O.O. Ayandipo1, 2, O.O. Afuwape1,2, A.B. Ojo2, I.K. Egbuchulem2 and D.O. Irabor1,2
- Department of Surgery, College of Medicine, University of Ibadan, Nigeria.
- Department of Surgery, University College Hospital, Ibadan, Nigeria.
Abstract
Objectives: While the epidemiology of benign colonic pathologies has not significantly changed in our region, colorectal cancer has steadily increased with a majority of patients presenting with late stage disease particularly large bowel obstruction. This study reviews the outcome of emergency and elective colon and proximal rectal cases with regards to perioperative morbidity and mortality.
Setting: All patients who had surgery for symptoms of lower gastrointestinal tract disease (caecum and proximal rectum) between January 2008 and January 2018 at University College Hospital, Ibadan were included. Data regarding elective or emergency presentation, peri-operative findings, operative details and postoperative course were recorded prospectively.
Results: Out of the 1618 patients with symptoms, 817 were operated on as emergencies (38.1%) and electives (61.9%). The median age of patients who had emergency and elective surgery were 56 (33-81) and 59 (27-87) respectively (p-0.05). Right hemicolectomy (152; 18.6%) was the commonest procedure, followed by anterior resection (115; 14.1%) and colostomy (114; 13.9%). Overall morbidity was 13.7% (elective 4.2%; emergency 9.5%), while mortality was 6.8% (elective 2.1%; emergency 4.7%). The commonest morbidities were superficial surgical site infection (SSSI) and wound dehiscence. Bowel perforation or gangrene was the most significant predictor of mortality.
Conclusion: Large bowel obstruction complicated with perforation and gangrene is a major risk factor for morbidity and mortality in colorectal surgery.
Correspondence:
Dr. O.O. Ayandipo
Department of Surgery,
University College Hospital,
Ibadan,
Nigeria
Email: yokebukola@yahoo.com
Introduction
Colorectal cancer has steadily increased in sub-Saharan Africa over the last 20 years1-4, with about two – fifth of patients presenting with late stage disease4,5. One of the commonest modes of presentation of advanced disease are symptoms of large bowel obstruction necessitating emergency treatment, which often leads to an increased morbidity and mortality6. The epidemiology of benign colonic pathologies has not changed significantly over time in our region; except for the noted reduction in colonic intussusception and sigmoid volvulus which hitherto accounted for a large volume of emergency colon surgeries 7-11. The outcomes following emergency and elective colorectal surgeries have been well studied with documented morbidity and mortality rates of between 1-30% 12-15. We prospectively reviewed all colon and proximalrectal surgical cases done since 2008 with the aims of auditing our outcomes with regards to perioperative morbidity and mortality. We also identified risk factors for peri-operative (in-hospital) mortality following colon and proximal rectal surgery in our practice.
METHODS
The study was undertaken at the Department of Surgery, University College Hospital, Ibadan between January 2008 and January 2018. Consecutive patients who had emergency or elective surgical intervention for lower gastrointestinal tract (caecum- proximal rectum) symptoms during the study period were included. Ethical approval was obtained from the state ethical review committee (AD 13/479/745) and conduct followed the guidelines of the Helsinki declaration on biomedical research in human subjects. Confidentiality of the identity of patients and personal health information was maintained.
Data regarding elective or emergency presentation, peri-operative findings, operative details, postoperative course and histopathology were recorded prospectively by the surgeon responsible for the surgical care of the patient. Mid- and distal rectal pathologies necessitating a perineal approach or operating below the peritoneal reflection were excluded. The emergency surgical cases were defined as unscheduled laparotomy due to acute symptoms necessitating emergency presentation at the emergency unit or intra-operative obstetrics and gynaecological consults that had surgical intervention without the standard peri-operative workup while elective colon surgical patients were reviewed and admitted via the surgical out-patients clinic. Resection was either segmental (anatomic) or partial (removal of the lesion- bearing segment). Primary anastomosis is defined as immediate restoration of bowel continuity and colostomy was either completely or partially defunctioning. Peri-operative short-term outcome was any sequelae attributable to surgical intervention which occurred in the first 30 days postoperatively.
Pre-operative care
All the patients had necessary clinical and radiopathologic diagnosis made. Routine cardiorespiratory, hematologic and biochemical investigations were done on admission. All emergency cases had fluid and electrolyte, blood, antibiotic and bowel decompression as part of initial resuscitation before contemplating surgery. Cardiology, endocrinology and pulmonology consults were sought as required for identified comorbidities while pre-operative anaesthesia review was mandatory before surgical intervention. Left-sided colonic surgery entailed bowel preparation in the elective setting only. A consent for a colostomy was obtained in all cases before surgery especially in the emergency setting.
Operative procedure
All the patients had an exploratory laparotomy under general anaesthesia except for extremis cases which necessitated mini-laparotomy for decompression under regional or local anaesthesia.
Post-operative care
This entailed care in either the ward, high dependency unit (HDU) or the intensive care unit (ICU). Deep venous thrombosis prophylaxis was discontinued after ambulation was established. Parenteral medications were only changed to oral when bowel function returned, indicated by the passage of flatus or faeces. Empirical antibiotics were given prophylactically or until features of sepsis resolved. Hospital discharge occurred between a week and ten days after laparotomy and was variable for the emergency surgical cases.
Out- patient care was at 2 weeks (histology or stoma/ wound review); 4 weeks (ascertain full recuperation or commencement of adjuvant treatment for malignancy) and at 8 weeks (discharge or work up for closure of stoma).