Emergency General Surgery in the Immunosuppressed Patient: Do Outcomes Differ?

Author(s):
Manuel Castillo-Angeles ; Barbara Okafor; Christine Wu; Stephanie Nitzschke; Reza Askari MD

Background:

Emergency General Surgery (EGS) patients are at increased risk of morbidity and mortality. Little is known about the impact of these high-risk procedures on immunosuppressed patients. The purpose of this study was to determine if outcomes differ for immunosuppressed patients undergoing EGS procedures.

Hypothesis:

We hypothesize that immunosuppressed patients undergoing EGS will have worse outcomes when compared with immunocompetent patients.

Methods:

This was a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database (2005-2014). All inpatients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally were included. Immunosupression was defined as regular administration of oral or parenteral corticosteroids or immunosuppressant medications within 30 days to the operative procedure. The primary outcomes were overall mortality, overall morbidity, major morbidity, and infectious complications (organ/space surgical site infection, urinary tract infection, pneumonia, sepsis, septic shock). Multivariate logistic regression was used to determine the association between immunosuppression and main outcomes.

Results:

We included a total of 222,519 EGS admissions, of which 6,919 (3.1%) were immunosuppressed patients. Mean age was 46 years and 51.4% were female. Overall mortality was 3.6% for the entire cohort and 15.8% within the immunosuppressed group. After adjusting for clinical and demographic variables, immunosuppressed EGS patients had higher rates of overall mortality (Odds Ratio [OR] 1.42, 95% Confidence Interval [CI] 1.25 – 1.60), higher overall morbidity (OR 1.41, 95% CI 1.28 – 1.54), major morbidity (OR 1.36, 95% CI 1.23 – 1.49), and infectious complications (OR 1.28, 95% CI 1.13 – 1.44) when compared with patients without immunosuppresion.

Conclusions:

Overall, immunosuppression was significantly associated with worse mortality and morbidity, particularly infectious complications, in patients undergoing EGS procedures. These results showed the added risk of this chronic condition, and its need for additional planning from preoperative evaluation to postoperative management, to maximize benefits in these EGS subpopulation.