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Background: Colorectal surgery is performed for a wide array of gastrointestinal disease, in patients with varied preoperative fitness and comorbidity rates. Postoperative outcomes, including bleeding rates, are shaped by preoperative diagnosis in addition to operative factors.
Aims: To determine incidence of postoperative bleeding after colorectal surgery and analyze outcomes in patients with postoperative bleeding by preoperative diagnosis.
Methods: This is a retrospective cohort study using the 2010 Nationwide Inpatient Sample (NIS), a nationally representative inpatient database. Adult patients were included if they had ICD-9 code for gastrointestinal malignancy, ulcerative colitis (UC), Crohn's disease (CD), ischemic colitis (IC), diverticulitis, diverticulosis, or diverticular bleeding. Inclusion was limited to patients with ICD-9 procedure code for colectomy, proctectomy, or colostomy. Inclusion also required ICD-9 code for intraoperative bleeding, intraoperative hematoma, or lower gastrointestinal bleeding during the postoperative period, as well as postoperative packed red blood cell transfusion. Charlson Comorbidity Index was calculated for each patient. Outcomes included rate of reoperation, incidence of shock, mortality, length of stay (LOS), and inpatient charge. Statistical significance was established if p<0.05.
Results: 214,933 patients met inclusion criteria. Of these, 1528 (0.7%) had postoperative bleeding requiring blood transfusion. Charlson score for patients with postoperative bleeding was 2.4 ±0.2 vs 2.3 ±0.1 in patients without bleeding. Rate of postoperative bleeding, which was highest in patients with IC, is shown by diagnosis in Table 1. Clinical outcomes are shown in Table 2. Reoperation was significantly more frequent after bleeding in each diagnosis except diverticulosis. Shock was more frequent after bleeding in patients who had surgery for malignancy and IC, but less frequent in patients with diverticular bleeding. Mortality was significantly more frequent after postoperative bleeding in patients with malignancy, CD, diverticulitis, and diverticular bleeding. Hospital outcomes are shown in Table 2. Length of stay was significantly longer after postoperative bleeding in patients with malignancy and diverticulitis; charge was significantly higher in patients with malignancy, CD, IC, and diverticulitis.
Conclusion: Preoperative diagnosis is associated with significant differences in outcome in patients with postoperative bleeding after colorectal surgery. Rates of shock and mortality are significantly increased in patients with gastrointestinal malignancy and IC. Mortality is substantially increased in patients with CD, UC, diverticulitis, and diverticular bleeding. Further study is needed to better understand the reasons for this disparity and to develop better management strategies.
Table 1: Rate of postoperative bleeding by diagnosis

	n	Postoperative bleeding (%)
Malignancy	113,202	0.59
UC	5572	0.25
CD	10,032	0.76
IC	11,735	2.95
Diverticulitis</b	61,405	0.59
Diverticulosis	8561	0.29
Diverticular bleeding	4056	0.99

* denotes statistical significance

Table 2: Clinical outcomes

	Reoperation (%)		Shock (%)		Mortality (%)		LOS, days (95% CI)		Charge x1000, USD (95% CI)
	Bleed	No Bleed	Bleed	No Bleed	Bleed	No Bleed	Bleed	No Bleed	Bleed	No Bleed
Malignancy	16.7 *	2.1	3.77 *	0.48	7.68 *	1.93	11 (8.3-14) *	7.5 (7.3-7.6)	110 (84.0-138) *	69.6 (66.4-72.8)
UC	35.7 *	3.0	0	0.79	0	1.97	7.9 (5.1-11)	8.6 (8.0-9.3)	96.2 (-11.4-204)	94.4 (83.2-105.6)
CD	26.3 *	1.3	0	0.40	13.2 *	0.54	14 (7.0-20)	6.9 (6.6-7.2)	131 (77.0-184) *	67.7 (62.1-73.2)
IC	31.2 *	9.3	2.89 *	3.13	36.1 *	17.2	18 (12-25)	13 (12-14)	255 (173-337) *	150 (139-161)
Diverticulitis	14.3 *	1.6	0	0.30	8.8 *	1.20	14 (10-19) *	6.9 (6.7-7.0)	140 (97.2-183) *	65.3 (62.3-68.4)
Diverticulosis	0	1.2	0	0.34	0	1.46	6.0 (4.3-7.8)	5.9 (5.7-6.1)	51.6 (38.6-64.7)	52.1 (48.9-55.2)
Diverticular bleeding	60.0 *	6.2	0 *	8.46	25 *	6.43	25 (10.8-39)	11 (9.9-12)	271 (78.1-465)	129 (118-140)

* denotes statistical significance