Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States

Background Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied. Objective The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations. Methods Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016–2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up. Results Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4–12.5%] vs 6.0% [95% CI 5.8–6.3%] for large bowel resection; 2.3% [95% CI 2.0–2.6%] vs 0.2% [95% CI 0.2–0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1–69.0%] vs 25.9% [95% CI 25.2–26.5%]) and cholecystectomy (33.7% [95% CI 32.7–34.7%] vs 2.9% [95% CI 2.8–3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days. Conclusions Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.

Covering Ileal Loop without Ostomy: A New Approach to Bring Down the Enterostomy-Related Morbidity

Ileostomy is a commonly performed procedure for colon surgeries and the following emergency small or large bowel resection and anastomosis. We proposed a successful new technique of covering ileal loop without opening it, to decrease the stoma and reversal-related complications.

Laparoscopic colopexy for neo-left colonic volvulus 10 years after anterior resection

Recurrent neo-left colonic volvulus is a rare complication following anterior resection. The conventional approach to treating recurrent volvulus is a large bowel resection with anastomosis or colostomy formation after successful endoscopic decompression. However, in elderly and comorbid patients, this can result in significant morbidity or mortality. Laparoscopic colopexy is a less invasive alternative that has not been previously reported for the treatment of neo-left colonic volvulus. We describe a case of an 86-year-old male who presented with recurrent neo-left colonic volvulus 10 years post-laparoscopic anterior resection for cancer. A laparoscopic colopexy was performed to resolve the volvulus and prevent future recurrence. Interrupted prolene sutures were used to fix the neo-left colon to the posterior stomach and the left lateral abdominal wall. The patient had an uncomplicated postoperative recovery and was discharged 6 days after surgery. He was well at 6 months follow-up.

Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program

Background and aims Colonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program. Methods We identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection. Results For those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%). Conclusions Serious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.

Morbidity and mortality following major large bowel resection for colorectal cancer detected by a population-based screening program

Background and aims In 2008, Ontario initiated a population-based colorectal screening program using guaiac fecal occult blood testing. This work was undertaken to fill a major gap in knowledge by estimating serious post-operative complications and mortality following major large bowel resection of colorectal cancer detected by a population-based screening program. Methods We identified persons with a first positive fecal occult blood result between 2008 and 2016, at the age of 50–74 years, who underwent a colonoscopy within 6 months, and proceeded to major large bowel resection for colon cancer within 6 months or rectosigmoid/rectal cancer within 12 months, and identified an unscreened cohort of resected cases diagnosed during the same years at the age of 50–74 years. We identified serious postoperative complications and readmissions ≤30 days following resection, and postoperative mortality ≤30 days, and between 31 and 90 days among the screen-detected and the unscreened cohorts. Results Serious post-operative complications or readmissions within 30 days were observed among 1476/4999 (29.5%) cases in the screen-detected cohort, and among 3060/8848 (34.6%) unscreened cases. Mortality within 30 days was 43/4999 (0.9%) among the screen-detected cohort, and 208/8848 (2.4%) among the unscreened cohort. Among 30 day survivors, mortality between 31 and 90 days was 28/4956 (0.6%) and 111/8640 (1.3%), respectively. Conclusion Serious post-operative complications, readmissions, and mortality may be more common following major large bowel resection for colorectal cancer between the ages of 50 and 74 among unscreened compared to screen-detected cases.

Fistulas Healing. Stable Gastric Pentadecapeptide BPC 157 Therapy

This review is focused on the healing of fistulas and stable gastric pentadecapeptide BPC 157. Assuming that the healing of the various wounds is essential also for the gastrointestinal fistulas healing, the healing effect on fistulas in rats, consistently noted with the stable gastric pentadecapeptide BPC 157, may raise several interesting possibilities. BPC 157 is originally an anti-ulcer agent, native to and stable in human gastric juice (for more than 24 h). Likely, it is a novel mediator of Robert’s cytoprotection maintaining gastrointestinal mucosal integrity. Namely, it is effective in the whole gastrointestinal tract, and heals various wounds (i.e., skin, muscle, tendon, ligament, bone; ulcers in the entire gastrointestinal tract; corneal ulcer); LD1 is not achieved. It is used in ulcerative colitis clinical trials, and now in multiple sclerosis, and addressed in several reviews. Therefore, it is not surprising that BPC 157 has documented consistent healing of the various gastrointestinal fistulas, external (esophagocutaneous, gastrocutaneous, duodenocutaneous, colocutaneous) and internal (colovesical, rectovaginal). Taking fistulas as a pathological connection, this rescue is verified with the beneficial effects in rats with the various gastrointestinal anastomoses, esophagogastric, jejunoileal, colo-colonic, ileoileal, esophagojejunal, esophagoduodenal, and gastrojejunal. This beneficial effect occurs equally when the gastrointestinal anastomoses are impaired with the application of NSAIDs, cysteamine, large bowel resection, as well as concomitant esophageal, gastric, and duodenal lesions and/or ulcerative colitis presentation, short bowel syndrome progression, liver and brain disturbances presentation. Particular aspects of the BPC 157 healing of the fistulas are especially emphasized.

Anastomotic Leak after Colorectal Surgery. Our Experience in three Years.

Background: One of the most severe complication after intestinal resection, often with catastrophic consequence for the patient is leakage from the anastomosis. The severity of complications after anastomotic leak may range from a small localized peritonitis or abscess formation without sepsis, to a development of a four quadrant peritonitis with septic shock. Until now despite the seriousness of this complications, the cause of anastomotic leakage are not yet definitively clear. Aim: The aim of this study is to submit our experience in treatment of patients with anastomotic leakage after intestinal resection and their outcome. Materials and Methods: The study included 63 patients with colorectal cancer operated in the Department of Surgery at the Clinical Hospital of Tetova. In all patients intestinal resection with end to end anastomosis was performed. Conclusions: Anastomotic leak after large bowel resection is a very serious complication with a great impact on patient’s morbidity and mortality. Multiple risk factors are associated with occurrence of this complication whereas the more suspected are: preoperative anaemia, hypoalbuminemia, emergent surgery without adequate preparation of patient, intraoperative blood loss and blood transfusion during surgery etc. Early detection of AL is very important and helpful to improve the outcome of patients and to minimize postoperative rate of morbidity and mortality. Keywords: anastomotic leaks, colorectal surgery, risk factors