The Impact of Immunosuppressive Therapy in Outcomes following Emergency General Surgery: A Nationwide Analysis

Authors:
Barbara Okafor, Joaquim Havens, Manuel Castillo-Angeles, Rebecca Wiener, Reza Askari, Stephanie Nitzschke

Body of Abstract:
Background: Patients who undergo Emergency General Surgery (EGS) are at increased risk of morbidity and mortality. Prior research has shown that emergency procedures are associated with worse outcomes in immunosuppressed patients, however, it is unclear if these differ based on the type of immunosuppresive therapy. Our objective was to determine the impact of immunosuppression on mortality and morbidity following EGS procedures.

Methods: This was a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database from 2021-2022. We included all adults patients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Immunosupression therapy was defined as regular administration of oral or parenteral corticosteroids, anti-rejection/transplant immunosuppressants, synthetic or biologic Disease-Modifying Anti-rheumatic Drugs (DMARDs)/Disease-modifying drugs (DMDs), others, or combinations of described medications within 30 days to the operative procedure. The primary outcomes were overall mortality, return to the OR, and readmission within 30 days. Multivariate logistic regression was used to determine the association between immunosuppression type and main outcomes.

Results: A total of 82,906 EGS admissions were included, of which 3,266 (3.9%) received immunosuppressive therapy (41.7% received corticosteroids, 6.2% anti-rejection/transplant immunosuppressants, 11.7% synthetic, and 10.7% biologic DMARDs/DMDs). Mean age was 48.9 (SD 19.6) years, 52% were female, and 78.7% were White. Overall mortality was 4.0% for the entire cohort and 12.6% within the immunosuppressed group. After adjusting for clinical and demographic variables, immunosuppressive therapy was significantly associated with higher likelihood of returning to the OR (Odds Ratio [OR] 1.49, 95% Confidence Interval [CI] 1.16 – 1.91), and readmission (OR 1.31, 95% CI 1.04 – 1.63). These associations were mainly driven by those patients receiving a combination of immunosuppressive medications.

Conclusions: Immunosuppression was not significantly associated with worse mortality, but these patients, in particular those receiving a combination of immunosuppressive medications, were more likely to return to the OR and be readmitted after undergoing EGS procedures. Our findings show the need for tailored improvements in both pre- and post-operative protocols for this population, which would lead to prevent complications.