Abstract
Background: When a patient with colorectal perforation is treated, there is no adequate information about what the best procedure for emergent operation is. In the present study, we examined the clinical features in hemodialysis (HD) and non-HD patients with colorectal perforations. Patients and Methods: Forty-four patients (8 HD and 36 non-HD patients) who underwent surgery for colorectal perforation at the Fukuoka Red Cross Hospital were reviewed and analyzed. Results: Poor prognostic factors for patients with colorectal perforation were high age, HD, idiopathic perforation, postoperative complication and Hartmann's operation procedure. Good prognostic factors were diverticulum perforation and operation with anastomosis. In the analysis between HD and non-HD patients, clinical characteristics in HD patients with colorectal perforation were advanced age and rectal perforation. Conclusion: High mortality rate of HD patients with colorectal perforation may be due to high age and rectal perforation in which cases it is technically difficult to perform operation. In case of emergent operation of colorectal perforation, the Hartmann's procedure may not be recommended.
Colorectal perforation is a life-threatening condition requiring emergency surgical intervention. Despite recent advances in surgical techniques and intensive care, operative mortality and morbidity rates in these patients remain prohibitive in around 15-30% of cases (1-4). The onset of colorectal perforation is sometimes difficult to diagnose, especially in non-traumatic cases (3), making it more difficult to treat patients in a timely manner. This high mortality rate is largely due to perforation-caused peritonitis, which affects patients systemically and can lead to multiple organ failure (5). While the ideal treatment or surgical procedure for colorectal perforation is controversial with a wide spectrum of recommendations (6-8), early diagnosis and treatment of poor-risk patients is key to improving their outcomes (3).
An estimated 13% of the adult population suffers from chronic kidney disease, which is treated with hemodialysis (HD); this percentage is expected to rise (9). Infection is a leading cause of morbidity and mortality among dialysis patients (10) possibly due to their often immunocompromised state, thought to be based on abnormalities of cellular, humoral and phagocytic immunity malfunctions (11-13). This is actually the reason why surgeons hesitate to operate HD patients. To date, there are few studies of characteristics of HD patients with colorectal perforation.
In the present study, we reviewed our experience with surgical and intensive treatment of colorectal perforation in HD and non-HD patients, and retrospectively studied their clinical characteristics.
Patients and Methods
The Fukuoka Red Cross Hospital (Fukuoka, Japan) is a central hospital for HD patients and also the site of about 10 renal transplants per year. We reviewed cases of 44 patients (8 HD and 36 non-HD patients) who underwent surgery for colorectal perforation at the Fukuoka Red Cross Hospital. Patients who died within 1 month after operation were counted as non-survivors. All enrolled patients were fully-informed about their medical condition, options and risks they provided written informed consent before treatment. The data collected included age, gender, causes of perforation, sites of perforation, white blood cell (WBC) numbers, serum C-reactive protein values, systolic blood pressure, time to operation, any post-operative complications and procedure performed. An unpaired two-tailed Student's t-test or chi-square test was used for statistical analysis. P<0.05 was considered significant.
Results
Analysis between survivors and non-survivors in patients with colorectal perforation. We first estimated the clinical characteristics of survivors vs. non-survivors (Table I). The mortality rate for all patients with colorectal perforation was 18.2%. Age of non-survivors (71.0±4.0 years) was significantly higher than that of survivors (59.9±7.5 years). There were significantly more HD patients than non-HD patients among non-survivors. Among non-survivors, diverticular perforation was significantly less common and idiopathic perforation was significantly more common as causes of perforation. There was no significant difference in gender, sites of perforation and preoperative findings examined. Postoperative complications, especially disseminated intravenous coagulation (DIC), occurred significantly more often in non-survivors. Among procedures, the Hartmann's surgical procedure was significantly preferred over anastomosis in non-survivors.
Analysis between survivors and non-survivors in patients with colorectal perforation.
Analysis between non-HD patients and HD patients with colorectal perforation. Next, we investigated the clinical characteristics of HD patients with colorectal perforation (Table II). Age in HD patients (71.1±2.4 years) was significantly higher than that in non-HD patients (60.0±6.5 years). Mortality rate in HD patients (62.5%) was significantly higher than that in non-HD patient (8.3%). There was no significant difference in causes of perforation, preoperative findings examined, postoperative complication and operation performed. The rectum as the site of perforation was significantly more common in HD patients.
Analysis between non-HD patients and HD patients with colorectal perforation.
Discussion
As shown in many studies, advanced age is a risk factor for colorectal perforation with a mortality rate of 18.2% for all patients with colorectal perforation in our series (Table I). In the present study, we showed that HD is a risk factor for the prognosis of colorectal perforation. Among patients with colorectal perforations, those with HD were more likely to be of advanced age and to have their perforations located in the rectum than non-HD patients; however, gender, causes of perforation, serum WBC number, serum C-reactive protein value, systolic blood pressure, time-to-operation, post-operative complication and operation performed were the same as in non-HD patients. Taken together, these results indicate that prognosis for HD patients may be worse than that of non-HD patients, even among those with the same preoperative conditions. High mortality rate of HD patients with colorectal perforation may be due to rectal perforation that is difficult to operate.
All patients with diverticulum perforation underwent operation with an anastomosis approach that may reflect better prognosis. On the contrary, patients who had undergone Hartmann's operation showed significantly worse prognosis. These results suggest that colorectal resection with perforation site may not be necessary; instead, colostomy and abdominal drainage with sufficient irrigation by saline may be recommended especially in patients with rectal perforation. On the other hand, anastomosis may be a good procedure for patients with better prognostic factors such as younger age, non-HD, non-cause of idiopathic perforation and cause of diverticulum perforation.
In the Fukuoka Red Cross Hospital, HD patients were treated surgically immediately after being diagnosed with colorectal perforation, without preoperative HD. Although timing of HD may be controversial, HD was carried-out from post-operative day 1 under close communication with a nephrologist. While colorectal perforation is a life-threatening condition requiring emergent surgery, there are no prior standardized guidelines or protocols in managing these patients and any decisions are at the discretion of the primary surgeon (14). Transfer to a facility that treats many patients with HD may be prudent over a facility that treats few HD patients.
Various scoring systems have been used to gauge prognoses of patients with colorectal perforation, including the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score (SAPS II), American Society of Anesthesiologists (ASA) and the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) (2, 15-17). In the present study, we could not use a scoring system because not all data were available. It is beyond any doubt that the use of the aforementioned scoring systems will yield additional risk factors for HD patients with colorectal perforation.
Although survival rates for HD patients with colorectal perforation are less than those in non-HD patients (37.5% vs. 91.7%, respectively), the lives of many HD patients as well as non-HD patients with colorectal perforation might be saved through emergent surgery. We, thus, need to collect data of such cases in order to improve the survival rate of HD patients with colorectal perforation.
Acknowledgements
We thank Ms. Kaori Nomiyama for her skillful technical assistance.
Footnotes
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Conflicts of Interest
The Authors declare no conflicts of interest regarding this study.
- Received June 6, 2014.
- Revision received July 17, 2014.
- Accepted July 18, 2014.
- Copyright © 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
