Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn’s Disease
Patients undergoing colon resection for Crohn’s disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn’s disease from a national database.
Patients who underwent colon resection for Crohn’s disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted.
A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04).
Approximately one third of the patients who undergo colon resection for Crohn’s disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.
KeywordsCrohn’s disease Morbidity Surgical management
All the authors contributed to the conception or design of the project; assisted with the acquisition, analysis, or interpretation of data; drafted and/or revised the manuscript; and had final approval of the version to be published. All the authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity may be resolved.
Compliance with Ethical Standards
Conflicts of Interest and Source of Funding
The authors have no conflicts of interest including relevant financial interests, activities, relationships, and affiliations.
The preliminary results of the study were presented as poster at the American Society of Colon and Rectal Surgery Annual Scientific Meeting, June 10–14, 2017, Seattle, WA.
- 1.Frolkis AD, Dykeman J, Negron ME, Debruyn J, Jette N, Fiest KM et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology. 2013;145(5):996–1006. https://doi.org/10.1053/j.gastro.2013.07.041.CrossRefPubMedGoogle Scholar
- 4.Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB et al. The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Annals of surgery. 1998;228(4):491–507.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA, Jr. et al. Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Annals of surgery. 2008;248(2):329–36. https://doi.org/10.1097/SLA.0b013e3181823485. CrossRefPubMedGoogle Scholar
- 6.American College of Surgeons. User Guide for the 2015 ACS NSQIP Participant Use Data File (PUF). https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_user_guide_2015.ashx. Accessed November 2, 2016.
- 7.American College of Surgeons User Guide for the 2015 ACS NSQIP Procedure Targeted Participant Use Data File (PUF). 2016. https://www.facs.org/~/media/files/quality%20programs/nsqip/pt_nsqip_puf_user_guide_2015.ashx. Accessed November 2, 2016.
- 8.Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Canadian Journal of Gastroenterology = Journal Canadien de Gastroenterologie. 2005;19 Suppl A:5a-36a.Google Scholar
- 9.Group WS. Nutritional anaemias. World Health Organization Technical Report Series. 1968;405:1–40.Google Scholar
- 13.Goyer P, Alves A, Bretagnol F, Bouhnik Y, Valleur P, Panis Y. Impact of complex Crohn's disease on the outcome of laparoscopic ileocecal resection: a comparative clinical study in 124 patients. Diseases of the colon and rectum. 2009;52(2):205–10. https://doi.org/10.1007/DCR.0b013e31819c9c08.CrossRefPubMedGoogle Scholar
- 15.Handler M, Dotan I, Klausner JM, Yanai H, Neeman E, Tulchinsky H. Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study. Techniques in coloproctology. 2016;20(5):287–92. https://doi.org/10.1007/s10151-016-1440-8.CrossRefPubMedGoogle Scholar
- 19.Lee Y, Fleming FJ, Deeb AP, Gunzler D, Messing S, Monson JR. A laparoscopic approach reduces short-term complications and length of stay following ileocolic resection in Crohn's disease: an analysis of outcomes from the NSQIP database. Colorectal disease : The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2012;14(5):572–7. https://doi.org/10.1111/j.1463-1318.2011.02756.x. CrossRefGoogle Scholar
- 21.Lesperance K, Martin MJ, Lehmann R, Brounts L, Steele SR. National trends and outcomes for the surgical therapy of ileocolonic Crohn's disease: a population-based analysis of laparoscopic vs. open approaches. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2009;13(7):1251–9. https://doi.org/10.1007/s11605-009-0853-3. CrossRefGoogle Scholar
- 24.Eshuis EJ, Polle SW, Slors JF, Hommes DW, Sprangers MA, Gouma DJ et al. Long-term surgical recurrence, morbidity, quality of life, and body image of laparoscopic-assisted vs. open ileocolic resection for Crohn's disease: a comparative study. Diseases of the Colon and Rectum. 2008;51(6):858–67. https://doi.org/10.1007/s10350-008-9195-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN Journal of parenteral and enteral nutrition. 2012;36(3):275–83. https://doi.org/10.1177/0148607112440285. CrossRefPubMedGoogle Scholar
- 30.Bozzetti F, Gianotti L, Braga M, Di Carlo V, Mariani L. Postoperative complications in gastrointestinal cancer patients: the joint role of the nutritional status and the nutritional support. Clinical Nutrition (Edinburgh, Scotland). 2007;26(6):698–709. https://doi.org/10.1016/j.clnu.2007.06.009.CrossRefGoogle Scholar
- 31.Yamada A, Komaki Y, Patel N, Komaki F, Aelvoet AS, Tran AL et al. Risk of Postoperative Complications Among Inflammatory Bowel Disease Patients Treated Preoperatively With Vedolizumab. The American journal of gastroenterology. 2017;112(9):1423–9. https://doi.org/10.1038/ajg.2017.201.CrossRefPubMedGoogle Scholar
- 34.Dreznik Y, Horesh N, Gutman M, Gravetz A, Amiel I, Jacobi H et al. Preoperative Nutritional Optimization for Crohn's Disease Patients Can Improve Surgical Outcome. Digestive Surgery. 2017. https://doi.org/10.1159/000481408.
- 35.Filmann N, Rey J, Schneeweiss S, Ardizzone S, Bager P, Bergamaschi G et al. Prevalence of anemia in inflammatory bowel diseases in european countries: a systematic review and individual patient data meta-analysis. Inflammatory bowel diseases. 2014;20(5):936–45. https://doi.org/10.1097/01.MIB.0000442728.74340.fd.CrossRefPubMedGoogle Scholar
- 36.Koutroubakis IE, Ramos-Rivers C, Regueiro M, Koutroumpakis E, Click B, Schoen RE et al. Persistent or Recurrent Anemia Is Associated With Severe and Disabling Inflammatory Bowel Disease. Clinical Gastroenterology and Hepatology : The Official Clinical Practice Journal of the American Gastroenterological Association. 2015;13(10):1760–6. https://doi.org/10.1016/j.cgh.2015.03.029.CrossRefGoogle Scholar
- 39.Morar PS, Hodgkinson JD, Thalayasingam S, Koysombat K, Purcell M, Hart AL et al. Determining Predictors for Intra-abdominal Septic Complications Following Ileocolonic Resection for Crohn's Disease-Considerations in Pre-operative and Peri-operative Optimisation Techniques to Improve Outcome. Journal of Crohn's & Colitis. 2015;9(6):483–91. https://doi.org/10.1093/ecco-jcc/jjv051.CrossRefGoogle Scholar
- 40.Kulaylat AN, Hollenbeak CS, Sangster W, Stewart DB, Sr. Impact of smoking on the surgical outcome of Crohn's disease: a propensity-score matched National Surgical Quality Improvement Program analysis. Colorectal Disease: The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2015;17(10):891–902. https://doi.org/10.1111/codi.12958. CrossRefGoogle Scholar
- 42.Barker K, Graham NG, Mason MC, De Dombal FT, Goligher JC. The relative significance of preoperative oral antibiotics, mechanical bowel preparation, and preoperative peritoneal contamination in the avoidance of sepsis after radical surgery for ulcerative colitis and Crohn's disease of the large bowel. The British Journal Of Surgery. 1971;58(4):270–3.CrossRefPubMedGoogle Scholar