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Postoperative Outcomes in Ustekinumab-Treated Patients Undergoing Abdominal Operations for Crohn’s Disease: Single-Center Series. CROHN'S & COLITIS 360 2019. [DOI: 10.1093/crocol/otz018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Abstract
Introduction
The impact of ustekinumab on adverse postoperative outcomes in Crohn’s disease (CD) remains largely unknown. We determined the difference in 90-day postoperative complication rates among CD patients exposed to ustekinumab within 12 weeks prior to an abdominal operation as compared to patients not exposed to biologic therapy.
Methods
A retrospective chart review of all adults with CD who underwent an abdominal operation between October 1, 2017 and December 31, 2018 at a single tertiary medical center was performed. Data collection included patient demographics, concurrent immunosuppression, serum laboratory values, operative values, and 90-day outcomes including superficial surgical site infection (sSSI), intra-abdominal sepsis, overall infectious complications, readmission, and reoperation rates. The primary outcome was the 90-day rate of intra-abdominal sepsis.
Results
Fifty-seven CD patients received ustekinumab and 277 received no biologic therapy in the 12 weeks prior to major abdominal surgery. Ustekinumab-exposed patients were younger, less likely to have diabetes mellitus or active tobacco exposure, were more often obese, and more often taking a concurrent immunomodulator. Ustekinumab remained an independent predictor of intra-abdominal sepsis on multivariable logistic regression. Immunomodulator exposure was associated with significantly increased rates of sSSI and overall complication rates.
Conclusions
Ustekinumab is associated with increased rates of 90-day postoperative intra-abdominal sepsis following a major abdominal operation for CD.
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Abstract
Every year 16 million operations are performed in Germany. Many patients have an autoimmune disorder, for example rheumatoid arthritis, psoriasis or chronic inflammatory bowel disease, which requires treatment. Immunosuppressants are widely applied. Physicians must make a risk-adapted decision whether the immunosuppressant medication can be continued perioperatively or if certain drugs must be paused and if so, with what risks. The handling of immunosuppressants during the perioperative period is very relevant as many patients, for example with rheumatoid arthritis are in need of a hip or knee replacement or patients with inflammatory bowel disease need an operation due to the chronic illness. The interruption of an immunosuppressant therapy should be discussed in an interdisciplinary board according to the underlying disease, because the continuation of immunosuppressants perioperatively can lead to an increased rate of complications, especially wound healing disorders. If a patient is on a glucocorticoid therapy the following must be considered: during the perioperative period the body has an increased demand for glucocorticoids due to the stress reaction. If glucocorticoids are administered in a dosage of more than 7.5 mg/day equivalent of prednisolone this stress reaction is inhibited. Thus, in these cases a perioperative substitution with hydrocortisone is recommended.
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Lin YS, Cheng SW, Wang YH, Chen KH, Fang CJ, Chen C. Systematic review with meta-analysis: risk of post-operative complications associated with pre-operative exposure to anti-tumour necrosis factor agents for Crohn's disease. Aliment Pharmacol Ther 2019; 49:966-977. [PMID: 30864199 DOI: 10.1111/apt.15184] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/18/2018] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative complications after anti-tumour necrosis agent treatment for Crohn's disease (CD) have been analysed with conflicting results. AIM To assess the effects of pre-operative anti-tumour necrosis factor (TNF) therapy on post-operative complications within 30 days post-operatively in patients with CD undergoing abdominal surgery. METHODS Systematic review with meta-analysis was performed on articles found in MEDLINE, Embase, Cochrane Library, Scopus, and the International Clinical Trials Registry Platform until September 2018. RESULTS Twenty studies (7115 patients) were included. Without confounder adjustment, pre-operative anti-TNF therapy in patients with CD undergoing abdominal surgery was associated with increased rates of infectious complications (unadjusted odds ratio, OR, 1.49; 95% CI, 1.08-2.06). After confounder adjustment, Pre-operative anti-TNF therapy was significantly associated with both increased rates of total and infectious complications (adjusted OR, 1.53 and 2.09; 95% CI, 1.11-2.09 and 1.19-3.65, respectively). After subgroup analyses, the association between anti-TNF agents and total complications was significant in high incidence countries (adjusted OR, 1.86; 95% CI, 1.43-2.42) but not in low incidence countries (adjusted OR, 0.77; 95% CI, 0.48-1.25). CONCLUSIONS Exposure to anti-TNF agents is an independent risk factor for post-operative infectious complications in patients with CD, especially in countries with a high incidence of Crohn's disease. We suggest postponing elective surgery or carefully monitoring these patients post-operatively.
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Affiliation(s)
- Yang-Sheng Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Sheng-Wei Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yuan-Hung Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Evidence-based Knowledge Translation Centre, Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ching-Ju Fang
- Medical Library, National Cheng Kung University, Tainan, Taiwan.,Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiehfeng Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Public Health, School of Medicine, College of Medicine, and Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Mege D, Garrett K, Milsom J, Sonoda T, Michelassi F. Changing trends in surgery for abdominal Crohn's disease. Colorectal Dis 2019; 21:200-207. [PMID: 30341932 DOI: 10.1111/codi.14450] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/23/2018] [Indexed: 12/12/2022]
Abstract
AIM The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohn's disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years. METHODS All patients who underwent abdominal surgery for CD between 2004 and 2016 were retrospectively identified. Data were compared between two periods (2004-2010 and 2011-2016). RESULTS A total of 908 procedures were performed (48% men, mean age 43 ± 16 years). Demographic and CD characteristics changed significantly over time: comorbidities were more frequent (35% vs 46%, P < 0.0001), and preoperative steroids (28% vs 36%, P < 0.01) and anti-tumour necrosis factor (20% vs 40%, P < 0.0001) treatments were more frequently used in the second period. Smoking (14% vs 8%, P < 0.0001) and use of immunosuppressors (32% vs 22%, P < 0.001) decreased significantly. More cases of penetrating disease (22% vs 32%, P < 0.001) were operated upon in the second period. The laparoscopic approach (49% vs 57%, P < 0.04) was more frequently performed and mean blood loss (167 ± 222 vs 123 ± 243 ml, P < 0.01) decreased significantly. Postoperative morbidity did not change between the two periods. CONCLUSION Despite a higher incidence of comorbidities and the use of biologics postoperative morbidity remained unchanged. An increased use of laparoscopy and a decreased intra-operative blood loss may have contributed to offsetting the impact of increased comorbidity.
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Affiliation(s)
- D Mege
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - K Garrett
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - J Milsom
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - T Sonoda
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
| | - F Michelassi
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
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Risk factors for early postoperative complications in patients with Crohn's disease after colorectal surgery other than ileocecal resection or right hemicolectomy. Int J Colorectal Dis 2019; 34:293-300. [PMID: 30460473 DOI: 10.1007/s00384-018-3196-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate risk factors for early postoperative complications in patients with Crohn's disease (CD) after extensive colorectal resection excluding mere ileocecal resection or right hemicolectomy at a university center. METHODS A retrospective analysis of the prospectively maintained database for surgical patients with CD at our institution was performed. All consecutive patients operated between December 2009 and December 2017 were included. RESULTS In total, 126 patients were eligible for this study. Most common types of operations performed were subtotal colectomy or proctocolectomy (37.3%) and resections of the rectum (34.1%) or the sigmoid colon (14.3%). Major postoperative complications occurred in 29 patients (23.0%). The rate of local septic complications (anastomotic leak, postoperative abscess) was 11.1%. In univariate analysis, low preoperative albumin, elevated preoperative C-reactive protein (CRP), and emergency surgery were factors associated with major postoperative complications. When multivariable analysis was performed, low preoperative albumin was the only independent risk factor for the occurrence of major postoperative complications (p = 0.0033; OR 0.899). The cut-off value for albumin was 32.6 g/L. CONCLUSIONS In this large cohort of consecutive patients undergoing surgery of the colorectum in CD, the rate of major postoperative complications was considerably higher compared to our recently published data from patients with ileocecal resection or right hemicolectomy. Preoperative albumin is the only independent risk factor for the occurrence of major postoperative complications. Preoperative albumin levels > 32.6 g/L significantly reduce the risk for postoperative complications.
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Hossne RS, Sassaki LY, Baima JP, Meira Júnior JDD, Campos LM. ANALYSIS OF RISK FACTORS AND POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2019; 55:252-257. [PMID: 30540087 DOI: 10.1590/s0004-2803.201800000-63] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The post-operative complications rate is greater in patients with Crohn's disease than in other abdominal surgeries due to other benign conditions. Prevention and management of such complications are important factors in the care of these patients. OBJECTIVE The objectives of this research are to analyze the rate of postoperative complications and the major risk factors in patients with Crohn's disease. METHODS A descriptive and retrospective study based on analysis of medical records of patients with Crohn's disease undergoing ileal and/or colonic resection, which analyzed the main surgical complications and their major risk factors. RESULTS Forty-four surgical procedures and thirty-seven patients were analyzed. Most were female (56.7%). Postoperative complications were observed in 18 (40.9%) surgeries. The disease duration (P=0.04), the penetrating behavior (P=0.013), the time between diagnosis and the first surgery (P=0.04), malnutrition with low body mass index (BMI), duration of surgery (P=0.016), and the size of the removed specimen (P=0.014) were associated with higher rates of complications. The use of drugs blocking tumor necrosis factor up to eight weeks before surgery was not significantly associated with higher complications rates or increased need for reoperation. CONCLUSION The complication rate observed in this study is similar to published data. The duration of the disease, the penetrating behavior, the size of the removed specimen, the duration of the surgery, and BMI are important risk factors for perioperative complications in Crohn's disease.
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Affiliation(s)
- Rogério Saad Hossne
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil
| | - Ligia Yukie Sassaki
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Clínica Médica, Botucatu, SP, Brasil
| | - Julio Pinheiro Baima
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Clínica Médica, Botucatu, SP, Brasil
| | - José Donizeti de Meira Júnior
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil
| | - Luana Moraes Campos
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil
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Xu Y, Yang L, An P, Zhou B, Liu G. Meta-Analysis: The Influence of Preoperative Infliximab Use on Postoperative Complications of Crohn's Disease. Inflamm Bowel Dis 2019; 25:261-269. [PMID: 30052982 DOI: 10.1093/ibd/izy246] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infliximab (IFX) is a breakthrough treatment for refractory Crohn's disease (CD) whose effect on postoperative complications of CD remains controversial. The purpose of this study was to conduct a meta-analysis examining the effect of IFX on postoperative complications of CD. METHODS We searched "PubMed," "EMBASE," and "Cochrane Library" databases from inception of each database until March 2018. All eligible articles were screened according to the inclusion criteria. The cumulative overall, major, minor, infectious, noninfectious, surgical, and medical complications, as well as reoperation, readmission, and mortality of CD patients who received IFX and underwent ileocolonic resection were extracted and analyzed using Review Manager 5.3. The random effects model was used to calculate the odds ratio (OR) and 95% confidence interval (CI). RESULTS A total of 18 nonrandomized controlled trial studies, with 1407 patients who received IFX and 4589 patients who did not were identified. The incidence of complications was 9.38%-60.56% in the IFX group and 12.73%-53.85% in the control group. Overall, major, minor, infectious, noninfectious, surgical, and medical complications could be assessed in 16, 12, 11, 14, 12, 12, and 11 studies, respectively. There were no statistically significant differences between the 2 groups for any complication (P > 0.05, all comparisons). Reoperation (P = 0.70), readmission (P = 0.22) and mortality (P = 0.86) showed no significant difference between the 2 groups. Subgroup analysis showed that complications were not significantly different among the countries represented in the studies. CONCLUSIONS Based on this analysis, there does not appear to be an association between preoperative IFX treatment and postoperative complications of CD; IFX appears relatively safe for preoperative use in the treatment of CD. 10.1093/ibd/izy246_video1izy246.video15813237394001.
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Affiliation(s)
- YanYan Xu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - LiSheng Yang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ping An
- Department of General Surgery, Binhai New Area Hospital of Traditional Chinese Medicine, Tianjin, China
| | - Bing Zhou
- Department of Proctology, Binhai New Area Hospital of Traditional Chinese Medicine, Tianjin, China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Rocha A, Bessa I, Lago P, Santos MD, Leite J, Castro-Poças F. Preoperative Enteral Nutrition and Surgical Outcomes in Adults with Crohn's Disease: A Systematic Review. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 26:184-195. [PMID: 31192287 DOI: 10.1159/000494674] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/16/2018] [Indexed: 12/14/2022]
Abstract
Background and Aim Enteral nutrition (EN) is applicable to adult Crohn's disease (CD) in treating malnutrition and in inducing remission - here as a less effective alternative than corticosteroids. The purpose of this review is to determine whether preoperative EN impacts postoperative complications of adult CD, either by means of nutritional or therapeutic effects. Summary A systematic review of English written full-text research articles published between January 1990 and November 2017, including adult patients undergoing abdominal surgery for complicated CD after EN, was performed. Four studies out of 22 were selected, all of which institutional, retrospective, case-control cohorts, one classified as "good quality" and three as "poor quality," as rated by the Newcastle-Ottawa Scale. The application of inclusion and exclusion criteria resulted in a non-intentional absence of studies referring to supplemental EN among those reviewed. The reduced number of heterogeneous eligible studies impeded meta-analysis. In all studies, exclusive EN (EEN) was used and well tolerated, allowing to defer or even avoid surgery altogether, improving patients' global state. The two studies with the greatest number of patients found preoperative EEN to be an independent factor against infectious and non-infectious complications in 219 patients and against anastomotic leaks or abscesses in 38 patients. Also, in univariate analysis, EEN was found to increase preop-erative immunosuppressant-free intervals and to protect against anastomotic dehiscences, intra-abdominal abscesses, surgical wound infections, ileus, stomas, and reoperations in the largest study; in another study it was related to fewer intra-abdominal septic complications. Key Messages All reviewed studies are retrospective and, consequently, of limited relevance. Nonetheless, all of them call the attention of the scientific community to the potential benefits of preoperative EEN on postoperative outcomes in adult CD, calling for prospective multi-institutional studies and randomized controlled trials.
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Affiliation(s)
- Anabela Rocha
- General Surgery Service - Digestive Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Inês Bessa
- General Surgery Service - Colorectal Unit, Hospital de São Sebastião, Centro Hospitalar de Entre-o-Douro-e-Vouga, Santa Maria da Feira, Portugal
| | - Paula Lago
- Gastroenterology Service, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Marisa D Santos
- General Surgery Service - Digestive Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Júlio Leite
- Surgery Service, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Fernando Castro-Poças
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal.,Gastroenterology Service, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
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Intra-abdominal Sepsis After Ileocolic Resection in Crohn's Disease: The Role of Combination Immunosuppression. Dis Colon Rectum 2018; 61:1393-1402. [PMID: 30303885 DOI: 10.1097/dcr.0000000000001153] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn's disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown. OBJECTIVE The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection. DESIGN This was a retrospective review of patient records from 2007 to 2017. SETTINGS The study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients with a diagnosis of Crohn's disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded. MAIN OUTCOME MEASURES Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis. RESULTS A total of 621 patients (55% women) underwent ileocolic resection for Crohn's disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27-9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25-4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01). LIMITATIONS This study is limited by its single-institution tertiary referral center scope. CONCLUSIONS Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.
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Zhu F, Feng D, Zhang T, Gu L, Zhu W, Guo Z, Li Y, Gong J, Li N, Li J. Toward a More Sensitive Endpoint for Assessing Postoperative Complications in Patients with Inflammatory Bowel Disease: a Comparison Between Comprehensive Complication Index (CCI) and Clavien-Dindo Classification (CDC). J Gastrointest Surg 2018; 22:1593-1602. [PMID: 29766444 DOI: 10.1007/s11605-018-3786-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The comprehensive complication index (CCI) is a novel approach to evaluate complications. However, application of the CCI in inflammatory bowel disease (IBD) population is scarce and the difference between the CCI and the Clavien-Dindo classification (CDC) remains unknown. The aim of this study was to compare the CCI to the conventional CDC by applying the CCI among the IBD patients. METHODS The data of 426 IBD patients who underwent surgery between September 1, 2015 and August 31, 2017 were collected. Univariate and multivariate analyses were conducted to identify risk factors for postoperative complications. The efficacy of CCI and CDC was compared using correlation analysis and logistic regression. Cumulative sum control (CUSUM) models were applied to monitor the CCI continuously. RESULTS Totally, 297 complications occurred in 144 (33.8%) patients. The rate of severe complications (CDC grade ≥ III) was 12.9% and the mean CCI was 9.8 ± 15.5. Preoperative glucocorticoids usage and previous abdominal surgery were related to higher CCI value (p = 0.002, p = 0.006, respectively) but not related to higher incidence of severe complications (CDC grade ≥ III) (p = 0.117, p = 0.177, respectively). In patients with multiple complications, the CCI demonstrated a stronger correlation with hospital stay (ρ = 0.604, p < 0.001) than CDC (ρ = 0.508, p < 0.001). Higher CCI value (p < 0.001, OR 1.161, 95% CI 1.093-1.234) and the CDC grade (p < 0.001, OR 3.811, 95% CI 2.283-6.362) were risk factors for prolonged LOS. In the CUSUM-CCI model of IBD surgery, a gradual decrease was observed over time. CONCLUSIONS The CCI and the CDC are both risk factors for prolonged postoperative LOS after surgery for IBD patients. The CCI is more strongly correlated with postoperative LOS than is the conventional CDC. The CUSUM-CCI model is effective in monitoring surgical quality.
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Affiliation(s)
- Feng Zhu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Dengyu Feng
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, East Zhongshan Road, 305, Nanjing, 210002, China. .,Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
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Galata C, Weiss C, Hardt J, Seyfried S, Post S, Kienle P, Horisberger K. Risk factors for early postoperative complications and length of hospital stay in ileocecal resection and right hemicolectomy for Crohn's disease: a single-center experience. Int J Colorectal Dis 2018; 33:937-945. [PMID: 29736773 DOI: 10.1007/s00384-018-3072-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine risk factors for early postoperative complications and longer hospital stay after ileocecal resection and right hemicolectomy in a single-center cohort of patients with Crohn's disease (CD). METHODS A retrospective analysis of the prospectively maintained surgical database for patients with CD at our institution was performed. All consecutive patients operated on between January 2010 and December 2016 were included. RESULTS A total of 305 patients were included. Median length of hospital stay was 7 days (interquartile range, IQR 6-10). Major postoperative complications were observed in 9.5% of patients (n = 29). Anastomotic leak was observed in five patients (1.8% of all patients with anastomosis). The rate of local septic complications was 4.3% (n = 13, anastomotic leak, postoperative abscess, and/or postoperative fistula). In multivariable analysis, independent risk factors for major postoperative complications were bowel perforation (odds ratio (OR) = 12.796, 95% CI = 1.144-143.178); elevated preoperative leucocyte levels (OR = 1.115, 95% CI = 1.013-1.228); and low levels of preoperative albumin (OR = 0.885, 95% CI = 0.827-0.948). The cutoff value for albumin was 32.5 g/L (sensitivity 75.9%, specificity 62.6%). CONCLUSIONS In this large cohort of patients surgically treated for CD in a tertiary referral center, 9.5% of the patients developed major postoperative complications. Preoperative albumin levels > 32.5 g/L significantly reduce the risk for postoperative complications and shorten the length of hospital stay. In a multidisciplinary concept with adequate preoperative management, surgery can be performed with a low rate of major complications and a very low rate of anastomotic leakage.
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Affiliation(s)
- Christian Galata
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julia Hardt
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Steffen Seyfried
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefan Post
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Peter Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Mannheim, Germany
| | - Karoline Horisberger
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
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Argeny S, Stift A, Bergmann M, Mittlböck M, Maschke S, Riss S. The modified Glasgow prognostic score in Crohn's disease-does it predict short-term outcome? Eur Surg 2018; 50:177-182. [PMID: 31497036 PMCID: PMC6724747 DOI: 10.1007/s10353-018-0518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/02/2018] [Indexed: 11/11/2022]
Abstract
Background The modified Glasgow prognostic score (mGPS) has recently gained increased attention as a prognostic marker for malignant disease survival and postoperative short-term complications. Due to lacking data, the present study was conducted to correlate the mGPS with the postoperative course in patients following surgery for Crohn’s disease. Methods We enrolled 341 patients who underwent intestinal resection for symptomatic Crohn’s disease at a tertiary referral centre between 2000 and 2014. All relevant data were obtained from the institutional database and individual chart review. Thirty-day morbidity was defined according to the Clavien–Dindo classification. Results A total of 79 (23.17%) postoperative complications were identified (grade I and II: n = 54, 15.84%; grade III and IV: n = 23, 6.74%; grade V: n = 2, 0.59%). The mGPS did not show any correlation with an eventful postoperative course following surgery (no complication: median mGPS: 1, range 0–2; complications: median mGPS: 1, range 0–2; p = 0.8521). In addition, the occurrence of an anastomotic leakage was not associated with a higher mGPS (p = 0.8592). Patients with an acute indication for surgery (n = 29, 11.44%) had higher median mGPS (median: 2, range 0–2) in contrast to patients who were operated on electively (median: 1, range 0–2; p = 0.0003). No other correlation between surgical characteristics and mGPS was detected. Conclusions In the present study, we could clearly demonstrate that an acute indication for surgery in symptomatic Crohn’s disease is associated with higher mGPS scores. However, the mGPS did not correlate with postoperative complications. Further studies are required to define the prognostic value of mGPS in Crohn’s disease patients.
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Affiliation(s)
- Stanislaus Argeny
- 1Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Anton Stift
- 1Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Michael Bergmann
- 1Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Martina Mittlböck
- 2Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Svenja Maschke
- 1Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Stefan Riss
- 1Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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What Is the Risk of Anastomotic Leak After Repeat Intestinal Resection in Patients With Crohn's Disease? Dis Colon Rectum 2017; 60:1299-1306. [PMID: 29112566 DOI: 10.1097/dcr.0000000000000946] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. OBJECTIVE The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. DESIGN This was a retrospective analysis of prospectively collected departmental data with 100% capture. SETTINGS The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. PATIENTS A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. MAIN OUTCOME MEASURES Clinical anastomotic leak within 30 days of surgery was measured. RESULTS Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). LIMITATIONS This was a retrospective study with limited data to perform a multivariate analysis. CONCLUSIONS Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.
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Is Anti-TNF Therapy Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease? Ann Surg 2017; 267:229-230. [PMID: 29166360 DOI: 10.1097/sla.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kotze PG, Magro DO, Martinez CAR, Saab B, Saab MP, Pinheiro LV, Olandoski M, Yamamoto T, Coy CSR. Adalimumab and postoperative complications of elective intestinal resections in Crohn's disease: a propensity score case-matched study. Colorectal Dis 2017; 20:211-218. [PMID: 29053220 DOI: 10.1111/codi.13929] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/21/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND data are scarce regarding the effect of preoperative Adalimumab (ADA) in postoperative complications in Crohn's disease (CD) patients. AIM to compare the rates of postoperative complications after intestinal resections in CD, with and without previous exposure to ADA. METHOD case-matched retrospective observational study of patients submitted to intestinal resections for CD. The patients were allocated to 2 groups, according to their previous exposure to ADA before surgery. The patients under ADA therapy were matched with controls (patients without previous biologics) with the propensity score method (PSM), according to age at surgery, CD location (Montreal L) and phenotype (Montreal B). Medical and surgical complications were compared. RESULTS 123 patients were initially considered, 71 with previous biologics (32 under ADA therapy) and 52 without. The PSM selected 25 ADA patients to be matched with 25 controls from the non-biologics group. There was no difference regarding overall surgical complications (40% in the control vs 36% in the ADA group; p = 1.0000) or medical complications (36% vs 12% in the control and ADA groups, respectively; p = 0.095). In univariate analysis, previous ADA was not considered a risk factor for higher postoperative complication rates. Stomas were considered a risk factor for surgical complications, and previous steroids were associated to higher medical complication rates. CONCLUSIONS preoperative ADA did not influence the rates of medical and surgical complications after elective intestinal resections for CD. This was the first study to include exclusively patients under ADA therapy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | | | | | - Barbara Saab
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Mansur Paulo Saab
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | | | - Marcia Olandoski
- Biostatistics department, Catholic University of Paraná (PUCPR), Curitiba, Brazil
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