From the R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center (B.O.A., L.O.M., J.K., B.B.R.), Baltimore, Maryland; Department of Surgery, Mayo Clinic (M.C.H., M.D.Z.), Rochester, Minnesota; Department of Surgery, Southside Hospital, Northwell Health (A.B.R., M.D.G.), Bay Shore, NY; Department of Surgery, UCHealth Memorial Hospital Central Trauma Center (T.J.S., H.H.), Colorado Springs, Colorado; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital (N.K., H.M.A.K.), Boston, Massachusetts; Department of Surgery, West Virginia University Medicine (A.W., D.G.), Morgantown, West Virginia; Department of Surgery, Robert Wood Johnson University Hospital (M.S., G.P.), New Brunswick, NJ; Department of Surgery, University of Southern California (G.C., K.M.), Los Angeles, California; Department of Surgery, Marshfield Clinic (D.C.C., L.M.C.), Marshfield, Wisconsin; Department of Surgery, Northwestern Memorial Hospital (B.S., J.P.), Chicago, Illinois; Department of Surgery, Loma Linda University Medical Center (U.J.S., R.D.C.), Loma Linda, CA; Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital (G.V., D.D.Y.), Miami, Florida; Department of Surgery, Methodist Dallas Medical Center (V.A., M.S.T.) Dallas, Texas; Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital (M.P., L.D.), Dallas, Texas; Department of Surgery, Reading Hospital (A.M., A.W.O.), West Reading, Pennsylvania; Cooper University Health Care (J.L.S.R., N.B.), Camden, NJ; Department of Surgery, University of Colorado (O.F., C.G.V.), Denver, Colorado; George Washington University (C.H., J.M.E), Washington, District of Columbia; Department of Surgery, University of California, Irvine (S.G., J.N.), Irvine, California; Department of Surgery, Tufts University (K.J., N.B), Boston, Massachusetts; and Department of Surgery, Medical City Plano (V. P., M.M.C.), Plano, Texas.
J Trauma Acute Care Surg. 2020 Dec;89(6):1023-1031. doi: 10.1097/TA.0000000000002894.
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.
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.
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.
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.
Therapeutic study, level IV.
有关急症或紧急结直肠切除术后造口术（STM）与吻合术的比较证据有限。本研究检查了急症普通外科患者结直肠切除术后的结局。
这是一项由东部创伤外科学会（Eastern Association for the Surgery of Trauma）赞助的前瞻性观察性多中心研究，纳入了接受紧急/紧急结直肠切除术的患者。21 个中心共招募了 11 个月的患者。记录了术前、术中、术后的变量。使用 χ²、Mann-Whitney U 检验和多变量逻辑回归模型来描述手术并发症/死亡率的结局和危险因素。
共纳入 439 例患者（ANST，184 例；STM，255 例）。中位（四分位距）年龄为 62（53-71）岁，中位 Charlson 合并症指数（CCI）为 4（1-6）。手术最常见的指征是憩室炎（28%）。造口组年龄更大（64 岁 vs. 58 岁，p < 0.001），CCI 更高，更有可能接受免疫抑制治疗。术前，STM 患者更有可能接受插管（57% vs. 15%，p < 0.001）、血管加压素（61% vs. 13%，p < 0.001）、气腹（131% vs. 41%，p < 0.001）或粪便污染（114% vs. 33%，p < 0.001），且血乳酸升高的发生率更高（149% vs. 67%，p < 0.001）。总体死亡率为 13%，STM 患者更高（18% vs. 8%，p = 0.02）。STM 患者的手术并发症更常见（35% vs. 25%，p = 0.02）。多变量分析显示，开放性腹部管理、术中输血和医院规模较大与手术并发症的发生有关，而 CCI、术前血管加压素使用、类固醇使用、开放性腹部和术中输血与死亡率独立相关。
本研究强调了在急性疾病患者中倾向于进行粪便转流的趋势。STM 患者的发病率和死亡率更高。死亡率的独立预测因素包括 CCI、术前血管加压素使用、类固醇使用、开放性腹部和术中输血。在调整了临床因素后，结直肠处理方法与手术并发症或死亡率无关。
治疗研究，IV 级。
