Factors related to anastomotic dehiscence and mortality after terminal stomal closure in the management of patients with severe secondary peritonitis.

摘要

INTRODUCTION: Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. Our aim was to determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. PATIENTS AND METHODS: We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30-month period. Several patient and disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student's t test for continuous variables and chi-square test when categorical variables were compared. Multivariate analyses were also performed. RESULTS: A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 had TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) was 2 (range, 1-15). A total of 76 (70%) had had diffuse peritonitis, and 39 (36%) required management with an open abdomen (26 of them with a skin-only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14-2,192). Stapled and hand-sewn anastomoses were done in 24 and 84 patients, respectively. AD occurred in 11 patients (10%). Univariate analyses disclosed age > or = 50 years (p < 0.05), high American Society of Anesthesiologists (ASA) score (> or = 3; p < 0.01), history of chronic renal failure (p < 0.04), history of diffuse peritonitis (p < 0.05), management with an open abdomen (p < 0.05), and lower preoperative hemoglobin values (p < 0.05) as risk factors for AD. Only age > or = 50 years prevailed after multivariate analyses. A total of seven patients died (6%). Factors associated with mortality were age > or = 65 years (p < 0.02), high ASA score (> or = 3; p < 0.01), preoperative use of total parenteral nutrition (p < 0.02), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure < 3 months (p < 0.01), AD (p < 0.02), and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, time interval between stomal creation and closure < 3 months and need for reoperation were the only ones that prevailed as independent risk factors for mortality (p < 0.05). CONCLUSIONS: Although several variables were related to AD and mortality, waiting at least >3 months before attempting restoration of intestinal continuity seems to be the best approach and a practical recommendation in this group of challenging patients.