Factors Associated With Mortality After Emergency Colectomy for Acute Lower Gastrointestinal Bleeding | Colorectal Surgery | JAMA Surgery | JAMA Network
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Figure.  Flow Diagram Illustrating Inclusion and Exclusion of Study Patients
Flow Diagram Illustrating Inclusion and Exclusion of Study Patients

CPT indicates Current Procedural Terminology; ICD-9, International Classification of Diseases Ninth Revision; ICD-10, International Classification of Diseases Tenth Revision; NSQIP, National Surgical Quality Improvement Program.

Table.  Characteristics of Study Patients
Characteristics of Study Patients
1.
Hoedema  RE, Luchtefeld  MA.  The management of lower gastrointestinal hemorrhage.  Dis Colon Rectum. 2005;48(11):2010-2024. doi:10.1007/s10350-005-0138-1PubMedGoogle ScholarCrossref
2.
Pfeifer  J.  Surgical management of lower gastrointestinal bleeding.  Eur J Trauma Emerg Surg. 2011;37(4):365-372. doi:10.1007/s00068-011-0122-5PubMedGoogle ScholarCrossref
3.
Cooper  Z, Koritsanszky  LA, Cauley  CE,  et al.  Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions.  Ann Surg. 2016;263(1):1-6. doi:10.1097/SLA.0000000000001491PubMedGoogle ScholarCrossref
4.
Khuri  SF.  The NSQIP: a new frontier in surgery.  Surgery. 2005;138(5):837-843. doi:10.1016/j.surg.2005.08.016PubMedGoogle ScholarCrossref
5.
Van Arendonk  KJ, Tymitz  KM, Gearhart  SL, Stem  M, Lidor  AO.  Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy.  JAMA Surg. 2013;148(4):316-321. doi:10.1001/jamasurg.2013.1010PubMedGoogle ScholarCrossref
6.
Ballian  N, Weisensel  N, Rajamanickam  V,  et al.  Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP.  World J Surg. 2012;36(10):2488-2496. doi:10.1007/s00268-012-1694-xPubMedGoogle ScholarCrossref
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    Research Letter
    November 13, 2019

    Factors Associated With Mortality After Emergency Colectomy for Acute Lower Gastrointestinal Bleeding

    Author Affiliations
    • 1Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
    JAMA Surg. 2020;155(2):165-167. doi:10.1001/jamasurg.2019.4467

    Patients admitted to the hospital for an acute lower gastrointestinal bleed (LGIB) require emergency colectomy in 10% to 25% of cases.1 Existing reports of mortality after emergency surgery for LGIB come from small, single-center series and vary between 2% to 60%.2 Furthermore, few studies describe outcomes in the context of modern critical care, endoscopy, and interventional radiology.2 Prognostic uncertainty is a barrier to providing goal-concordant care in the emergency setting.3 We therefore aimed to describe the risk of mortality after emergency colectomy for acute LGIB.

    Methods

    We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which systematically collects data from participant hospitals and is fully described elsewhere.4 The University of Toronto research ethics board approved this study. Informed consent was waived because of the deidentified nature of the data.

    We included adult patients undergoing emergency surgery during 2005 to 2017 with diagnostic and procedural codes associated with LGIB and colectomy, respectively (Figure). Emergency cases were defined using the emergency field in the NSQIP database. We excluded cancer cases and patients with sepsis.

    The outcome was 30-day mortality. Mortality for the cohort was summarized as a proportion and 95% Wald confidence interval (CI). Univariable associations between patient characteristics and mortality were explored using χ2 tests and t tests. We used multivariable logistic regression to identify factors associated with mortality, including variables selected a priori (age, sex, dyspnea, functional status, hypertension, preoperative international normalized ratio, preoperative platelets, preoperative hematocrit, bleeding disorder, preoperative systemic inflammatory response syndrome, time between admission and surgery, American Society of Anesthesiologists [ASA] classification, operative approach, and procedure) based on a literature review and clinical reasoning. Odds ratios (ORs) and 95% CIs are reported for factors significantly associated with mortality on multivariable analysis.

    All analyses were performed using SAS, version 9.4 (SAS Institute). Two-tailed P < .05 indicated statistical significance. Missing data were handled with a complete case analysis.

    Results

    A total of 1614 patients underwent emergency colectomy for acute LGIB from 2005 to 2017. Thirty-day mortality was 12.2% (95% CI, 10.6%-13.8%). Nonsurvivors were older, had more comorbidities, had a higher preoperative international normalized ratio, lower hematocrit, and higher ASA class. Nonsurvivors more often had systemic inflammatory response syndrome, underwent open surgery, and received total/subtotal colectomy (Table).

    In the multivariable logistic regression model, older age (OR, 1.42; 95% CI, 1.20-1.68 per 10-year increase), functional dependence (OR, 2.14; 95% CI, 1.48-3.08), and higher ASA class (OR, 8.40; 95% CI, 1.15-61.59) were associated with statistically significant increases in the odds of mortality. A laparoscopic approach (OR, 0.46; 95% CI, 0.23-0.89) and higher hematocrit value (OR, 0.65; 95% CI, 0.47-0.90 per 10% increase) were associated with statistically significant reductions in the odds of mortality.

    Discussion

    Using a large, multi-institutional database, we found that emergency colectomy for LGIB is uncommon but is associated with high 30-day mortality compared with elective colectomy (in-hospital mortality is <1%5).

    Of the examined patient and operative characteristics, high ASA class conferred the highest odds of mortality on multivariable analysis. This finding is consistent with existing literature describing an association between ASA and mortality after emergency colectomy.6 This finding, along with the association between lower preoperative hematocrit and mortality, underscores the importance of obtaining early surgical consultation to ensure patients who need surgery receive it in a timely fashion.

    This study has limitations. Preoperative interventions are not documented in the database, so we could not describe associations between postoperative mortality and interventions, such as colonoscopy. Functional outcomes, while important, are also not available in the database. That laparoscopic approach was associated with a lower odds of mortality likely represents confounding by indication.

    This study provides a robust estimate of the risk of mortality for patients undergoing emergency surgery for acute LGIB in the contemporary context. This prognostic information will better equip surgeons to provide goal-concordant care.

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    Article Information

    Corresponding Author: Nancy N. Baxter, MD, PhD, St Michael’s Hospital, 30 Bond St, 040-16 Cardinal Carter Wing, Toronto, ON M5B 1W8, Canada (nancy.baxter@unityhealth.to).

    Published Online: November 13, 2019. doi:10.1001/jamasurg.2019.4467

    Author Contributions: Dr Sue-Chue-Lam had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Sue-Chue-Lam, Baxter.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Sue-Chue-Lam.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Sue-Chue-Lam, Castelo.

    Supervision: Baxter.

    Funding/Support: Dr Sue-Chue-Lam is supported by a Queen Elizabeth II Graduate Scholarship in Science and Technology.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in this program are the sources of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

    References
    1.
    Hoedema  RE, Luchtefeld  MA.  The management of lower gastrointestinal hemorrhage.  Dis Colon Rectum. 2005;48(11):2010-2024. doi:10.1007/s10350-005-0138-1PubMedGoogle ScholarCrossref
    2.
    Pfeifer  J.  Surgical management of lower gastrointestinal bleeding.  Eur J Trauma Emerg Surg. 2011;37(4):365-372. doi:10.1007/s00068-011-0122-5PubMedGoogle ScholarCrossref
    3.
    Cooper  Z, Koritsanszky  LA, Cauley  CE,  et al.  Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions.  Ann Surg. 2016;263(1):1-6. doi:10.1097/SLA.0000000000001491PubMedGoogle ScholarCrossref
    4.
    Khuri  SF.  The NSQIP: a new frontier in surgery.  Surgery. 2005;138(5):837-843. doi:10.1016/j.surg.2005.08.016PubMedGoogle ScholarCrossref
    5.
    Van Arendonk  KJ, Tymitz  KM, Gearhart  SL, Stem  M, Lidor  AO.  Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy.  JAMA Surg. 2013;148(4):316-321. doi:10.1001/jamasurg.2013.1010PubMedGoogle ScholarCrossref
    6.
    Ballian  N, Weisensel  N, Rajamanickam  V,  et al.  Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP.  World J Surg. 2012;36(10):2488-2496. doi:10.1007/s00268-012-1694-xPubMedGoogle ScholarCrossref
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