Japanese Journal of Acute Care Surgery 2013; 3: 55~60 原著 非外傷性大腸穿孔 86 症例の臨床的検討 上田健太郎岩﨑安博山添真志川副友川嶋秀治國立晃成酒谷佳世山上裕機加藤正哉 x 所属 : 和歌山県立医科大学救急集中治療医学講座住所 : 641-8510 和歌山県和歌山市紀三井寺 811-1
Table 1 Comparsion of background of the 86 patients with colorectal perforation All Survival Death p-value No. of patients 86 (100%) 74 (86%) 12 (14%) A ge 71.2 ± 15.3 69.9 ± 15.8 79.0 ± 9.1 0.0495 Gender 0.7605 Male 41 (48%) 36 (42%) 5 (6%) Female 45 (52%) 38 (44%) 7 (8%) Preoperative comorbidity 0.282 Comorbidity (+) 64 (74%) 53 (62%) 11 (12%) Heart disease 22 16 6 Lung failure 6 4 2 Renal failure (HD) 16 14 2 Hepatitis 7 5 2 Collagen disease (Steroid patients) 15 13 2 Hypertension 35 32 3 Diabetes mellitus 11 11 0 Brain disease 11 10 1 Hypothyroidism 3 3 0 Cancer 10 7 3 Comorbidity (-) 22 (26%) 21 (24%) 1 (2%) Table 2 Comparsion of primary disease and site of perforation All (n=86) Survival (n=74) Death (n=12) p-value Primary disease 1.0000 Benign 74 (86%) 63 (74%) 11 (12%) Diverticulitis 42 37 5 Idiopathic 7 5 2 Ischemic 7 5 2 Hard stools 6 5 1 Iatrogenic 6 5 1 Torsion 2 2 0 Crohn disease 2 2 0 Foreign body 2 2 0 Malignant 12 (14%) 11 (12%) 1 (2%) Site of perforation 0.6829 Right colon 15 (17%) 14 (16%) 1 (1%) Cecum 0 0 0 Ascending 8 8 0 Transverse 7 6 1 Left colon, rectum 71 (83%) 60 (70%) 11 (13%) Descending 9 8 1 Sigmoid 46 38 8 Rectum 16 14 2
Table 3 Analysis of preoperative status (A) and preoperative blood examination (B) All (n=86) Survival (n=74) Death (n=12) p-value (A) preoperative status SIRS 0.2863 P resent 67 (78%) 56 (65%) 11 (13%) 19 (22%) 18 (21%) 1 (1%) Vital shock 0.0001 P resent 22 (26%) 13 (15%) 9 (11%) 64 (74%) 61 (71%) 3 (3%) DIC 0.1556 Present 21 (24%) 16 (18%) 5 (6%) 65 (76%) 58 (68%) 7 (8%) Time from onset to surgery 0.3219 24 hours 58 (67%) 48 (55%) 10 (12%) >24 hours 28 (33%) 26 (31%) 2 (2%) Time from onset to surgery 0.0608 12 hours 41 (48%) 32 (37%) 9 (11%) >12 hours (B) preoperative blood examination 45 (52%) 42 (49%) 3 (3%) ph 7.43 (7.06-7.63) 7.44 (7.28-7.63) 7.36 (7.06-7.53) 0.0326 Lactate (mmol/dl) 1.8 (0.1-12) 1.7 (0.1-12) 6.1 (1.2-11.6) 0.0004 Total protein (g/dl) 6.6 (2.6-8.1) 6.7 (3.8-8.1) 5.7 (2.6-7.3) 0.0049 AST (IU/l) 25 (9-371) 23 (9-313) 37 (22-371) 0.001 CPK (IU/l) 85 (8-2905) 80 (8-2905) 155 (54-1766) 0.009 BUN (mg/dl) 25 (5-143) 23 (5-143) 32 (15-55) 0.0291 Table 4 Comparsion of surgical and postoperative management All (n=86) Survival (n=74) Death (n=12) p-value Peritonitis 0.1683 General peritonitis (+) 63 (74%) 52 (61%) 11 (13%) General peritonitis (-) 23 (26%) 22 (25%) 1 (1%) Localized peritonitis 9 9 0 Retoroperionitis 7 7 0 Mesenteric abscess 5 4 1 No peritonitis 2 2 0 Surgical method 0.4813 Resection with proximal stoma 63 (74%) 52 (61%) 11 (13%) Resection with primary anastomosis 20 (24%) 19 (23%) 1 (1%) Simple closure 1 (1%) 1 (1%) 0 (0%) Colostomy 2 (2%) 2 (2%) 0 (0%) O peration time (min) 142 ± 42 141 ± 42 145 ± 48 0.9196 ICU management 0.0932 P resent 58 (67%) 47 (54%) 11 (13%) PMX-DHP 28 (33%) 27 (32%) 1 (1%) 0.068 Present 22 (26%) 16 (19%) 6 (7%) 64 (74%) 58 (67%) 6 (7%)
Table 5 The multivariate analyses of the factors predicting survival using logistic regression Predictive factor Univariable analyses Multivariable analyses P value Relative Risk (95% CI) P value Age (years) 0.0495 1.098 (1.001-1.248) 0.0472 Vital Shock (+ / -) 0.0001 18.429 (1.914-349.903) 0.0107 ph 0.0326 1.594 (0.001-19771.81) 0.9208 Lactate 0.0004 1.333 (0.959-1.997) 0.0897 Total protein 0.0490 1.169 (0.385-4.276) 0.7929 AST CPK BUN Mann-Whitney U-test 0.0010 0.0090 0.0291 Fisher's exact test 1.029 (0.995-1.074) 0.997 (0.993-1.001) 1.013 (0.956-1.056) 0.1036 0.1479 0.5938 Table 6 Summary of 12 dead patients No Age Preoperative complication Cause of death ICU PMX-DHP Lactate 1 80 Heart failure, Af Sepsis, DIC, MOF + + 8 2 59 Renal failure (HD), Hepatitis Sepsis, DIC, MOF + + 1.2 3 80 Liver cirrhosis Sepsis, DIC, MOF + + 11.6 4 82 No complication Sepsis, DIC, MOF + + 9.3 5 87 Interstitial pneumonia, Steroid Interstitial pneumonia + - 3.4 6 81 Polymyalgia rheumatica, Steroid Aspiration pneumonia - - 6.4 7 70 Hypertension Sepsis, DIC, MOF + - 3.1 8 79 Angina pectoris, Terminal cancer ARDS, End stage of cancer + - 2.5 9 77 Heart failure, OMI, Hypertension Congestive herat failure + - 7.8 10 95 Heart failure, Cerebral infarction Congestive herat failure + - 1.5 11 72 Renal failure (HD), Angina pectoris, Sepsis, DIC, MOF + + Terminal cancer 9.2 12 86 Heart failure, OMI, Hypertension, Congestive herat failure + + Asthma 5.7
Clinical study of prognostic factors in 86 patients with non-traumatic colorectal perforation Kentaro Ueda 1), Yasuhiro Iwasaki 1), Shinji Yamazoe 1), Yu Kawazoe 1), Syuji Kawashima 1), Kosei Kunitatsu 1), Kayo Sakatani 1), Hiroki Yamaue 2), Seiya Kato 1) Department of Emergency and Critical Care Medicine, Wakayama Medical University 1) Second Department of Surgery, Wakayama Medical University 2) Background: Colorectal perforation easily causes septic shock and life-threatening complications. We studied the predictive factors regarding prognoses of patients with a colorectal perforation. Methods: We reviewed 86 patients who underwent emergency surgery for non-traumatic colorectal perforation between April 2006 and March 2013 in our medical center. Results: The average age of 86 patients was 71 years, and the most common cause and site of colorectal perforation were each diverticulitis (49%) and the left colon and rectum (83%). Before surgery, 78%, 26%, 24%, and 73% of patients had SIRS, vital shock, DIC, and general peritonitis, respectively. The overall survival rate was 86%, and the main cause of death in 12 cases was septic shock in six cases and a worsening of comorbidity in six cases. The survival rate in 22 patients undergoing postoperative endotoxin absorption therapy (PMX-DHP) was 73%. The predictive factors in univariate analysis were age, shock vital, ph, lactate, total protein, AST, CPK, and BUN. And, multivariate logistic regression analysis showed the age and shock vital to be significantly associated with mortality. Conclusion: The age and shock vital were the independent prognostic determinant of survival identified by this study, and careful managements of the comorbidity were important to improve the survival rate. Key words :colorectal perforation,prognostic factor, septic shock