M. Harary1,2, J. S. Jolissaint2, A. Tavakkoli1,2 1Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA
Introduction: Surgery in neutropenic patients is often avoided due to presumed increased morbidity and mortality although limited data on actual outcomes is available. Here, we report on post-operative outcomes in neutropenic patients undergoing abdominal surgery, stratifying the severity of neutropenia to examine whether there is a critical number below which surgical risks are significantly different.
Methods: We performed an institutional database search between 1988-2017 to identify patients who were neutropenic in the 24-hours prior to undergoing abdominal surgery. Endoscopic and percutaneous procedures were excluded. Neutropenia was defined as an Absolute Neutrophil Count (ANC) of <1500, determined either via direct measurement or extrapolation from leukocyte values. Patient outcomes were extracted by chart review. Severity of neutropenia was stratified as mild (1,000<ANC≤1,500), moderate (500<ANC≤1,000) or severe (ANC≤500). Comparisons were made using two-sided ANOVA, Kruskall-Wallis test, Chi-Squared test and binary logistic regression on SPSS.
Results: A total of 134 patients were identified with a mean age of 56 years (SD 15.8); 41% were male. Of these, 69, 37, and 29, were mildly, moderately, and severely neutropenic, respectively (see Table). These subgroups did not vary significantly in age or gender distribution (F(2,131,) p=0.821, p=0.388). Rates of 30-day mortality significantly vary among the subgroups (p=0.02) with 2.9%, 16.2% and 27.6%, in the mild, moderate and severe neutropenic respectively. The presence of severe neutropenia and urgency of procedure were both independent predictors of 30-day mortality (p=0.013, p=0.02). Severity of neutropenia was not a predictor of 30-day morbidity, ICU stay, disposition status, length of stay or likelihood of 30-day readmission. Overall, 61.2% of procedures were performed as an emergency. These cases were associated with significantly higher rates of 30 days morbidity in the moderate and severe neutropenia subpopulations (p=0.028, p=0.026) and higher rates of ICU stay in the moderate group (p=0.032), compared to non-urgent cases in the same neutropenia group
Conclusion: Abdominal surgery in neutropenic patients, particularly in those with ANC<1,000, is associated with high rates of mortality regardless of etiology of the neutropenia. Ideally, surgery should be delayed whenever possible in order to allow ANC to rise, however this needs to be balanced against the possibility of an acute worsening and need for emergency surgery which is associated with a significant further increase in mortality.
