Emergency right colectomy: which strategy when primary anastomosis is not feasible?

Elective right colectomy entails a risk for postoperative complications and mortality around 22 and 1 % respectively [1, 2]. In the emergency setting, these rates grow up to 50 and 10 %, especially if risk factors are present. [3‐5], Patient-related risk factors are age >70 years, male, malnutrition, ASA score >3, diabetes, tobacco smoking or immunosuppression. Procedure-related risk factors other than emergency include intra-operative blood transfusion, surgeon experience, operative duration or operations performed during night-shift [6‐8].

Safety strategies are useful for emergency procedures if several risk factors are present. For left-sided emergency colonic resections, valuable options are creation of an end colostomy or primary anastomosis with diverting ileostomy [9, 10]. However, safety strategies have not been established for emergency right-sided resections. Resection with primary anastomosis remains the standard of care also in the emergency setting [11, 12]. Nevertheless, overall morbidity and mortality rates raise the question whether safer strategies are needed.

Therefore, the aim of the present study was to assess our institutional practice and outcome for emergency right colectomy and to evaluate alternative treatment to primary anastomosis and if definitive ostomy rate can be reduced.

Primary anastomosis was performed in most patients after emergency right colectomy. Due to retrospective data analyse and obvious differences between patients from PA group and from no-PA group are incomparable. Two bailout options were applied in patients at high risk: split stoma confection and two-staged procedure with delayed ostomy or anastomosis. Our results suggest that a two-stage strategy might help to reduce permanent ostomy rate.

In accordance with the current literature[18], primary anastomosis was performed in 80 % of patients in this study Anastomotic leak rate was 9 % which was slightly higher than in the literature (4–6 %) probably because of increased co-morbidities, particularly more cardiac disease (30 % in this present study vs. 15 to 20 % in other studies) and higher ASA score 64 % III-IV vs. 40–50 %)[4, 18, 19]. None of these leaks resulted in death.

As expected, patients in the group with no primary anastomosis were significantly sicker and older. Furthermore, intraoperative risk factors and aetiologies differed significantly. All of these parameters have arguably influenced on surgical decision-making. Unfortunately, due to the retrospective nature of this study, it remains unclear which risk factors influenced surgical strategy most. Of note, the choice of surgical strategy was not influenced by surgeon’s experience in our present series as suggested by other reports [4].

Two main factors may probably have influenced the decision-making in the present study, both having a major impact on blood supply of an eventual anastomosis and hence its perceived safety. High intraoperative vasopressor requirements (>10ug/min of noradrenalin/min) and colic ischemia were more common in the no-PA group. In accordance, safety strategies were liberally employed on a case-by-case basis. It would be interesting to analyze the pathway of decision-making but due to emergency and retrospective analysis we could not do that. Interestingly, primary anastomosis was performed with good results even in case of tumour obstruction with proximal bowel dilatation. Surgeon’s experience or dayshifts did not play any role on strategy decision or on postoperative complications. Even when bailout procedures were performed and primary anastomosis was avoided, outcomes were disappointing in the high-risk patients group with an overall morbidity of 100 % and a mortality of 25 %. Other groups reported similar results underlining the overwhelming impact of the concomitant metabolic stress response do to preoperative comorbidities, emergent surgery and hemodynamic instability during anaesthesia [20]. A surgical safety strategy can only aim to obtain local control with low surgical morbidity; avoiding a high-risk anastomosis can certainly play a role in this concept. Further, surgical aggression should be reduced to a minimum in the context of an overshooting systemic inflammatory response; this can be achieved by primary resection, open abdomen and second look once the patient has been stabilized [21]. Nevertheless, outcomes remain dismal and early and aggressive reanimation at the intensive care unit is arguably as decisive with regards to outcomes as surgery[22]. The surgeon's decision seems to be adequate when a primary anastomosis is chosen. Mortality and morbidity rate are low and comparable to series in the literature [1, 23].

This study also shows that junior surgeons more often performed split stoma than two stage procedures. Comparison with senior surgeons was not significant, but a trend can not be denied. Unfortunately, we did not record reasons that drove junior consultants to opt for split stoma.

The present study is limited by its retrospective design. Furthermore, results from a single centre cannot be generalized by principle. However, this audit might help in certain situations with the decision to anastomose or not. It definitely warrants a prospective trial. Only large datasets could help to overcome limitations of heterogeneity and low power.

In conclusion, primary anastomosis was performed in 80 % of patients undergoing emergency right-sided colectomy. In patients considered more fragile (e.g. patients with heart disease, immunocompromised patients, hemodynamically unstable or with ischemic colic lesions) and where the surgeon initially does not anastomose, a two-staged procedure with a second look might facilitate continuity restoration in the long-term.