Patient Acuity and Operative Technique Associated with Post-Colectomy Mortality Across New York State: an Analysis of 160,792 Patients over 20 years

Differential Perioperative Outcomes in Patients With Obstructive Sleep Apnea, Obesity, or a Combination of Both Undergoing Open Colectomy: A Population-Based Observational Study

BACKGROUND

An increasing body of evidence demonstrates an association between obstructive sleep apnea (OSA) and adverse perioperative outcomes. However, large-scale data on open colectomies are lacking. Moreover, the interaction of obesity with OSA is unknown. This study examines the impact of OSA, obesity, or a combination of both, on perioperative complications in patients undergoing open colectomy. We hypothesized that while both obesity and OSA individually increase the likelihood for perioperative complications, the overlap of the 2 conditions is associated with the highest risk.

METHODS

Patients undergoing open colectomies were identified using the national Premier Healthcare claims-based Database (2006-2016; n = 340,047). Multilevel multivariable models and relative excess risk due to interaction (RERI) analysis quantified the impact of OSA, obesity, or both on length and cost of hospitalization, respiratory and cardiac complications, intensive care unit (ICU) admission, mechanical ventilation, and inhospital mortality.

RESULTS

Nine thousand twenty-eight (2.7%) patients had both OSA and obesity diagnoses; 10,137 (3.0%) had OSA without obesity; and 33,692 (9.9%) had obesity without OSA. Although there were overlapping confidence intervals in the binary outcomes, the risk increase was found highest for OSA with obesity, intermediate for obesity without OSA, and lowest for OSA without obesity. The strongest effects were seen for respiratory complications: odds ratio (OR), 2.41 (2.28-2.56), OR, 1.40 (1.31-1.49), and OR, 1.50 (1.45-1.56), for OSA with obesity, OSA without obesity, and obesity without OSA, respectively (all P < .0001). RERI analysis revealed a supraadditive effect of 0.51 (95% confidence interval [CI], 0.34-0.68) for respiratory complications, 0.11 (-0.04 to 0.26) for cardiac complications, 0.30 (0.14-0.45) for ICU utilization, 0.34 (0.21-0.47) for mechanical ventilation utilization, and 0.26 (0.15-0.37) for mortality in patients with both OSA and obesity, compared to the sum of the conditions' individual risks. Inhospital mortality was significantly higher in patients with both OSA and obesity (OR [CI], 1.21 [1.07-1.38]) but not in the other groups.

CONCLUSIONS

Both OSA and obesity are individually associated with adverse perioperative outcomes, with a supraadditive effect if both OSA and obesity are present. Interventions, screening, and perioperative precautionary measures should be tailored to the respective risk profile. Moreover, both conditions appear to be underreported compared to the general population, highlighting the need for stringent perioperative screening, documentation, and reporting.

Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics

OBJECTIVE

The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use.

BACKGROUND

Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery.

METHODS

New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery.

RESULTS

Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD.

CONCLUSIONS

Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.