Preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease

Revisiting Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) Scores: Are They Valid in Cases of Ileal Perforation?

Introduction Ileal perforation due to typhoid is common in tropical countries, and the ensuing secondary peritonitis is treated by resuscitation and surgery. The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) was developed to predict postoperative outcomes to overcome systemic obstacles in any healthcare setup and is considered fairly accurate. The Portsmouth-POSSUM (P-POSSUM) score was developed as a corrective scoring system for overestimations made by the POSSUM score vis-à-vis mortality. Our study aimed to examine the validity of these two scores in the postoperative prediction of surgical outcomes in patients with ileal perforation. Materials and methods An observational study involving 40 patients diagnosed with ileal perforations was undertaken over 18 months. The postoperative outcome for each patient was calculated as per the POSSUM and P-POSSUM parameters. Statistical analysis was done using SPSS (IBM Corp., Armonk, NY) and the results were tabulated. Results We found that age, gender, respiratory dysfunction, propensity for multiple surgeries, duration of surgery, co-morbidities, underlying malignancy, and systolic blood pressure played a significant role in determining postoperative outcomes. Haemoglobin, potassium, and urea levels were also found to be significantly associated with outcome. Cardiac signs, pulse, white blood cell count, Glasgow Coma Scale score, sodium, and electrocardiography, part of the physiological score parameters, were found to be insignificant in the prediction of postoperative outcomes. Among the intraoperative parameters, peritoneal soiling was found to be insignificant. Conclusion Some parameters inherent to POSSUM and P-POSSUM calculations appear to bear no statistical significance to the final score, highlighting that these need to be revisited and perhaps modified to further simplify the calculation. The POSSUM score is an excellent predictor of postoperative morbidity and mortality in ileal perforation patients but is of questionable reliability due to its tendency to overestimate them. P-POSSUM has a better predictive power of postoperative mortality by correcting POSSUM mortality overestimation.

Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review

Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.

Peri-Operative Optimization of Patients with Crohn's Disease

PURPOSE OF REVIEW

The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach.

RECENT FINDINGS

Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

Preoperative Identification and Management of Anemia in the Colorectal Surgery Patient

Preoperative anemia is a common finding in patients undergoing colorectal surgery, particularly those with cancer. While often multifactorial, iron deficiency anemia remains the most common cause of anemia in this patient population. Although seemingly innocuous, preoperative anemia is associated with an increased risk of perioperative complications and need for allogenic blood transfusions, both of which may worsen cancer-specific survival. Preoperative correction of anemia and iron deficiency is thus necessary to diminish these risks. Current literature supports preoperative screening for anemia and iron deficiency in patients slated to undergo colorectal surgery for malignancy or for benign conditions with associated patient- or procedure-related risk factors. Accepted treatment regimens include iron supplementation-either oral or intravenous-as well as erythropoietin therapy. Autologous blood transfusion should not be utilized as a treatment for preoperative anemia when there is time to implement other corrective strategies. Additional study is still needed to better standardize preoperative screening and optimize treatment regimens.

ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD

BACKGROUND AND AIMS

Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.

METHODS

A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.

RESULTS

A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.

CONCLUSION

Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.

Clinical characteristics and quality of life in patients with inflammatory bowel disease-associated anemia in Southeast China

BACKGROUND/AIMS

Clinical characteristics of inflammatory bowel disease (IBD) with anemia have not been fully elucidated. This study aimed to investigate the frequency of, risk factors for, and management of anemia in IBD patients and to evaluate the quality of life (QOL) in IBD patients with anemia.

METHODS

We included two patient cohorts. In cohort 1, clinical data from 697 IBD patients were retrospectively collected. In cohort 2, the Short Form-36 Health Survey (SF-36) and Fatigue Scale-14 (FS-14) questionnaires for IBD patients were completed to evaluate the QOL.

RESULTS

Anemia was present in 35.6% of IBD patients [38.2% of Crohn's disease (CD) patients vs. 29.3% of ulcerative colitis (UC) patients, P = 0.025]. Elevated platelet (PLT) count (CD: OR, 1.004; 95% CI, 1.001-1.007; P = 0.007; UC: OR, 1.010; 95% CI, 1.004-1.016; P = 0.001), elevated erythrocyte sedimentation rate (ESR) (CD: OR, 1.024; 95% CI, 1.012-1.036; P < 0.001; UC: OR, 1.025; 95% CI, 1.001-1.051; P = 0.044), and lower albumin levels (CD: OR, 0.801; 95% CI, 0.749-0.857; P < 0.001; UC: OR, 0.789; 95% CI, 0.720-0.864; P < 0.001) were associated with anemia. Among the IBD patients with anemia, only 25.8% received treatment for anemia. IBD patients with anemia had significantly lower SF-36 scores (P = 0.011) and higher FS-14 scores (P = 0.026) than those without anemia.

CONCLUSION

Anemia is common in IBD patients. Elevated PLT count and ESR are risk factors for anemia in IBD patients. Anemia may negatively impact IBD patients' QOL, but few anemia patients receive treatment for anemia.

Diseño y validación de una herramienta para la predicción de desenlaces adversos en pacientes con obstrucción intestinal por bridas: La escala HALVIC

Introducción. La obstrucción intestinal por bridas representa una causa común de consulta a los servicios de urgencias, pero hay poca claridad sobre qué pacientes tienen mayor riesgo de desarrollar complicaciones. El objetivo de este estudio fue diseñar y validar una escala de predicción de riesgo de desenlaces adversos en pacientes con obstrucción intestinal por bridas. Métodos. Estudio de cohorte retrospectivo realizado a partir de la base de datos MIMIC-IV. Se incluyeron pacientes adultos admitidos al servicio de urgencias entre 2008 y 2019, con diagnóstico de obstrucción intestinal por bridas. El desenlace principal fue el compuesto de resección intestinal, ingreso a unidad de cuidados intensivos y mortalidad por cualquier causa. Se diseñó una escala de predicción de riesgo asignando un puntaje a cada variable. Resultados. Se incluyeron 513 pacientes, 63,7 % hombres. El desenlace compuesto se presentó en el 25,7 % de los casos. La edad, historia de insuficiencia cardiaca y enfermedad arterial periférica, nivel de hemoglobina, recuento de leucocitos e INR constituyeron el mejor modelo de predicción de estos desenlaces (AUC 0,75). A partir de este modelo, se creó la escala simplificada HALVIC, clasificando el riesgo del desenlace compuesto en bajo (0-2 puntos), medio (3-4 puntos) y alto (5-7 puntos). Conclusión. La escala HALVIC es una herramienta de predicción simple y fácilmente aplicable. Puede identificar de manera precisa los pacientes con obstrucción intestinal por bridas con alto riesgo de complicaciones, permitiendo el ajuste individualizado de las estrategias de manejo para mejorar los desenlaces.

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Pediatric Management of Crohn's Disease

Pediatric Crohn's disease is often more severe, requires higher levels of immunosuppression, and is associated with greater morbidity compared with adult Crohn's disease. Unique considerations in pediatric Crohn's disease include growth impairment, pubertal delay, bone disease, longevity of disease burden, and psychosocial impact. Treatment options are limited, requiring off-label use of therapy in this challenging patient population. Understanding the medications available, the existing evidence supporting their use, and side effects is important. There is tremendous potential for growth and improvement in this field and it is essential that all gastroenterologists have an understanding of this complex and unique patient population.

Impact of Biological Agents on Postsurgical Complications in Inflammatory Bowel Disease: A Multicentre Study of Geteccu

Background: The impact of biologics on the risk of postoperative complications (PC) in inflammatory bowel disease (IBD) is still an ongoing debate. This lack of evidence is more relevant for ustekinumab and vedolizumab. Aims: To evaluate the impact of biologics on the risk of PC. Methods: A retrospective study was performed in 37 centres. Patients treated with biologics within 12 weeks before surgery were considered “exposed”. The impact of the exposure on the risk of 30-day PC and the risk of infections was assessed by logistic regression and propensity score-matched analysis. Results: A total of 1535 surgeries were performed on 1370 patients. Of them, 711 surgeries were conducted in the exposed cohort (584 anti-TNF, 58 vedolizumab and 69 ustekinumab). In the multivariate analysis, male gender (OR: 1.5; 95% CI: 1.2–2.0), urgent surgery (OR: 1.6; 95% CI: 1.2–2.2), laparotomy approach (OR: 1.5; 95% CI: 1.1–1.9) and severe anaemia (OR: 1.8; 95% CI: 1.3–2.6) had higher risk of PC, while academic hospitals had significantly lower risk. Exposure to biologics (either anti-TNF, vedolizumab or ustekinumab) did not increase the risk of PC (OR: 1.2; 95% CI: 0.97–1.58), although it could be a risk factor for postoperative infections (OR 1.5; 95% CI: 1.03–2.27). Conclusions: Preoperative administration of biologics does not seem to be a risk factor for overall PC, although it may be so for postoperative infections.

Iron Deficiency Anemia in Inflammatory Bowel Disease: What Do We Know?

One of the most common extraintestinal manifestations of inflammatory bowel disease is iron deficiency anemia. It is often an untreated condition that significantly impairs patients' quality of life and elevates mortality and morbidity. Although it is often accompanied by mild symptoms (e.g., fatigue, lethargy), it can provoke severe health conditions, such as dyspnea, palpitation, angina, and mental disorders, and increases hospitalization and mortality rate as well. As anemia develops through several pathomechanisms, such as occult bleeding, chronic inflammation, and medicines (e.g., methotrexate), treating anemia effectively requires to manage the underlying pathological changes as well. Based on international publications and data, it is a frequent condition and more frequent in pediatrics. According to Goodhand et al., iron deficiency is present in more than 60% of children, whereas only 14% of them received oral iron therapy. Compared to adult patients, 22% have iron deficiency, and 48% of them received oral and 41% intravenous iron therapy. Miller et al. also highlighted that among young patients iron deficiency anemia is a frequent condition, as almost 50% of the patients were anemic in their cohort. European Crohn's and Colitis Organisation's statements are clear regarding the diagnosis of iron deficiency anemia, and the iron supplementation as well. Third-generation parenteral iron supplementations seem to be safer and more effective than oral iron pills. Oral iron in many cases cannot replace the iron homeostasis as well; furthermore, it can provoke dysbiosis, which can potentially lead to relapse. As a result, we claim that both oral and parenteral should be used more frequently; furthermore, intravenous iron could replace oral medicines as well in certain cases. Despite the fact that iron deficiency anemia is examined by many aspects, further questions can be raised. Can it imply underlying pathological lesions? Are both oral and intravenous iron therapy safe and effective? When and how are they used? We demand that more studies should be conducted regarding these issues.

Socioeconomic disparities in the comorbidities and surgical management of pediatric Crohn's disease

BACKGROUND

To examine differences in comorbidities and surgical management based on socioeconomics in hospitalized children with Crohn's disease (CD).

METHODS

Using the Kids' Inpatient Database for 2006-2012, we identified patients (<21 years) with a CD diagnosis. Cases were analyzed and stratified by median parental income by zip code. Multivariable logistic regression was performed.

RESULTS

Of the 28,337 pediatric CD hospitalizations identified, patients were more likely male (51.1%), non-Hispanic white (71.3%), and had a mean age of 15.9 years. The proportion of minority patients increased as income quartile declined. Higher income quartile patients were more likely to be coded with anxiety and less likely with anemia. The highest income quartile was more likely to have a bowel obstruction, and peritoneal/intestinal abscess and was also 28% more likely to undergo a major surgical procedure.

CONCLUSIONS

Significant variability exists in the reported comorbidities and surgical interventions associated with CD by income quartile. Lower income quartile patients are more likely to be of minority ethnicity and anemic, but less likely to undergo a major surgical procedure. Further investigation is warranted to determine whether these differences represent disease variability, differences in healthcare resource allocation, or implicit bias in management.

IMPACT

There is a disparity in the care of children and young adults with Crohn's disease based on parental income. Links between parental income and the treatment of Crohn's disease in children and young adults has not been assessed in national datasets in the United States. Children in the highest income quartile were more likely to undergo a major surgical procedure. The variations in healthcare for hospitalized children and young adults with CD found in this study may represent variability in patient disease, implicit bias, or a disparity in healthcare delivery across the United States.

Anemia is associated with the risk of Crohn's disease, not ulcerative colitis: A nationwide population-based cohort study

Anemia is a common manifestation of inflammatory bowel disease (IBD), but it remains unclear whether anemia is associated with the development of IBD. We assessed the risk of developing IBD in anemic patients, and stratified the results with respect to their hemoglobin concentrations. A population-based study was conducted using the National Healthcare Insurance Service database in South Korea. We included individuals over 20 years’ old who participated in the national health screening program in 2009 (n = 9,962,064). Anemia was defined as a hemoglobin level less than 13 g/dL in men and less than 12 g/dL in women. We compared the rate of newly diagnosed IBD in anemic patients and non-anemic individuals. Newly diagnosed IBD was identified using both the ICD-10 medical code and specialized V codes for rare intractable diseases in South Korea. During the mean follow-up period of 7.3 years, the incidences of CD and UC in anemic patients were 2.89 and 6.88 per 100,000 person-years, respectively. The risk of CD was significantly higher in anemic patients than in non-anemic individuals [adjusted hazard ratio (aHR), 2.084; 95% confidence interval (CI), 1.769–2.455]. The risk of CD development was inversely proportional to the hemoglobin concentration. A J-curve relationship was observed between age and the risk of CD in anemic patients. The risk of CD in male anemic patients was significantly higher than that in female anemic patients (aHR, 1.432 vs. 1.240, respectively). By contrast, there was no statistically significant difference in the risk of developing UC in anemic and non-anemic individuals (aHR, 0.972; 95% CI, 0.880–1.073). This work indicates that anemia is related to the development of CD, and this risk was inversely proportional to the hemoglobin concentration.

ANEMIA AND IRON DEFICIENCY IN INFLAMMATORY BOWEL DISEASE PATIENTS IN A REFERRAL CENTER IN BRAZIL: PREVALENCE AND RISK FACTORS

ABSTRACT BACKGROUND: Data regarding the prevalence of anemia in inflammatory bowel disease (IBD) patients are scarce in Brazil. Anemia and iron deficiency anemia have been known to cause significant functional impairment, lower quality of life, and higher morbidity and mortality and may be correlated with an impact on the cost of treatment. OBJECTIVE: The aim of this study was to estimate the prevalence and risk factors for anemia and iron deficiency anemia in patients with IBD in a tertiary IBD unit in Southeast Brazil. METHODS: We conducted an Institutional Review Board-approved retrospective analysis of an adult IBD cohort (IBD Unit, Ribeirão Preto Medical School, University of São Paulo, Brazil) consisting of 579 patients between January 2014 and July 2018. Clinicoepidemiological data, hemoglobin measurements and serum ferritin were extracted from electronic medical records. Anemia prevalence was calculated among ulcerative colitis (UC) and Crohn’s disease (CD) phenotypes. Risk factors for anemia were also calculated. RESULTS: A total of 529 (91%) patients had complete blood counts available in their medical records. Only 35.5% of IBD patients were fully screened for anemia. The prevalence of anemia in IBD patients was 24.6% (29.1% in CD and 19.1% in UC, P=0.008). The anemia was moderate to severe in 16.9% (19.8% in CD and 11.4% in UC, P=0.34). The prevalence of iron deficiency was 52.3% (53.6% in CD and 51.2% in UC, P=0.95). Anemia of chronic disease was present in 14.1% of IBD patients. A total of 53.8% of patients with anemia were in clinical remission. CD was associated with an increased prevalence of anemia (P=0.008; OR=1.76; CI 95% =1.16-2.66) compared to UC. The penetrant disease phenotype in CD was associated with a lower risk of anemia (P<0.0001; OR=0.25; CI 95% =0.14-0.43). Active disease compared to the disease in clinical remission was associated with an increased risk of anemia (P=0.0003; OR=2.61; CI 95% =1.56-4.36) in CD. The presence of anemia was less frequent in patients with CD who underwent surgical bowel resection compared to those who did not undergo surgery (P<0.0001; OR=0.24; CI 95% =0.14-0.40). No differences in anemia prevalence were observed regarding CD localization, age at diagnosis, UC extension or biological therapy (P>0.05). CONCLUSION: Despite the low levels of full screening, anemia and iron deficiency anemia were common manifestations of IBD. CD was associated with an increased risk of anemia, especially with active disease. In addition, patients with CD who underwent surgical bowel resection and penetrant disease phenotype in CD were associated with lower risk of anemia.

Impact of Nutritional Deficiencies on Children and Young Adults with Crohn's Disease Undergoing Intraabdominal Surgery

PURPOSE

We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery.

METHODS

Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed.

RESULTS

We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation.

CONCLUSIONS

Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients.

LEVEL OF EVIDENCE

III.

Risk Factors for Prolonged Length of Stay and Readmission After Parathyroidectomy for Renal Secondary Hyperparathyroidism

BACKGROUND

Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population.

METHODS

Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011-2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy.

RESULTS

The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09-4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25-2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22-11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31-11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21-3.87), p = 0.009, and 2.40 (95%-CI 1.15-5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07-0.80, p = 0.021).

CONCLUSION

In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission.

Anaemia in patients undergoing major bowel surgery - Prevalence and current practice: A public and private institution experience

AIM

The study aimed to compare the frequency and alignment of preoperative anaemia screening and treatment with Australian guidelines in elective bowel surgery and determine the impact on clinical outcomes.

METHODS

We performed a retrospective observational study, with an audit of 559 adult patients who underwent major elective bowel surgery in an Australian metropolitan hospital, January 2016-December 2018. Outcome measures included rate of anaemia, guideline compliance, hospital length of stay, and transfusion rate.

RESULTS

Preoperative anaemia assessment occurred in 82.6% of patients. However, only 5.2% received recommended biochemical tests at least one week before surgery. Only 25.2% of anaemic patients received preoperative treatment; they experienced a longer hospital length of stay (9.93 days versus 7.88 days, p < 0.001) and an increased rate of transfusion (OR: 3.186, p < 0.05).

CONCLUSION

The gaps between current preoperative anaemia screening, management and national guidelines may place patients at higher risk of poor surgical outcome.

Is preoperative anemia a significant risk factor for splenectomy patients? A NSQIP analysis

Background

Prior literature has examined the association between preoperative anemia and complications across surgical settings; however, evidence is lacking for splenectomy patients. We investigated the association between preoperative hematocrit and 30-day postoperative outcomes in this population using a national database.

Methods

Patients who underwent splenectomy (2012–2017) were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Analyses were performed for the overall cohort and elective versus emergent subsets, adjusting for transfusion among other covariates.

Results

Our sample included 5,580 patients. As hematocrit decreased, complication rates increased incrementally in both the univariate and multivariate analyses. Adjusted odds ratios (and 95% confidence intervals) for moderate anemia (26% ≤ hematocrit < 30%) as compared to no anemia (hematocrit ≥ 38%) were readmission = 1.5 (1.1–1.8), sepsis = 2.2 (1.6–3.0), and composite outcome = 1.8 (1.0–3.2). Parameter estimates (standard error, P value) for the moderate versus no anemia group were length of stay = 3.0 (0.5, P < .001) and days to discharge = 1.2 (0.3; P < .001).

Conclusion

Our results demonstrate a dose-response relationship between increasing degree of anemia and odds of various postoperative adverse outcomes after adjusting for several potential confounders. The subset analysis further suggests that elective splenectomy cases are more likely to have poor outcomes when in the presence of anemia or when transfusions are performed as compared to emergent cases. This suggests that the harm associated with transfusion may offset the benefit of optimizing anemia in an elective splenectomy case.

Association of Preoperative Anemia With 30-Day Morbidity and Mortality Among Patients With Thyroid Cancer Who Undergo Thyroidectomy

Importance

Despite the ease of preoperative anemia diagnosis and the availability of treatment options, the morbidity and mortality associated with this condition remain unacceptably high, and the literature describing the association of preoperative anemia with postoperative outcomes following thyroid surgery in patients with thyroid cancer remain sparse. Reporting outcomes in this patient population may help to facilitate preoperative optimization.

Objective

To assess whether an association exists between preoperative anemia and outcomes following thyroid surgery in patients with thyroid cancer.

Design, Setting, and Participants

This retrospective, cross-sectional, cohort study used the American College of Surgeons National Surgical Quality Improvement Program database to identify 32 166 patients between 2007 and 2016 with Current Procedural Terminology codes for thyroid surgery and with the International Classification of Diseases, Ninth Revision code of malignant thyroid cancer.

Exposures

Preoperative anemia as defined using the World Health Organization criteria of hematocrit less than 36% in nonpregnant females and less than 39% in males.

Main Outcomes and Measures

Multivariable logistic regression analysis was conducted to assess the association of preoperative anemia with the following 30-day postoperative outcomes: pulmonary, infectious, and cardiac complications, overall and serious morbidity (surgical site infection and medical complications), prolonged hospital length of stay (≥75th percentile for the cohort), and mortality.

Results

Among the 24 912 patients with thyroid cancer who underwent thyroidectomy included in the final analysis, the median (interquartile range) age was 51 (40-62) years and the majority were women (18 705 [75.1%]). The prevalence of preoperative anemia was 12.5% (n = 3108). Within the overall study population, hypertension (9242 patients [37.1%]) followed by active smoking (2992 patients [12.0%]) were the most prevalent comorbidities. The unadjusted odds of anemia vs no anemia were significantly higher for every 10-year increase in age (odds ratio [OR], 1.10; 95% CI, 1.08-1.13) and for black vs white patients (OR, 2.82; 95% CI, 2.51-3.17). The adjusted odds of postoperative overall morbidity (OR, 1.68; 95% CI, 1.29-2.17), mortality (OR, 3.36; 95% CI, 1.37-8.28), and pulmonary (OR, 2.36; 95% CI, 1.65-3.34) and infectious (OR, 1.62; 95% CI, 1.12-2.29) complications were higher in patients with preoperative anemia than in those without preoperative anemia.

Conclusions and Relevance

The findings from this study suggest that preoperative anemia may not only be associated with racial differences and a higher comorbidity burden but may also increase the likelihood of postoperative morbidity and mortality. These results may provide a basis for further risk reduction strategies and preoperative optimization.

The ACS National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative: Design, Implementation, and Validation of a Disease-specific Module

BACKGROUND

Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD.

STUDY DESIGN

A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated.

RESULTS

Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68).

CONCLUSION

We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population.

Management of Biological Therapy Before Elective Inflammatory Bowel Disease Surgeries

Increasing uptake of biologic therapy has contributed to declining surgical rates for inflammatory bowel disease (IBD). However, a significant number of patients on biologic therapy will go on to require surgery. The literature is conflicted with regard to the preoperative management of biologic therapy before urgent or elective IBD surgery. This article reviews the available data on postoperative complications following preoperative treatment with anti-tumor necrosis factor alpha therapy, anti-integrin therapy, and anti-interleukin therapy.

Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture

STUDY OBJECTIVE

To identify modifiable preoperative factors that might influence the morbidity and mortality associated with non-elective, inpatient hip fracture surgeries in the geriatric surgical population.

DESIGN

Retrospective database analysis from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project.

SETTING

Inpatient, perioperative.

PATIENTS

Geriatric patients undergoing surgery.

INTERVENTIONS

Non-elective hip repair surgery.

MEASUREMENTS

Preoperative demographic, medical, surgical, and anesthetic variables; post-operative rates of delirium, decline in functional status, and 30-day mortality.

MAIN RESULTS

The 1261 patients in this study were predominantly female (74%), white (89%), and non-Hispanic (92%). Ages were distributed across groups from 65 to over 90 years. Most patients were categorized as American Society of Anesthesiologists Physical Status class 3 (64%). General anesthesia (57%) was the most common anesthetic, followed by spinal (38%). Preoperative functional status was recorded in 79% as independent in activities of daily living (ADLs). About one third of patients had baseline dementia. Post-operatively, 42% experienced delirium, and most patients required partial or total assistance with ADLs (72% and 12%, respectively). Reoperation was required in 2.8% of cases. Mortality at 30 days was 5.0%. In the multivariable analysis, risk factors associated with post-operative delirium included dementia and lack of competency to sign consent. In the analysis for postoperative decline in functional status, the major risk factor was a history of falls, while emergently performed surgery was protective. The analysis for mortality at thirty days was under-powered.

CONCLUSIONS

Hip fractures remain a major source of morbidity in geriatric patients. Baseline dementia and inability to sign surgical consent are significant risk factors for adverse outcomes after hip fractures and should be considered in the informed consent process. Data from this study and currently ongoing randomized trials will help guide reductions in morbidity and mortality in this population.

Risk of postoperative morbidity in patients having bowel resection for colonic Crohn's disease

BACKGROUND

The aim of the present multicenter study was to analyze the incidence and risk factors associated with postoperative morbidity in patients who had colorectal resection for colonic Crohn's disease.

METHODS

Consecutive patients undergoing colorectal resection for colonic Crohn's disease at seven surgical units in 1992-2017 were included. Exclusion criteria were: proctectomy for perianal disease, surgery for cancer, previous colectomies, surgery before 1998. Abdominal colectomy and proctocolectomy were defined as extended resections; all other operations were classified as segmental resections. Postoperative intraabdominal septic complications (IASC) were: anastomotic leaks, peritonitis and abscess.

RESULTS

One hundred ninety-nine patients met the inclusion criteria: 116 patients had segmental resections and extended resections were performed in 83 patients. An anastomosis was constructed in 122 patients and an additional stoma was formed in 15 of those cases. Segmental resections were performed significantly more frequently in stricturing or penetrating disease (93% vs. 61%, p < 0.001) and were completed by an anastomosis more often than extended resections (78% vs. 37%, p < 0.001). The overall IASC rate was 17%. On multivariate analysis, formation of an anastomosis (Hazard ratio 2.9; 95% CI 1.1-7.7; p = 0.036) and preoperative hemoglobin level of < 10 g/dl (Hazard ratio 3.1; 95% CI 1.1-9.1; p = 0.034) were associated with an increase of postoperative IASC rate. Preoperative medication did not influence postoperative outcome.

CONCLUSIONS

Severe preoperative anemia is associated with an increased postoperative morbidity. Resections completed by an anastomosis pose an increased postoperative complication risk in patients with colonic Crohn's disease as compared to resections without an anastomosis.

Optimizing Preoperative Anemia to Improve Patient Outcomes

Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.

Transfusion in Head and Neck Cancer Patients Undergoing Pedicled Flap Reconstruction

OBJECTIVE

Blood product utilization is monitored to prevent unnecessary transfusions. Head-and-neck pedicled flap reconstruction transfusion-related outcomes were assessed.

METHODS

One hundred and thirty-six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap-related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre- and perioperative factors.

RESULTS

Of all head-and-neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap-survival, or medical/flap-related complications.

CONCLUSION

Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E409-E415, 2018.

The impact of preoperative anemia and malnutrition on outcomes in paraesophageal hernia repair

BACKGROUND

Patients with a paraesophageal hernia may experience gastroesophageal reflux symptoms and/or obstructive symptoms such as dysphagia. Some patients with large and complex paraesophageal hernias unintentionally lose a significant amount of weight secondary to difficulty eating. A subset of patients will develop Cameron's erosions in the hernia, which contribute to anemia. Given the heterogeneous nature of patients who ultimately undergo paraesophageal hernia repair, we sought to determine if patients with anemia or malnutrition suffered from increased morbidity or mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program datasets from 2011 to 2015 were queried to identify patients undergoing paraesophageal hernia repair. Malnutrition was defined as preoperative albumin < 3.5 g/dL. Preoperative anemia was defined as hematocrit less than 36% for females and 39% for males. Thirty-day postoperative outcomes were assessed.

RESULTS

A total of 15,105 patients underwent paraesophageal hernia repair in the study interval. Of these patients, 7943 (52.6%) had a recorded preoperative albumin and 13.9% of these patients were malnourished. There were 13,139 (87%) patients with a documented preoperative hematocrit and 23.1% met criteria for anemia. Both anemia and malnutrition were associated with higher rates of complications, readmissions, reoperations, and mortality. This was confirmed on logistic regression. The average postoperative length of stay was longer in the malnourished (6.1 vs. 3.1 days when not malnourished, p < 0.0001) and anemic (4.1 vs. 2.8 days without anemia, p < 0.0001).

CONCLUSION

Malnutrition and anemia are associated with increased morbidity and mortality in patients undergoing paraesophageal hernia repair, as well as a longer length of stay. This information can be used for risk assessment and perhaps preoperative optimization of these risk factors when clinically appropriate.

Preoperative autologous blood collection before bone marrow harvests in haploidentical related donors: is it justified?

BACKGROUND

With the increasing safety of allogeneic blood supply and declining need for transfusion due to patient blood management, the practice of preoperative autologous donation (PAD) continues to decline. The practice gained popularity during the 1980s and 1990s with the emergence of transfusion-transmitted human immunodeficiency virus and hepatitis C. At the peak of this public concern, the National Marrow Donor Program recommended that marrow donors have 1 to 3 autologous units of blood collected before their marrow harvest to minimize the likelihood of allogeneic transfusion. After three decades, the practice remains prevalent in marrow donors. We aimed to study the efficacy of PAD in healthy marrow donors.

STUDY DESIGN AND METHODS

PADs performed before marrow harvest in healthy donors at our center between January 2013 and July 2015 were reviewed. The utilization of autologous units and decrease in hemoglobin levels due to PAD and marrow harvest were studied. Similar practices were assessed in the rest of the United States through a brief survey.

RESULTS

Of a total of 262 autologous units collected from 136 donors, 25.2% were wasted. Ninety-nine percent of the marrow donors received at least 1 unit of blood irrespective of the need. PAD contributed to preoperative anemia, exposing three donors to allogeneic blood transfusion. The survey results showed a mixed response with some institutions continuing and others not practicing PAD.

CONCLUSION

PADs are not justified in healthy marrow donors as they expose them to a risk of preoperative anemia and hence a greater risk of transfusion.