M. W. El Hechi1, A. Mendoza1, J. Lee1, N. Saillant1, M. Rosenthal1, P. Fagenholz1, D. King1, G. Velmahos1, H. Kaafarani1 1Massachusetts General Hospital,Division Of Trauma, Emergency Surgery & Surgical Critical Care,Boston, MA, USA
Introduction:
The impact of immunosuppression on the outcomes of emergent surgery remains largely unknown. We aimed to examine the effect of chronic immunosuppression on mortality and morbidity of patients undergoing emergent colectomies.
Methods:
The Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2016 was analyzed for the study. All patients older than 18 undergoing emergent colectomies were included except those with a diagnosis of inflammatory bowel disease. Immunosuppression is defined by the ACS-NSQIP as the regular administration of oral/parenteral corticosteroid medications or immunosuppressants for a chronic condition within the 30 days prior to the operative procedure. Univariate analyses were initially performed comparing immunosuppressed and immunocompetent patients. Backward stepwise multivariable models were then created to identify the independent impact of immunosuppression on 30-day mortality, morbidity and 30 postoperative complications, as well as hospital length of stay, controlling for all demographics, comorbidities, preoperative laboratory values, as well as intraoperative and procedure-related factors.
Results:
Out of a total of 16,782 patients undergoing an emergency colectomy, 15,826 were included. The median age was 66 years, 7241 (45.7%) were male, and 1280 (8.1%) were immunosuppressed. Compared to immunocompetent patients, immunosuppressed patients were more likely to be female (58.3% vs 53.9%, p=0.003) and have higher ASA scores (III-V) (95.3% vs 71.3%, p <0.001), less likely to undergo laparoscopic surgery (12% vs. 19.6%, p<0.001), and less likely to have primary anastomosis without diverting loop ileostomy (33.4% vs 55.4%, p-value). In both groups, procedures were most often wound classified as “Dirty” (70%and 50%, p<0.001), and most often performed for colonic perforation as an indication (70% and 46%, <0.001). At 30-days, the immunosuppressed patients had a higher mortality (21% vs. 10%p <0.001), higher morbidity (70% vs. 52%, p<0.001), and a longer median length of stay (12 vs. 9 days, p <0.001). On multivariable analyses, adjusting for all aforementioned variables, immunosuppression was independently correlated with more than 25% increase in mortality (OR = 1.26, 95% CI. 1.02-1.56) and overall morbidity (OR = 1.29, 95% CI. 1.08-1.53). Immunosuppression was associated with twice the risk of wound dehiscence (OR = 2.07,95% CI. 1.48-2.89), and 31% increase in unplanned intubation (OR = 1.31, 95% CI. 1.04-1.67).
Conclusion:
Immunosuppression is independently associated with more than 25% increase in 30-day mortality and morbidity (especially wound dehiscence) for patients undergoing emergent colectomy. Such information is essential for preoperative patient counseling and to mitigate such increased postoperative risks.