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Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection
  1. Michael P DeWane,
  2. Kimberly A Davis,
  3. Kevin M Schuster,
  4. Adrian A Maung,
  5. Robert D Becher
  1. Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Michael P DeWane, Surgery, Yale School of Medicine, New Haven, CT 06520, USA; michael.dewane{at}yale.edu

Abstract

Background The postoperative outcomes of emergency general surgery patients can be fraught with uncertainty. Although surgical risk calculators exist to predict 30-day mortality, they are often of limited utility in preparing patients and families for immediate perioperative complications. Examination of trends in mortality after emergent colectomy may help inform complex perioperative decision-making. We hypothesized that risk factors could be identified to predict early mortality (before postoperative day 5) to inform operative decisions.

Methods This analysis was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database (2012–2014). Patients were stratified into three groups: early death (postoperative day 0–4), late death (postoperative day 5–30), and those who survived. Multivariable logistic regression was used to explore characteristics associated with early death. Kaplan-Meier models and Cox regression were used to further characterize their impact.

Results A total of 18 803 patients were analyzed. Overall 30-day mortality was 12.5% (3316); of these, 37.1% (899) were early deaths. The preoperative factors most predictive of early death were septic shock (OR 3.62, p<0.001), ventilator dependence (OR 2.81, p<0.001), and ascites (OR 1.63, p<0.001). Postoperative complications associated with early death included pulmonary embolism (OR 5.78, p<0.001), presence of new-onset or ongoing postoperative septic shock (OR 4.45, p<0.001) and new-onset renal failure (OR 1.89, p<0.001). Patients with both preoperative and postoperative shock had an overall mortality rate of 47% with over half of all deaths occurring in the early period.

Conclusions Nearly 40% of patients who die after emergent colon resection do so before postoperative day 5. Early mortality is heavily influenced by the presence of both preoperative and new or persistent postoperative septic shock. These results demonstrate important temporal trends of mortality, which may inform perioperative patient and family discussions and complex management decisions.

Level of evidence Level III. Study type: Prognostic.

  • emergency general surgery
  • colectomy
  • inflammation

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Footnotes

  • Contributors MPDW, RDB: literature search, study design, data analysis, data interpretation, writing and critical revision. KAD, KMS, AAM: data analysis, data interpretation, writing and critical revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer American College of Surgeons NSQIP Disclaimer. The following disclaimer is required of all studies published using the NSQIP database as a data source: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the American College of Surgeons NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open-access repository.

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