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The Influence of the Type of Surgery on the Immediate Postoperative Results in Patients with Colorectal Cancer Operated in Emergency

The emergency surgery for colorectal cancer is associated with high rates of morbidity and mortality due to factors related to the characteristics of the patients but also the therapeutic attitude. This study aims to identify the surgical interventions associated with the postoperative complications, with the main causes of morbidity, with the reinterventions and with the postoperative deaths. We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei ”from Galati, in the period 2008-2017. The patients' data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. The postoperative morbidity was 10.44%. The resections with anastomosis were associated with the presence of postoperative complications (p<0.01): pseudomembranous colitis, (p<0.01) and postoperative intestinal occlusion (p<0.01). The practice of lymph node dissection was associated with postoperative complications (p<0.01): pseudomembranous colitis (p<0.01) and intestinal occlusion (p<0.01). The reinterventions were associated with resections with anastomosis (p<0.01), lymph node dissection (p<0.01) or patients with open /semi-open abdomen (p<0.04). The postoperative mortality was 9.28%. It was associated with the practice of lymph node dissection (p<0.01), of the ileostomy (p<0.01), with the open /semi-open abdomen (p<0.04). Patients with colostomy had the lowest number of hospitalization days (p<0.01). The resections with anastomosis per primam and the lymph node dissection were associated with morbidity. The type of main surgery did not influence the postoperative mortality, this being associated with the concomitant surgery: the lymph node dissection, the ileostomy, and the abdomen closure type. The reinterventions were associated with resections with anastomosis per primam, with lymph node dissection and with the open /semi-open abdomen. The duration of hospitalization was significantly shorter in patients with a colostomy. complicated colorectal cancer, emergency surgery, results, morbidity, mortality G.B. Constantin et al 228 www.revistachirurgia.ro Chirurgia, 115 (2), 2020 patients who are subjected to such operations (age, comorbidities, biological status), but also by the therapeutic attitude and the tumor aggressivity. Besides, the colorectal cancer emergency surgery is also associated with a high percentage of stomas (temporary or definitive) (2). These poor postoperative results were attributed to the technical difficulties, the instability of the patients, the incomplete lymph node dissection leading to understaging (3). For patients who present in an emergency with perforated tumors, the cause of the high rate of postoperative mortality is the multiple organ dysfunction, given by fecaloid peritonitis (4). No consensus has yet been reached on the factors on which the results of the various types of emergency surgery for complicated colorectal cancer depend, in particular, the choice of the type of surgery in obstructions of the left colon remains controversial (2,5). In the literature, numerous studies analyze the safety of different types of emergency surgery for complicated colorectal cancer in terms of postoperative morbidity and mortality and the results differ greatly. Some authors believe that one-time operations are reasonable (5-8), others have reported significantly lower morbidity and mortality in the case of serial interventions (9-11). Although the Hartmann operation is associated with relatively low mortality (2.69%), serial interventions still have an inherent problem, especially in the elderly, with many hospitalizations, in which the stoma reversal will often no longer be realized. For those with stoma reversal, the morbidity ranges from 5 to 57% and the mortality from 0 to 34% (12). According to WSES recommendations, Hartmann's procedure does not provide a benefit in terms of postoperative morbidity and mortality compared with resections with anastomosis in left colon obstructive cancer (recommendation grade 2C +); Hartmann interventions should be considered in patients at increased surgical risk (recommendation grade 2C) (5). Patients and Methods We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei ” from Galati, in the period 2008-2017. The patients' data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. We performed a descriptive analysis of the tumors' location as well as the practiced types of surgery. We analyzed the immediate postoperative results evaluated by the postoperative morbidity and mortality, the necessity of the surgical reinterventions, the duration of the hospitalization, as well as the medium-term results -the stoma reversal after Hartmann operations or other serial interventions. We made correlations with the type of main intervention, the associated surgical interventions: lymph node dissection, splenectomy, ileostomy, liver biopsy, other associated interventions and the way of abdomen closure. The patients included in this study were grouped according to the presence or absence of morbidity factors, reinterventions, and post-operative deaths. There were made correlations of the presence of postoperative complications, parietal suppurations, pseudomembranous colitis, anastomotic fistulas, postoperative occlusion, reinterventions and postoperative deaths with the type of main intervention, lymph node dissection, ileostomy, liver biopsy, splenectomy, other associated interventions, and abdomen


Abstract
The emergency surgery for colorectal cancer is associated with high rates of morbidity and mortality due to factors related to the characteristics of the patients but also the therapeutic attitude. This study aims to identify the surgical interventions associated with the postoperative complications, with the main causes of morbidity, with the reinterventions and with the postoperative deaths.
We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei "from Galati, in the period 2008-2017. The patients' data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions.
The postoperative morbidity was 10.44%. The resections with anastomosis were associated with the presence of postoperative complications (p<0.01): pseudomembranous colitis, (p<0.01) and postoperative intestinal occlusion (p<0.01). The practice of lymph node dissection was associated with postoperative complications (p<0.01): pseudomembranous colitis (p<0.01) and intestinal occlusion (p<0.01). The reinterventions were associated with resections with anastomosis (p<0.01), lymph node dissection (p<0.01) or patients with open /semi-open abdomen (p<0.04). The postoperative mortality was 9.28%. It was associated with the practice of lymph node dissection (p<0.01), of the ileostomy (p<0.01), with the open /semi-open abdomen (p<0.04). Patients with colostomy had the lowest number of hospitalization days (p<0.01).
The resections with anastomosis per primam and the lymph node dissection were associated with morbidity. The type of main surgery did not influence the postoperative mortality, this being associated with the concomitant surgery: the lymph node dissection, the ileostomy, and the abdomen closure type. The reinterventions were associated with resections with anastomosis per primam, with lymph node dissection and with the open /semi-open abdomen. The duration of hospitalization was significantly shorter in patients with a colostomy. complicated colorectal cancer, emergency surgery, results, morbidity, mortality patients who are subjected to such operations (age, comorbidities, biological status), but also by the therapeutic attitude and the tumor aggressivity. Besides, the colorectal cancer emergency surgery is also associated with a high percentage of stomas (temporary or definitive) (2). These poor postoperative results were attributed to the technical difficulties, the instability of the patients, the incomplete lymph node dissection leading to understaging (3). For patients who present in an emergency with perforated tumors, the cause of the high rate of postoperative mortality is the multiple organ dysfunction, given by fecaloid peritonitis (4).
No consensus has yet been reached on the factors on which the results of the various types of emergency surgery for complicated colorectal cancer depend, in particular, the choice of the type of surgery in obstructions of the left colon remains controversial (2,5). In the literature, numerous studies analyze the safety of different types of emergency surgery for complicated colorectal cancer in terms of postoperative morbidity and mortality and the results differ greatly. Some authors believe that one-time operations are reasonable (5-8), others have reported significantly lower morbidity and mortality in the case of serial interventions (9)(10)(11).
Although the Hartmann operation is associated with relatively low mortality (2.6-9%), serial interventions still have an inherent problem, especially in the elderly, with many hospitalizations, in which the stoma reversal will often no longer be realized. For those with stoma reversal, the morbidity ranges from 5 to 57% and the mortality from 0 to 34% (12). According to WSES recommendations, Hartmann's procedure does not provide a benefit in terms of postoperative morbidity and mortality compared with resections with anastomosis in left colon obstructive cancer (recommendation grade 2C +); Hartmann interventions should be considered in patients at increased surgical risk (recommendation grade 2C) (5).

Patients and Methods
We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei " from Galati, in the period 2008-2017.
The patients' data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. We performed a descriptive analysis of the tumors' location as well as the practiced types of surgery. We analyzed the immediate postoperative results evaluated by the postoperative morbidity and mortality, the necessity of the surgical reinterventions, the duration of the hospitalization, as well as the medium-term results -the stoma reversal after Hartmann operations or other serial interventions. We made correlations with the type of main intervention, the associated surgical interventions: lymph node dissection, splenectomy, ileostomy, liver biopsy, other associated interventions and the way of abdomen closure.
The patients included in this study were grouped according to the presence or absence of morbidity factors, reinterventions, and post-operative deaths. There were made correlations of the presence of postoperative complications, parietal suppurations, pseudomembranous colitis, anastomotic fistulas, postoperative occlusion, reinterventions and postoperative deaths with the type of main intervention, lymph node dissection, ileostomy, liver biopsy, splenectomy, other associated interventions, and abdomen closure.
We made statistical correlations between each of the main or associated types of surgery and the presence of postoperative complications, the main causes of morbidity, the reinterventions and the postoperative deaths. For these, we used the p-value obtained with the Pearson-Chi Square, Fisher Exact and Likelihood Ratio tests or the Kruskal-Wallis test (to correlate the length of hospitalization). The statistical conclusions were formulated using a statistically significant difference threshold value p<0.05 for all assessments performed.
Liver biopsy (from the macroscopic aspect of secondary disseminations) was performed in 17 patients (3.94%). The intraoperative suspicion of metastasis (or preoperative ultrasound) was confirmed pathologically in all cases. In 12 patients, other associated interventions were performed (such as the treatment of incarcerated hernias).
Most of the times, in 417 cases (96.75%), a classical abdomen closure was performed and only in 11 cases (2.55%) it was practiced a semi-open abdomen on Georgescu rings or even open abdomen in 3 cases (0.69 %) with tumor perforation, when it was considered that the septic source was not completely resolved in an emergency, with scheduled   Table 1). Reinterventions were not associated with an ileostomy, splenectomy, liver biopsy or other associated interventions ( ). The postoperative mortality was 9,28% ( ). Postoperative mortality was not associated with the type of main intervention, splenectomy, liver biopsy, and other associated interventions. The postoperative mortality was associated with lymph node dissection (p<0.01), ileostomy      The distribution of cases according to postoperative mortality

Discussions
In this study, we showed that the negative prognostic factors for the postoperative morbidity and mortality of patients with colo-rectal cancer operated in an emergency were: the type of surgery (the resections with anastomosis had the highest rate of postoperative complications and reinterventions; the colostomies were associated with the highest postoperative mortality), practicing an ileostomy and lymph node dissection (higher postoperative mortality in these patients) and absence of abdominal closure (higher morbidity rates, reoperations and postoperative mortality in patients with open / semi-open abdomen). Colorectal cancer is a major cause of morbidity and mortality and the emergency presentation increases the rate of complications and mortality even more. The choice of the type of operation depends on the location of the tumor, the biological and nutritional status of the patient, the age. For tumors on the right colon, the most indicated is a right hemicolectomy, according to the majority of authors, but for those located on the left colon, the type of resection may be debatable (2).
Several studies and meta-analysis have shown that the higher postoperative mortality in elderly patients with complicated colorectal cancer is caused by pre-existing comorbidities and not by the emergency surgery itself (13)(14)(15)(16)(17)(18).
A meta-analysis that included all the emergency colorectal cancer patients in France in 2006-2008 identified 6 factors that negatively influenced the postoperative mortality: age over 70, respiratory, vascular and neurological comorbidities, presence of liver metastases and malnutrition (19).
There has been an increasing tendency in recent years to practice resections with anastomosis for complicated colorectal cancer. A study conducted at the Royal Infirmary of Edinburgh, Scotland, from 1990 to 2000, which included 323 patients with colorectal cancer, operated in an emergency, reports much lower rates of postoperative morbidity and mortality for resections with anastomosis than for Hartmann operations (20), in contrast to the results of our study, in which we found the highest rates of morbidity and mortality in the cases of resections with anastomosis. Our findings are also supported by   Table 2.
Correlation between the type of surgery and the length of hospitalization with resections with anastomosis. The mortality rate was higher in the cases of resections with anastomosis (9.2%) compared to the Hartmann operations (7.5%) (22).
In a study conducted in 2018 at Good Hope Hospital in Birmingham, which included 74 patients with complicated colorectal cancer who underwent Hartmann's surgery in 2008-2014, this procedure is shown to be viable and its use justified, given the low risk of postoperative complications and almost zero mortality (23).
A recent study made at the University of Medicine and Pharmacy of Cluj-Napoca, which included 118 patients with colorectal cancer operated in an emergency, reports a postoperative mortality rate of 3.9%. The authors obtained statistically significant differences between the practice or not of a protective ileostomy and postoperative mortality, similar to the data in our study (24).
The patients who present with complicated colon cancer are usually in an advanced stage of the disease and have a poor biological condition. In these cases, the utility of performing surgical resections that respect the oncological principles becomes questionable. In a study conducted at the University of Sao Paolo, Brazil, the authors reported a very high rate (71%) of lymph node dissection in the group of patients, but at the same time, the postoperative morbidity was significant (12% anastomotic fistulas) (25). We also found this correlation between lymph node dissection and postoperative complications in our study.
According to the latest recommendations from the international guidelines, the open abdomen has indications in severe peritonitis, with septic shock, when a second look for the source control is planned (degree of recommendation 2C according to WSES) (26). In a study conducted at the University Hospital of Istanbul, during 2000-2006, which included 37 patients with severe peritonitis, of which 14 by perforation of colorectal tumors, it is shown that these patients had the highest rates of postoperative morbidity and mortality (27), correlations that we also found. Studies on the use of laparostomy, including only emergency colorectal cancer patients, are missing from the literature. The authors declare no conflicts of interest.
The study design was approved by the Ethic Committee of "Dunarea de Jos" University, Galati, Romania (nr. 1/22.02.2018), for a retrospective study in patients with colorectal