In the present study, firstly, we evaluated the factors that impacted on the surgeon’s decision of surgical procedure. In the univariate analysis, age, sex, serum albumin level, APACHE II score, SOFA score, and the site of perforation were identified as predictive factors for deciding surgical procedure. In the multivariate analysis, the serum albumin level and the site of perforation were remained as independent predictive factors for deciding the surgical procedure. The serum albumin level reflects the preoperative nutritional status and general condition (13,14). A low serum albumin level is a risk factor for anastomotic leakage and is a risk factor for mortality during sepsis due to vascular hyperpermeability (15–19). In our study, the serum albumin level of the HP group was significantly lower than that of the PAWODS group, which means that surgeons had appropriately selected HP for patients with poor conditions. This result was similar to previous studies; the HP group was significantly older, more hemodynamically unstable, and more immunosuppressive than the PAWODS group (8,9). Also, APACHE II and SOFA scores are other indicators of the general condition that are useful for predicting the severity and prognosis of sepsis (10,11). Although we speculated that the APACHE II and SOFA scores could be associated with decision-making in relation to the surgical procedures, these factors were not associated with the surgical procedures in the present study. Furthermore, regarding the simplicity of calculation, the serum albumin level is much simpler to determine in comparison to the than APACHE II and SOFA scores, which require complicated calculations. The serum albumin level was a simple predictive factor that was useful for deciding the surgical procedure in the present study cohort.
Considering the postoperative results in the present study, the HP group had significantly higher mortality and morbidity rates than the PAWODS group. Zingg et al. reported that in the HP group, the mortality and morbidity rates were significantly higher and that the baseline characteristics were significantly worse in comparison to the PAWODS group (8). On the other hand, Tsuchiya et al. revealed that the 30-day mortality and re-operation rates were significantly higher in the PAWODS group than in the HP group; however, in that study, the baseline characteristics were adjusted using propensity score matching (7). Thus, although it may be risky to perform PAWODS for all patients with colorectal perforation, it may be safely performed with equivalent mortality and morbidity rates to HP in appropriately selected patients. In the present study, the favorable postoperative outcomes of PAWODS also supported that the intraoperative decision regarding the choice of surgical procedure was appropriate.
In the present study, the incidence rate of anastomotic leakage was 9.8% (5/51) and 7.8% (4/51) of patients required re-operation. These rates of anastomotic leakage were similar to the incidence rates of 4–14% that were reported in patients who underwent primary anastomosis with or without diverting stoma for perforated diverticulitis (3,4,20–22). However, in these studies, most patients received primary anastomosis with diverting stoma, a diverting stoma in 50–100% of cases (3,4,21). The rate of anastomotic leakage in patients who received PAWODS for perforated diverticulitis has only been reported in one study and the rate of anastomotic leakage of any grade was 28.3% (8). Therefore, we thought that the anastomotic leakage rate of 9.8% in the present study was acceptable. This acceptable anastomotic leakage rate may also imply that we could appropriately assign patients to PAWODS and HP groups intraoperatively.
We investigated the risk factors for anastomotic leakage in patients treated with PAWODS. In the present study, no anastomotic leakage occurred in patients with right-sided colon perforation and only patient treated with FEEA developed anastomotic leakage. Although the right-side location and FEEA tended to be associated with less anastomotic leakage in comparison to left-side location and DST, we could not find significant differences between these groups. We thought that the location and procedure of anastomosis were strong candidate factors; however, we speculated that significant differences were not found due to the weak statistical power of the present study as a result of its relatively small population. Notably, in this study, 16 patients (94%) with right-sided colon perforation received PAWODS and none of these patients developed anastomotic leakage. A previous study of right-sided colon perforation also reported that none of 34 patients with right hemicolectomy developed anastomotic leakage (23). Although serum albumin level is known to be associated with anastomotic leakage, we found no significant association in our study (15). As described above, the serum albumin levels in HP patients were significantly lower than those in PAWODS patients. Therefore, after the exclusion of HP patients with relatively lower serum albumin levels, the serum albumin level may not have remained as an independent risk factor for anastomotic leakage among patients with serum albumin levels above a certain level. In the appropriately selected patients, PAWODS may be a safe surgical procedure that is associated with an acceptable rate of anastomotic leakage. Especially, we thought that PAWODS could be safely performed for patients with right-sided colon perforation.
The present study was associated with some limitations. First, this was a single-center, retrospective observational study with a relatively small population; thus, selection biases may have existed and the results might have been affected by the retrospective design. Second, we included right-sided colon perforation. There are only two retrospective studies of right-sided colon perforation (23,24). However, the results obtained after the exclusion of right-sided cases did not differ from the results of analyses that included the right-sided cases (data not shown). In our study, the rate of anastomotic leakage in patients with left-sided perforation was 14%, and this may also be acceptable in comparison to previous studies (8). Third, thirty-nine patients (40%) had localized peritonitis classified as Hinchey I-II, and this rate was relatively high in comparison to previous studies (3–5,25).