September 27, 2023
Which patients are likely to have adverse outcomes after intestinal resection?
Post-operative complications in patients with IBD are driven by age, comorbidity, nutrition and functional status but not by their IBD therapies. Presurgical optimization should include better disease control.
Fernandez C, Gajic Z, Esen E, et al. Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of ACS-NSQIP Compared with Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study. Am J Gastroenterol. Epub ahead of print July 7, 2023; https://journals.lww.com/ajg/abstract/.aspx
To identify preoperative risk factors for adverse outcomes following IBD-related intestinal resection, researchers at New York University examined data between 2005 and 2019 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). ACS-NSQIP is a large US prospective surgical database to which hospitals provide risk-adjusted information on short-term surgical outcomes.
The primary outcome in this study was a 30-day composite of postoperative mortality, hospital readmission, unplanned reoperation, infection, wound disruption, thromboembolism, cardiac event, pulmonary complication, renal complication, or packed red blood cell transfusion within 72 hours.
The analysis included data from 49,746 intestinal resections, of which 18.8% were performed in adults 60 years of age or older. Roughly half of all individuals were male, 41% had Crohn’s disease and 80% identified as non-Hispanic white. Similar percentages of older and younger patients were malnourished (roughly 9.3%), although older adults were more likely to have multiple comorbidities (14.8% vs. 2.2%; p<0.01), dependent functional status (1% vs. 0.2%; p<0.02), preoperative sepsis (9.3% vs. 8.2%; p<0.01) and to have undergone emergency resection (8.8% vs. 5.4%; p<0.01).
After 2,474 patient-years of follow-up, the primary measure—a composite of one or more of CD-related hospitalization or surgery, systemic corticosteroid exposure or perianal disease—occurred at rates of 110 per 1,000 person-years and 202 per 1,000 person-years in the surgery and anti-TNF groups, respectively.
Results showed that roughly 37% of older adults met the composite adverse event endpoint, compared to 28.1% of younger adults with IBD (p<0.01). The two most common complications among all patients were postoperative infections (17.8%) and need for transfusion (9.1%). Older adults were significantly more likely than younger adults to experience any of the adverse outcomes in the composite outcome. The most profound differences were for overall mortality and cardiopulmonary complications, which were 4-to-8 times more common among older adults.
Risk factors for adverse postoperative outcomes, regardless of age, included preoperative albumin <3.0 g/dL (adjusted Odds Ratio [aOR]: 1.73; 95% Confidence Interval [CI], 1.61–1.85), malnutrition (aOR: 1.22; 95% CI, 1.14–1.31), two or more comorbidities (aOR: 1.51; 95% CI, 1.36–1.66), preoperative sepsis (aOR: 2.08; 95% CI, 1.94–2.24), dependence in activities of daily living (aOR: 6.92; 95% CI, 4.36–11.57), and emergency intestinal resection (aOR: 1.50; 95% CI, 1.38–1.64). Use of preoperative immunosuppression, including corticosteroids, did not affect these associations.
Study Design: Nationwide prospective database analysis
Funding: The Danish National Research Foundation.
Allocation: Not applicable
Level of Evidence: 1a