Abdominal sepsis and the open abdomen in the geriatric patient: to operate or not to operate?

Author(s):
Jefferson Proaño-Zamudio; Dias Argandykov; Anthony Gebran; Charudutt N. Paranjape; Stephanie J. Maroney; April Mendoza; Haytham Kaafarani; Peter Fagenholz; David King; George Velmahos; John Hwabejire

Background:

Elderly patients are presenting more commonly with emergency surgical conditions. The open abdomen technique is widely used in patients with abdominal emergencies who need rapid control of intrabdominal contamination. However, specific predictors of mortality in this population are understudied.

Methods:

The 2013-2017 ACS-NSQIP database was queried for emergent laparotomies performed in geriatric patients with pre-operative sepsis or septic shock in whom closure of the fascia was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-day mortality. Univariable analysis was performed, followed by multivariable logistic regression. Mortality was computed for combinations of the five predictors with the highest odds-ratios (OR).

Results:

A total of 1519 patients were identified. Median age was 73 years and 53.3% were females. 30-day mortality was 47.9%. Compared to survivors, non-survivors were older (median age (IQR) 75.9 (69.5-80.0) vs. 72.0 (78.0-78.0),  p < 0.001), had a higher incidence of chronic obstructive pulmonary disease (COPD) (22.1% vs 16.3 %, p = 0.004), congestive heart failure (CHF) (10.9% vs 4.6%, p < 0.001), dependence on dialysis (12.4% vs. 4.3%, p < 0.001), dependence on mechanical ventilation (37.7% vs 17.3%, p < 0.001), and pre-operative septic shock (71.4% vs 49.3%, p < 0.001). In the multivariable analysis, the most important predictors were: American Society of Anesthesiologists (ASA) status 5 (OR = 4.10, 95%CI, 1.69 – 9.94 p =0.002), dialysis dependence (OR = 2.53, 95%CI 1.59 – 4.02, p < 0.001), CHF (OR = 2.34, 95%CI 1.49 –3.67, p < 0.001), disseminated cancer (OR = 2.12, 95%CI 1.29 –3.47, p = 0.003) and pre-operative thrombocytopenia (OR = 1.94, 95%CI 1.24 – 3.04, p = 0.004). Mortality for combinations of these predictors was computed (Figure 1); five combinations resulted in 100% mortality. The absence of all these risk factors results in a survival rate of 64.2%.

Conclusions:

In elderly patients, abdominal sepsis or septic shock requiring open abdomen for surgical management is a highly lethal condition. The presence of several combinations of pre-operative comorbidities is uniformly lethal, and should preclude surgical management.