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.     

Elective and emergency abdominal surgery in patients 90 years of age or older

Background

Few studies have examined perioperative outcomes in nonagenarians undergoing abdominal surgery, and fewer have reported on 1-year mortality. Our objectives were to determine the outcomes of abdominal surgery in nonagenarians and to assess the performance of Physiologic and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (p-POSSUM) as predictors of mortality.

Methods

We conducted a retrospective chart review of all patients 90 years and older who underwent abdominal surgery between 2000 and 2007 at a tertiary care hospital.

Results

We included 145 patients (median age 91, range 90–101 yr). The most common diagnoses were colorectal cancer (19.3%) and hernias (19.3%), and the most common procedures were bowel resection with anastomosis (25.5%) and hernia repair (18.6%). Overall in-hospital mortality was 15.2% (20.8% in the emergent group and 9.6% in the elective group; p = 0.06). The 1-year mortality (49.1% v. 27.8%; p = 0.016), complication (81.9% v. 61.6%; p = 0.007) and intensive care unit admission rates (44.4% v. 11.0%; p < 0.001) were significantly higher among emergent than elective surgical patients. The operative indications and procedures associated with the highest in-hospital mortality were large bowel obstruction (42.3%) and bowel resection with anastomosis (27.0%). Both the POSSUM and p-POSSUM scoring systems significantly overpredicted mortality, particularly in higher risk groups.

Conclusion

Nonagenarians undergoing abdominal surgery have substantial operative morbidity and mortality, particularly in emergent surgical cases. Nearly 50% of patients who undergo emergency procedures die within 1 year after surgery. The POSSUM and p-POSSUM scoring systems were not reliable predictors of in-hospital mortality.     

The morbidity and mortality of emergent operations for colorectal disease.

p6 participants in the Veterans Administration Cooperative Studies Program investigating antibiotic prophylaxis in colorectal operations, 693 consecutive patients (1978-1981) from three hospitals were studied. This report concerns 20% of these patients who presented with either perforation, obstruction, or hemorrhage necessitating emergent surgical intervention on unprepared bowel. The 30-day, in-hospital mortality of the 138 patients undergoing emergency operations was 28%. Elective colorectal procedures during the same period had a six per cent mortality rate. There is a striking difference in the cause of death in prepared patients and those needing emergent surgery. Death in prepared patients was usually of a vascular etiology, while septic-related mortality was present in only one per cent. On the other hand, despite massive doses of antibiotics, fecal diversion, surgical drainage and lavage, abdominal sepsis was documented in 20% and septic related mortality was present in 17% of patients undergoing emergency operations. Early, elective treatment and prevention of obstruction and perforation will improve our results in colorectal disease.     

Renal dysfunction after myocardial revascularization.

OBJECTIVES: In this study, we evaluate the incidence of and analyse the pre and intraoperative risk factors for the development of postoperative renal dysfunction (PRD), and the impact of such an event on perioperative mortality and on hospital length of stay. In addition, we sought to investigate the influence of a mildly increased serum creatinine (1.3-2.0 mg/dl) on perioperative mortality and morbidity. METHODS: The study included 2445 consecutive patients who had no pre-existing renal disease (creatinine or=2.1 mg/dl with a preoperative-to-postoperative increase >or=0.9 mg/dl. Univariate and multivariate analyses were performed where appropriate. RESULTS: Global 30-day mortality was 0.7%. The incidence of PRD was 5.6% (136 patients). Mortality for patients who experienced PRD was 8.8 vs. 0.1% for patients who did not (P<0.001). PRD increased the length of hospital stay by 3.4 days (7.6 vs. 11.0 days; P<0.001), and patients who needed haemodialysis (11%) had a perioperative mortality of 33.3% and a mean hospital length of stay of 16 days. Multivariable logistic regression identified the following variables as independent predictors of PRD: age (P=0.017; odds ratio (OR) 1.3 per 10 years), angina class III/IV (P=0.003; OR 1.7); cardiopulmonary bypass time (P=0.007; OR 1.01 per minute); preoperative serum creatinine levels: group 1 (1.3-1.6 mg/dl (P<0.001; OR 5.5)) and group 2 (1.7-2.0 mg/dl (P<0.001; OR 14.2)). Finally, a mild elevation of the preoperative creatinine level (1.3-2.0 mg/dl) increased significantly the probability of perioperative mortality, low cardiac output, haemodialysis and prolonged hospital stay. CONCLUSIONS: Although the likelihood of PRD in patients without pre-existing renal dysfunction is relatively low, it dramatically increases mortality, morbidity and length of stay after CABG. Mildly elevated (>1.2 mg/dl) preoperative serum creatinine level significantly increases the perioperative mortality and morbidity.     

After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors

Surgeons are becoming increasingly involved in the care of elderly patients. The purpose of this project was to evaluate contemporary outcomes of emergent surgeries performed after hours in elderly patients and to determine any risk factors for poor outcome. We retrospectively reviewed patients 80 years or older undergoing an urgent or emergent surgery at our medical center from 6 pm to 6 am from October 2006 through July 2009. Comparisons were made between survivors and nonsurvivors using Wilcoxon rank sum and Fisher exact test when indicated. P < 0.05 was considered significant. During the study period, 59 patients met inclusion criteria; the average age was 84 years (range, 80 to 102 years). A total of 70 procedures were performed; the most common were colectomy (18), small bowel resection (13), lysis of adhesions (9), and gastric surgery (8). The majority of patients were female (68%) with 47 per cent and 53 per cent of patients undergoing emergent and urgent surgery, respectively. Sixty-seven complications occurred in 38 patients; the morbidity rate was 64 per cent, and the mortality rate was 25 per cent. The only studied factors significantly associated with mortality were higher American Society of Anesthesiologists score (P = 0.004), increased intravenous fluids (P = 0.03), decreased intraoperative urine output (P = 0.03), and the need for intraoperative blood (P = 0.003). After-hours urgent and emergent surgery in the elderly has a high morbidity and mortality rate. We identified several risk factors for a poor prognosis that may be useful to the surgeon when discussing the patient's prognosis with the family.     

Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery

BACKGROUND: Preoperative creatinine values higher than 2.5 mg/dL are associated with markedly increased risk for both mortality and morbidity in patients undergoing coronary artery bypass surgery. We aimed to determine the effects of prophylactic perioperative hemodialysis on operative outcome in patients with nondialysis-dependent moderate renal dysfunction. METHODS: Forty-four adult patients with creatinine levels greater than 2.5 mg/dL but not requiring dialysis underwent coronary artery bypass surgery with cardiopulmonary bypass. The patients were randomly divided into two groups. In group 1 (dialysis group, 21 patients), perioperative prophylactic hemodialysis was performed in all patients. Group 2 (23 patients) was taken as a control group and hemodialysis was performed only if postoperative acute renal failure was diagnosed. RESULTS: The hospital mortality was 4.8% (1 patient) in the dialysis group, and 30.4% (7 patients) in the control group (p = 0.048). Postoperative acute renal failure requiring hemodialysis was seen in 1 patient (4.8%) in the dialysis group and in 8 patients (34.8%) in the control group (p = 0.023). Thirty-three postoperative complications were observed in the control group for an early morbidity of 52.2% (12 patients) and 13 complications occurred in 8 patients in the dialysis group (38.1%). The average length of the intensive care unit and postoperative hospital stay were shorter in the dialysis group than in the control group (p = 0.005 and p = 0.023, respectively). CONCLUSIONS: Preoperative creatinine levels higher than 2.5 mg/dL, increase the risk of mortality and the development of acute renal failure and prolong the length of hospital stay after on-pump coronary artery bypass surgery. Perioperative prophylactic hemodialysis decreases both operative mortality and morbidity in these high-risk patients.     

Modest serum creatinine elevation affects adverse outcome after general surgery

BACKGROUND: Modest preoperative serum creatinine elevation (1.5 to 3.0 mg/dL) has been recently shown to be independently associated with morbidity and mortality after cardiac surgery. It is important to know if this association can be applied more broadly to general surgery cases. METHODS: Multivariable logistic regression analyses of 46 risk variables in 49,081 cases from the Veterans Affairs National Surgical Quality Improvement Program, undergoing major general surgery from 10/1/96 through 9/30/98. RESULTS: Thirty day mortality and several cardiac, respiratory, infectious and hemorrhagic morbidities were significantly (P < 0.001) higher in patients with a serum creatinine>1.5 mg/dL. With multivariable analysis, the adjusted odds ratio for mortality for patients with a serum creatinine of 1.5 to 3.0 mg/dL was 1.44 [95% confidence interval (95% CI) 1.22 to 1.71] and for creatinine>3.0 mg/dL was 1.93 (95% CI 1.51 to 2.46). The adjusted odds ratio for morbidity (one or more postoperative complications) for patients with a serum creatinine of 1.5 to 3.0 mg/dL was 1.18 (95% CI 1.06 to 1.32) and for creatinine>3.0 mg/dL was 1.19 (95% CI 0.99 to 1.43). Further stratification and recursive partitioning of creatinine levels revealed that a serum creatinine level>1.5 mg/dL was the approximate threshold for both increased morbidity and mortality. CONCLUSIONS: Modest preoperative serum creatinine elevation (>1.5 mg/dL) is a significant predictor of risk-adjusted morbidity and mortality after general surgery. A preoperative serum creatinine of 1.5 mg/dL or higher is a readily available marker for potential adverse outcomes after general surgery.     

Cardiac surgery with cardiopulmonary bypass in patients with chronic renal failure.

OBJECTIVE: Renal failure is known to increase the morbidity and mortality in patients undergoing cardiac surgery. The results of heart surgery in patients with non-dialysis-dependent, mild renal insufficiency are not clear. METHODS: One hundred nineteen adult patients with chronic renal failure underwent cardiac surgery. Group I consisted of 93 patients who had creatinine levels between 1.6 and 2.5 mg/dL but who were not supported by dialysis. Group II consisted of 18 patients with creatinine levels higher than 2.5 mg/dL who were not supported by dialysis. Group III consisted of 8 patients with end-stage renal disease who were receiving hemodialysis. RESULTS: The hospital mortality rates were 11.8%, 33.0%, and 12.5%, respectively. Morbidity was 21.5%, 44.4%, and 75.0%, respectively, in groups I, II, and III. Postoperative hemodialysis was needed in 2 (2.15%) patients from group I and 6 (33%) patients from group II. On multivariable logistic regression analysis, risk factors for mortality were preoperative creatinine level more than 2.5 mg/dL, angina class III-IV, emergency operation, excessive mediastinal hemorrhage, postoperative pulmonary insufficiency, low cardiac output, and rhythm disturbances. Risk factors for morbidity were preoperative creatinine level more than 2.5 mg/dL and postoperative dialysis. CONCLUSIONS: Chronic renal failure increases the mortality and morbidity in patients undergoing cardiac surgery. Renal insufficiency with creatinine levels higher than 2.5 mg/dL increases the risk of postoperative dialysis and prolongs the length of hospital stay. Careful preoperative management and intraoperative techniques, such as avoiding low perfusion pressure and using low-dose dopamine, may be useful for a good operative outcome.     

Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.     

Profile and significance of emergency colonic resections

The objectives of this study are to define the distinguishing features between elective and emergency colonic surgery. The records of adult patients who underwent elective and emergent colonic resection over a 4-year period were retrospectively reviewed. Univariate analysis was performed to compare outcomes for elective and emergency procedures and multiple logistic regression analysis was performed to identify the significant predictors of outcome. Three hundred and thirty-eight elective and 147 emergency colonic resections were performed. Diverticular disease was most common in the emergency group (43.5% vs 14.2%, P = 0.001) whereas malignancy predominated in the elective group (56.2% vs 5.4%, P = 0.001). The emergency group accounted for 54.7 per cent and 79.3 per cent of the total morbidity and mortality. Emergency colonic surgery has distinctive features and significance. Emergency surgery for colonic obstruction and total/subtotal resection are associated with higher morbidity and mortality. Diverticular disease compares favorably to other pathologies in postoperative outcome.     

Operative acute small bowel obstruction: admitting service impacts outcome.

Early surgical intervention in acute small bowel obstruction (SBO) has long been recognized as an important factor in preventing morbidity and mortality. Factors associated with surgically managed acute SBO were analyzed for delay in intervention and impact on outcome. A retrospective review of all patients evaluated for SBO on the surgical teaching service of the Greenville Hospital System from July 1, 1997 to June 30, 2000 was performed. Data were collected on patient demographics, admission information (date, admitting service, physical examination, and laboratory values), comorbidity, diagnostic studies, surgery date, operative findings, postoperative complications, operative mortality, and discharge date. Analysis of the data revealed 157 cases of presumed SBO of which 61 were managed nonoperatively and 96 required surgery. Acute SBO was diagnosed in 65 patients who constitute the basis for this review. Of these 65 patients 43 (66%) were admitted to the surgical service, 25 (38%) required small bowel resection, and 17 (26%) developed morbidity and/or mortality. When analyzed for morbidity and mortality the only characteristics that were statistically significant were the admitting service (P = 0.003) and length of stay (P = 0.003). On further analysis of admitting service and patient outcomes several factors were significant when we compared medical service admissions to surgical service admissions. These included days from admission to surgery (P = 0.003), length of stay (P = 0.019), morbidity (P = 0.004), mortality (P = 0.005), and combined morbidity and mortality (P = 0.003). Mortality of patients admitted to the medical service was 27 per cent compared with 2 per cent for the surgical service. There were no differences in morbidity and mortality when analyzed by the need for small bowel resection, patient age, etiology of obstruction, or presence of comorbidities. None of the factors studied were useful in predicting the need for small bowel resection. Our findings agree with those of previous investigators with regard to 1) lack of association between the preoperative evaluation and the need for small bowel resection and 2) the association between delay in diagnosis and increased morbidity and mortality. In addition we have found that one of the primary causes of delay in treatment for SBO was admission to the medical service. This delay led to significantly higher mortality in these patients. We recommend early surgical evaluation for any patient admitted with SBO as a differential diagnosis.     

Serum creatinine and perioperative outcome--a matched-pairs approach using computerised anaesthesia records

BACKGROUND AND OBJECTIVE: A study was designed to utilise the resources of our computerised anaesthesia record keeping system to assess the attributable effects of increased preoperative creatinine (> 1.3 mg dL(-1)) on outcome in patients undergoing non-cardiac surgery. METHODS: This retrospective study was based on data sets of 58 458 patients recorded with a computerised anaesthesia record keeping system over a period of 4 yr at a tertiary care university hospital. Cases were defined as patients with a preoperative creatinine > 1.3 mg dL(-1); controls (creatinine < or = 1.3 mg dL(-1)) were selected and automatically matched according to several parameters (ASA physical status, high risk and urgency of surgery, age and gender) in a stepwise fashion. Main outcome measures were hospital mortality and the incidence of intraoperative cardiovascular events. RESULTS: Three-thousand-and-twenty-eight patients (5.2%) had preoperative creatinine values > 1.3 mg dL(-1). Matching was successful for 54.5% of the cases, leading to 1649 cases (mean creatinine 3.3 +/- 2.2 mg dL(-1)) and 1649 controls (1.0 +/- 0.2 mg dL(-1)). The crude mortality rates for the cases and matched controls were 2.2% (n = 36) and 0.9% (n = 15), respectively (P = 0.003). Intraoperative cardiovascular events were found in 30.1% of the patients (n = 496) and in 28.3% of the matched controls (n = 466; P = 0.25, power = 0.46). Using logistic regression analyses a significant association between preoperative increased creatinine and hospital mortality was found (odds ratio 2.62; 95% confidence interval [1.39; 4.931). CONCLUSIONS: An increased preoperative serum creatinine in patients undergoing non-cardiac surgery is associated with an increased perioperative risk, but not with a higher incidence of intraoperative cardiovascular events.     

Carotid artery stenting: identification of risk factors for poor outcomes

OBJECTIVES: Age greater than 80 has been identified as a risk factor for complications, including stroke and death, in patients undergoing carotid artery angioplasty and stenting (CAS). This study evaluates other potential predictors of perioperative complications in patients undergoing CAS. METHODS: All cerebrovascular endovascular procedures performed by the vascular surgery division at our university hospital between July 2003 and December 2005 were retrospectively examined. During the course of 212 admissions, 198 patients underwent 215 procedures. Patient age, comorbidities, and admission status were analyzed as independent (predictor) variables. Complication rate, discharge disposition, and length of hospital stay were considered dependent (outcome) variables. Logistic regression and Fisher exact test or Student t test were performed, as appropriate. RESULTS: Complications included major and minor stroke, myocardial infarction, femoral artery pseudoaneurysm, and death. The rates of perioperative major and minor stroke were 0.5% and 2.8%, respectively. Chronic renal insufficiency was a predictor of perioperative complications, including stroke: patients with serum creatinine greater than 1.3 mg/dL had a 37% complication rate and a 11.1% stroke rate, while those with normal renal function had a 13% complication rate (P = .003) and a 0.6% stroke rate (P =.001). Similar association was seen between creatinine clearance and both stroke and complications. Obesity was a risk factor for complications, but not stroke: obese patients had a complication rate of 28%, while others had a 16% complication rate (P = .024). Emergency admission predicted both extended hospital stay (P < .001) and requirement for further inpatient care in a rehabilitation or nursing facility (P = .007). There was no significant difference in complication rate or stroke rate between octogenarians and others. CONCLUSION: This experience demonstrates that chronic renal insufficiency, obesity, and emergent clinical setting are risk factors for patients undergoing CAS.     

Perioperative factors as predictors of operative mortality and morbidity in pneumonectomy

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure (P < 0.021), sepsis (P < 0.008), and male sex (P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.     

Cholangitis: analysis of admission prognostic indicators and outcomes

Acute cholangitis is a life-threatening complication of biliary obstruction that is exacerbated by delays in diagnosis and treatment. Since the introduction of endoscopic retrograde cholangiography and endoscopic therapeutic modalities, few investigations have addressed admission prognostic indicators of adverse outcomes. A retrospective review of all patients with a diagnosis of acute cholangitis from 1995 to 2005 was performed. Primary endpoints were organ failure and death. One-hundred and seventeen patients met criteria for acute cholangitis. Only 49 (42%) had Charcot's triad and 3 (3%) had Reynolds' pentad. One-hundred and four (89%) patients underwent biliary decompression, of which 79 (76%) were treated by endoscopic methods. There were 29 (25%) cases of organ failure and 9 (8%) deaths. The admission white blood cell (WBC) count (P = 0.0003) and total bilirubin (TBili) (P = 0.04) were statistically significant predictors of organ failure or death. With an admission of WBC > or = 20,000 cells/mm3, the sensitivity, specificity, positive predictive value, and negative predictive value for organ failure and death were 50 per cent, 92 per cent, 63 per cent, and 88 per cent, respectively. A TBili of > or =10 mg/dL had sensitivity, specificity, positive predictive value, and negative predictive value of 56 per cent, 85 per cent, 21 per cent, and 96 per cent, respectively for predicting death. Admission WBC > or = 20,000 cells/mm3 and TBili > or =10 mg/dL are selective predictors of adverse outcomes in acute cholangitis.     

Emergent right hemicolectomies

Emergent right hemicolectomies have historically been associated with surprisingly high morbidity and mortality rates. A retrospective review of emergent right hemicolectomies over a 7-year period was performed to assess current morbidity and mortality. Emergent right hemicolectomy was defined as a procedure performed for an acute abdomen with no formal preoperative cleansing of the colon. Demographic data, diagnostic evaluation, length of stay and outcomes were evaluated. Over the study period, 122 emergent right hemicolectomies were performed on both general surgery and trauma patients. The average patient was 52.9 +/- 18.5 years old, and the majority of patients (66.4%) were male. The indications for the procedures performed were bowel perforation (51), hemorrhage (25), cancer (16), benign obstruction (14), phlegmon (8), ischemia (6), or other (2). Resection with primary anastomosis was performed in 98 patients, 16 had an end ileostomy, and 8 underwent damage control procedures in which gastrointestinal continuity was not reestablished at the time of the original operation. Postoperative complications developed in 48 patients (39.3%). The majority of the complications (83.3%) were related to infection including intra-abdominal abscess (21 patients), sepsis (16), and wound infection (5). Other complications included anastomotic leak (5), wound dehiscence (3), stoma-related (3) and postoperative bowel obstruction (2). The patients who developed complications did not differ from those who had an uneventful postoperative course in terms of age, indication for procedure, or presence of intraabdominal abscess or gross contamination at the time of the original procedure. The overall mortality rate was 13 per cent. Patients who died were older than those who lived (63 +/- 19 vs 52 +/- 18; P = 0.03) and were significantly more likely to have evidence of shock on presentation (P = 0.0013). Emergent right hemicolectomies continue to be associated with high morbidity and mortality rates. The most common complications are related to infection. Age and manifestations of shock at the time of admission are strong predictors of mortality.     

Intestinal obstruction.

One hundred severty-one cases of mechanical intestinal obstruction were studied. One hundred fifteen had small bowel obstruction and fifty-six had large bowel obstruction. Adhesion (32.8 per cent), hernia (21.6 per cent), and neoplasm (18.1 per cent) were the cause of obstruction in more than 70 per cent of all cases. More than 40 per cent of patients were older than 60 years and the average age was 52.7. The numbers of males and females were approximately equal. There were twice as many whites as blacks, and the mortality rate was higher among blacks. The overall uncorrected mortality rate was 18.7 per cent. Operation was performed in 105 patients (61.4 per cent), with a postoperative mortality of 19 per cent and corrected postoperative mortality of 4.5 per cent. Contributing factors that were significant were high incidence of metastatic diseases, elderly patients, and delay in admission.     

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.     

Orthotopic liver transplantation: postoperative complications and their management

The Birmingham liver transplant programme started in 1982. Forty-six patients have been transplanted with a follow-up of 3 months or longer. Twenty-seven patients are still alive, of whom sixteen have lived for more than one year. The 30 day hospital mortality was 30.4 per cent and the actuarial predicted one year survival 55.5 per cent. Four patients have been regrafted for chronic rejection and graft failure. Thirteen patients have required surgery in the postoperative period for: bleeding (two), removal of abdominal packs (four), biliary leaks and obstruction (five), duodenal perforation (one) and small bowel obstruction (one). Acute rejection was common, occurring in 30 patients and progressing to chronic rejection in 4. Ten patients developed renal failure with an 80 per cent mortality and eleven patients developed grand mal fits. Severe bleeding (greater than 70 units) was associated with previous abdominal surgery and a high mortality (88.9 per cent). Opportunistic fungal infection carried a 100 per cent mortality. Although more than half of all transplanted patients will survive for more than one year, the postoperative period is still one of high morbidity and mortality.     

Mortality,morbidity and functional outcome after ileorectal anastomosis

BACKGROUND: Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. The aim of this study was to review postoperative mortality, morbidity and functional results in an effort to identify risk factors predictive of a poor outcome. METHODS: Some 215 patients (118 women and 97 men) with a median age of 33 (interquartile range (i.q.r.) 25-47) years underwent an IRA between November 1990 and December 1999. Median follow-up was 2 years 9 months (i.q.r. 1-5 years). The clinical notes of these patients were reviewed retrospectively to analyse the postoperative course, bowel function and long-term clinical outcome. RESULTS: The indications for surgery included familial adenomatous polyposis (52.1 per cent), Crohn's disease (14.4 per cent), functional bowel disorder (14.4 per cent), ulcerative colitis (8.4 per cent) and colonic carcinoma (4.7 per cent). The overall 30-day mortality and morbidity rates were 0.9 and 26.0 per cent respectively. This included anastomotic leak (6.5 per cent), small bowel obstruction (14.4 per cent), fistula (2.8 per cent) and anastomotic stricture (1.4 per cent). The incidence of fistula and anastomotic stricture was significantly higher in Crohn's disease (P < 0.001 and P = 0.005 respectively). Only 16 of 31 patients with Crohn's disease had a functioning IRA at long-term follow-up. Median stool frequency was 3 (i.q.r. 3-5) per day one year following surgery and did not change with longer follow-up. CONCLUSION: Mortality and morbidity rates following IRA are low. Postoperative fistula and anastomotic stricture are more common in patients with Crohn's disease, approximately half of whom will eventually need a permanent ileostomy. Long-term bowel function for all groups is satisfactory.