Congestive Heart Failure and Chronic Obstructive Pulmonary Disease Predict Poor Surgical Outcomes in Older Adults Undergoing Elective Diverticulitis Surgery
ABSTRACT Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain.
This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups.
This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis.
Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007.
Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy.
The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications.
Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality.
Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors.
Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.
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ABSTRACT: Postoperative pulmonary complications (atelectasis, pneumonia, pulmonary edema, acute respiratory failure) are common, particularly after abdominal and thoracic surgery, pneumonia and atelectasis being the most common. Postoperative pneumonia is associated with increased morbidity, length of hospital stay, and costs. Few institutions have pneumonia prevention programs for surgical patients, and these should be strongly considered. Acute respiratory failure is a life-threatening pulmonary complication that requires institution of mechanical ventilation and admission to the intensive care unit, and is associated with increased risk for ventilator-associated pneumonia. This article discusses epidemiology, risk factors, diagnosis, treatment, and prevention of these pulmonary complications in surgical patients.Surgical Clinics of North America 04/2012; 92(2):321-44, ix. DOI:10.1016/j.suc.2012.01.013 · 1.93 Impact Factor
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ABSTRACT: Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies. This study investigated national trends in management of perforated diverticulitis. This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008. The study was conducted in Ireland. Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included. The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications. Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p < 0.001), complications (14.1% vs 25.0%, p < 0.001), and length of stay (10 days vs 20 days, p < 0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p < 0.001), as were those with connective tissue disease (OR 7.3, p < 0.05) or chronic kidney disease (OR 8.0, p < 0.001). This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group. The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.Diseases of the Colon & Rectum 09/2012; 55(9):932-8. DOI:10.1097/DCR.0b013e31826178d0 · 3.20 Impact Factor
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ABSTRACT: BACKGROUND: There is a paucity of quality data on the effects of chronic kidney disease in abdominal surgery. The aim of this study was to define the risk and outcome predictors of bowel resection in stage 5 chronic kidney disease using a large national clinical database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from years 2005-2010 for major bowel resection in dialysis-dependent patients. Patient demographics, preoperative risk factors, and intraoperative variables were evaluated. Primary endpoints were mortality and morbidity after 30 days. Predictors of outcome were assessed by multivariate regression. RESULTS: The study included 1,685 patients with chronic kidney disease undergoing bowel resection. Overall mortality and morbidity were 27.5 and 58.3 %, respectively. Acute presentation was the strongest predictor of mortality (OR 2.39, CI 1.54-3.72, p < 0.001). Other predictors of mortality included hypoalbuminemia (OR 2.12, CI 1.39-3.24, p < 0.001), pulmonary comorbidity (OR 2.25, CI 1.67-3.03, p < 0.001), and cardiac comorbidity (OR 1.54, CI 1.16-2.05, p = 0.003). CONCLUSION: This study demonstrates that bowel resection in patients with chronic kidney disease confers a high mortality risk. Preoperative optimization of comorbid conditions may reduce mortality after bowel resection in dialysis-dependent patients. In addition, laparoscopy was associated with a reduction in postoperative morbidity suggesting that it should be used preferentially.Journal of Gastrointestinal Surgery 09/2012; 17(1). DOI:10.1007/s11605-012-2027-y · 2.39 Impact Factor