had no influence on the need for NGT reinsertion. Severe discomfort was recorded in 21 patients in the NGT group and premature removal of the tube was required in 19. Pneumonia (13.0 versus 5.0 per cent; P = 0.047) and atelectasis (81 versus 67 per cent; P = 0.043) were significantly more common in the NGT group. CONCLUSION: Routine NGT decompression after elective hepatectomy had no advantages. Its use was associated with an increased risk of pulmonary complications.     

Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation

Background

A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery.

Methods

A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery.

Results

Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively).

Conclusions

No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery.     

Complications after colorectal surgery without mechanical bowel preparation

BACKGROUND: The current practice of mechanical bowel preparation (MBP) before colorectal surgery is questionable. Mechanical bowel preparation is unpleasant for the patient, often distressful, and potentially harmful. The results are often less than desired, increasing the risk of contamination. Cleansing the colon and rectum before surgery has never been shown in clinical trials to benefit patients. In animal experiments MBP has a detrimental effect on colonic healing. STUDY DESIGN: To investigate the outcomes of colorectal surgery without MBP, we prospectively evaluated a consecutive series of patients who underwent resection and primary anastomosis of the colon and upper rectum, including emergency operations. One surgeon performed all operations. Endpoints were wound infection, anastomotic failure, and death. Late signs and symptoms that might be secondary to leakage of the anastomosis were considered as an anastomotic failure as well, during a followup of 1 year. RESULTS: Two hundred fifty operations were performed, of which 199 (79.6%) were elective. Colectomies were left-sided in 65.6%. Anastomoses were ileocolic in 32%, colocolic in 20.8%, colorectal intraperitoneal in 34.4%, and extraperitoneal in 12.8%. No patient suffered from fecal impaction. Followup was complete in 97.2%. Eight patients (3.3%; 95% confidence interval [CI]: 1.4-6.4) developed superficial wound infections. In three patients there was leakage from an extraperitoneal colorectal anastomosis, in two of them after hospital discharge. The overall anastomotic failure rate was 1.2% (95% CI: 0.3-3.6). The in-hospital mortality rate was 0.8% (95% CI: 0.1-2.9) and was not related to abdominal or septic complications. CONCLUSION: Mechanical bowel preparation is not a sine qua non for safe colorectal surgery.     

Early oral feeding after colorectal resection: a randomized controlled study

BACKGROUND: Nasogastric (NG) intubation is widely used following elective abdominal operations although it is associated with morbidity and discomfort. The present study is a randomised controlled trial on the effect of early oral feeding without NG decompression following elective colorectal resection for cancer. METHODS: One hundred patients were randomized to group A (NG catheter and fasting until passage of flatus, followed by liquid diet advanced to soft-solid) or group B (no NG tube, clear liquids the day after surgery, followed by soft-solid food). The endpoints were: (i) morbidity; (ii) resumption of intestinal function; (iii) length of hospital stay; and (iv) patients' well being evaluated by short-form health survey [36 items] (SF-36). RESULTS: Twelve complications occurred in group A (50 patients) and 13 in group B (50 patients) (P = NS). Seven patients developed vomiting in group A as compared to 16 in group B (P < 0.05). Twenty per cent of patients required NG decompression in group B hence 80% did not need NG tubes. Resumption of intestinal function occurred after 4 days, and length of hospital stay was 7 days in both groups. No significant difference was detected between groups (P = NS) in the SF-36 score change before and after the operation. CONCLUSION: Patients undergoing elective colorectal resection can be managed without postoperative NG catheters, starting oral feeding on the first postoperative day. Albeit, no reduction in postoperative hospital stay or patients' well being could be detected, abolition of postoperative NG intubation with early oral feeding was a safe approach, with only 20% of patients requiring NG decompression because of repeated episodes of vomiting.     

Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer

BACKGROUND: A randomized comparison of D1 (level 1 lymphadenectomy) and D3 (levels 1, 2 and 3 lymphadenectomy) dissection was performed to evaluate morbidity and effects on survival from gastric cancer. METHODS: A total of 221 patients were studied after resection for gastric cancer, 110 after D1 surgery and 111 after D3 surgery. RESULTS: The morbidity rate was higher after D3 than after D1 resection (17.1 (95 per cent confidence interval (c.i.) 10.1 to 24.1) versus 7.3 (95 per cent c.i. 2.4 to 12.2) per cent respectively; P = 0.012). The difference was largely related to abdominal abscess (8.1 per cent after D3 versus none after D1 resection; P = 0.003). The D3 group had an anastomotic leak rate of 4.5 per cent whereas there was no leakage in the D1 group (P = 0.060). All anastomotic leaks were minor and were managed non-operatively with nutritional support. Patients who had D3 resection had longer operating times, greater blood loss and postoperative drain outputs, and more patients needed blood transfusion. There was no death in either group. The hospital stay was longer after D3 than D1 surgery (mean(s.d.) 19.6(13.9) (range 10-98) versus 15.0(4.0) (range 10-30) days; P = 0.001). CONCLUSION: Extended lymphadenectomy for gastric cancer is associated with more complications than limited lymphadectomy but this does not lead to significant mortality.     

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND: The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis. METHODS: Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications. RESULTS: Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors. CONCLUSION: Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.     

Emergency and elective surgery in patients over age 70

Emergency surgery in 100 patients over age 70 was associated with a 31 per cent morbidity and a 20 per cent mortality, significantly greater than the 6.8 per cent morbidity and 1.9 per cent mortality following elective procedures in the same age group (P less than .0005). Sixteen per cent (100 of 613) of all geriatric patients were operated on under emergent conditions and the postoperative hospitalization was often significantly prolonged when compared with similar elective operations (P less than .05). Emergency surgery was most commonly performed on the large bowel (25%), abdominal wall (17%), stomach (17%), biliary tract (11%), and small bowel (10%). Inguinal herniorraphy was the most frequently performed elective procedure (33%), followed by colon resection (25%), and cholecystectomy (12%). Fifty-nine per cent (23 of 39) of complications associated with urgent operation and 39 per cent (16 of 41) following elective surgery involved the cardiorespiratory systems and were frequently related to underlying diseases. Of the 20 patients who died in the intensive care unit of multisystem failure, 16 had undergone emergency procedures. Elective surgery in the elderly may be performed safely; however, emergency surgery entails a high risk to the patient and a high cost in hospital resources.     

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial

OBJECTIVE: To assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. SUMMARY BACKGROUND DATA: Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. METHODS: Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. RESULTS: Three hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. CONCLUSIONS: These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.     

Prophylactic antibiotics in elective colorectal surgery

A randomized prospective study was conducted on 194 patients who underwent elective colorectal surgery for carcinoma. All patients received the same mechanical bowel preparation. In addition, patients in group A received oral neomycin and erythromycin base; patients in group B received systemic metronidazole and gentamicin, while patients in group C received both oral and systemic antibiotics. Postoperative septic complications related to colorectal surgery occurred in 27.4 per cent, 11.9 per cent and 12.3 per cent respectively in groups A, B and C (chi 2 = 7; P less than 0.05). The incidence of sepsis in groups B and C was almost identical. Patients who received oral antibiotics alone (group A) had significantly higher risks of postoperative sepsis when compared with patients in either group B or group C (P less than 0.05). As there is no additional advantage of combining oral and systemic antibiotics, we recommend systemic metronidazole and gentamicin to be used with mechanical bowel preparation in elective colorectal surgery.     

Final 12-year follow-up of surgery versus surveillance in the UK Small Aneurysm Trial

BACKGROUND: The aim was to determine whether early open surgical repair would benefit patients with small abdominal aortic aneurysm compared with surveillance on long-term follow-up. METHODS: The 1090 patients who were enrolled into the UK Small Aneurysm Trial between 1991 and 1995 were followed up for aneurysm repair and mortality until November 2005. RESULTS: By November 2005, 714 patients (65.5 per cent) had died, 929 (85.2 per cent) had undergone aneurysm repair, 150 (13.8 per cent) had died without aneurysm repair and 11 (1.0 per cent) remained alive without aneurysm repair. After 12 years, mortality in the surgery and surveillance groups was 63.9 and 67.3 per cent respectively, unadjusted hazard ratio 0.90 (P = 0.139). Three-quarters of the surveillance group eventually had aneurysm repair, with a 30-day elective mortality of 6.3 per cent (versus 5.0 per cent in the early surgery group, P = 0.366). Estimates suggested that the cost of treatment was 17 per cent higher in the early surgery group, with a mean difference of 1326 pounds. The death rate in these patients was about twice that in the population matched for age and sex. CONCLUSION: There was no long-term survival benefit of early elective open repair of small abdominal aortic aneurysms. Even after successful aneurysm repair, the mortality among these patients was higher than in the general population.     

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer

Objective Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution. Method All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients’ demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival. Results One hundred and ninety‐three patients were identified with a median age of 79 years (31–94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty‐nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty‐four patients underwent bypass procedures. Thirty‐day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1‐year survival of 38%. Patients undergoing operation on an emergent basis had poorer long‐term survival (127 vs 320 days, P = 0.002). Conclusion Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.     

French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease

BACKGROUND: The aim of this study was to compare in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD). METHODS: This prospective national multicentre observational study included all consecutive patients undergoing open or laparoscopic elective colectomy for SDD in a 4-month period between June and September 2002. Postoperative in-hospital mortality and morbidity in the two groups were compared. RESULTS: Three hundred and thirty-two consecutive patients undergoing either laparoscopic (163 patients) or open (169 patients) colectomy for SDD were analysed. Overall postoperative mortality and morbidity rates were 0.3 and 23.8 per cent respectively. The morbidity rate was significantly higher in the open than in the laparoscopic group (P < 0.001), leading to a significantly longer hospital stay (P < 0.001). The morbidity rate remained significantly higher in the open group when the patients were matched for age (P = 0.015) or American Society of Anesthesiologists score (P = 0.028). An open procedure (relative risk (RR) 2.13 (95 per cent confidence interval (c.i.) 1.29 to 3.45)), age over 70 years (RR 1.62 (95 per cent c.i. 1.14 to 2.30)) and intraperitoneal contamination (RR 2.54 (95 per cent c.i. 1.18 to 5.50)) were identified as independent risk factors for morbidity. CONCLUSION: A laparoscopic approach to elective treatment of SDD may be associated with reduced postoperative morbidity and hospital stay. A randomized study is required to confirm these results.     

Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer

BACKGROUND: The impact of anastomotic leakage on immediate postoperative mortality in patients undergoing potentially curative resection for colorectal cancer is well recognized. Its impact on long-term survival is less clear. The aim of the present study was to evaluate the relationship between anastomotic leakage and long-term survival in patients undergoing potentially curative resection for colorectal cancer. METHODS: A total of 2235 patients who underwent potentially curative resection for colorectal cancer between 1991 and 1994 in Scotland were included in the study. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Fourteen (16 per cent) of the 86 patients with an anastomotic leak died within 30 days of surgery compared with 83 (3.9 per cent) of 2149 without a leak. The 5-year cancer-specific survival rate, including postoperative deaths, was 42 per cent in patients with an anastomotic leak compared with 66.9 per cent in those with no leak (P < 0.001). Excluding postoperative deaths, respective values were 50 and 68.0 per cent (P < 0.001). The adjusted relative hazard ratios, for patients with an anastomotic leak compared with those without a leak, and excluding 30-day mortality, were 1.61 (95 per cent confidence interval (c.i.) 1.19 to 2.16; P = 0.002) for overall survival and 1.99 (95 per cent c.i. 1.42 to 2.79; P < 0.001) for cancer-specific survival. CONCLUSION: Development of an anastomotic leak is associated with worse long-term survival after potentially curative resection for colorectal cancer.     

Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit

BACKGROUND: Surgery for rectal cancer is associated with high morbidity and mortality rates. The reason for this has been much debated. This population-based study reports the findings on postoperative morbidity and mortality after rectal cancer surgery following the introduction of a centralized colorectal unit in a county central hospital, supervised by a colorectal surgeon using the most recent techniques. METHODS: All consecutive patients with rectal cancer who underwent surgery at four county hospitals in the V?stmanland county in Sweden during 1993-1996 (n = 133) were compared with patients who underwent surgery at the new colorectal unit in the county central hospital from 1996 to 1999 (n = 144). RESULTS: The number of operating surgeons was reduced from 26 to four. The postoperative mortality rate decreased from 8 to 1 per cent (P = 0.002) and the total postoperative complication rate was reduced from 57 to 24 per cent (P < 0.001). Surgical complications dropped from 37 to 11 per cent (P < 0.001). The relaparotomy rate fell from 11 to 4 per cent (P < 0.05). Postoperative stay in hospital was reduced from a median of 13 to 9 days (P < 0.001). CONCLUSION: The new organization, with centralized rectal cancer surgery using modern techniques, reduced postoperative mortality and overall morbidity rates to less than half.     

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery

BACKGROUND: Hypothermia is common in the operating theatre and may increase susceptibility to postoperative complications. Intraoperative systemic warming has been shown to improve outcomes of surgery. This study aimed to examine the effects of additional perioperative systemic warming on postoperative morbidity. METHODS: All patients admitted for elective major abdominal surgery and fulfilling the inclusion criteria were randomized into control or warming groups. Both groups were warmed during surgery, but patients in the warming group were additionally warmed 2 h before and after surgery using a conductive carbon polymer mattress. RESULTS: The trial recruited 103 patients (56 in the control group, 47 in the warming group). Both groups were well matched for age, sex and clinical state. Patients in the warming group had lower blood loss (median 200 (range 5-1000) ml versus median 400 (range 50-2300) ml in the control group; P = 0.011) and complication rates (15 (32 per cent) of 47 versus 30 (54 per cent) of 56 in the control group; P = 0.027). There were three deaths; two in the control group (P = 0.566). CONCLUSION: Extending systemic warming to the perioperative period had additional beneficial effects, with minimal additional cost and patient discomfort.