Article 1
Colorectal resection in emergency general surgery: An EAST multicenter trial. Aicher BO, Hernandez MC, Betancourt-Ramirez A, Grossman MD, Heise H, Schroeppel TJ, et al. J Trauma Acute Care Surg. 2020 Dec; 89(6):1023-1031.
Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study examined patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. A total of 439 patients were enrolled. 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.
Take away
This study highlighted a tendency to perform fecal diversion in patients who are acutely ill at presentation. There was 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.
Article 2
Biologic mesh implantation is associated with serious abdominal wall complications in patients undergoing emergency abdominal surgery: A randomized-controlled clinical trial. Jakob MO, Haltmeier T, Candinas D, Beldi G. J Trauma Acute Care Surg. 2020 Dec; 89(6):1149-1155.
Summary
Open, emergency abdominal surgery is associated with a high incidence of fascial dehiscence and incisional hernia. Implantation of biologic meshes potentially reinforces the abdominal wall and therefore decreases such complications. The aim of this prospective randomized study was to compare the outcome after prophylactic intraperitoneal implantation of a biologic Strattice mesh with standard abdominal closure in patients undergoing emergency abdominal surgery. The authors performed a two-arm randomized clinical trial was performed in patients undergoing emergency abdominal surgery. Patients were randomly assigned to prophylactic implantation of a biological intraperitoneal mesh using Strattice, Allergan (mesh group), or standard abdominal closure using a single, continuous running suture (no-mesh group). Because of safety concerns, patient enrollment was closed prematurely. Eligibility for inclusion was assessed in 61 patients. A total of 48 patients were randomized (21 in the mesh group, 27 in the no-mesh group). No differences in baseline characteristics were found. Abdominal wall complications requiring reoperations were more frequent in the mesh group compared to the no-mesh group (5 [83.3%] of 13 vs. 1 [14.3%] of 13 patients, p = 0.026). Mesh-associated abdominal wall complications included nonintegration of the mesh into the abdominal wall, dissolution of the mesh, and mesh-related infections.
Take Away
In patients undergoing emergency abdominal surgery, intraperitoneal biologic Strattice mesh implantation is associated with significantly more frequent abdominal wall complications requiring reoperation. Therefore, the use of such meshes cannot be recommended in the contaminated environment of emergency abdominal surgery.
