LAPAROSCOPIC SURGERY REDUCES THE RISK OF SHOCK/SEPSIS AMONG CHRONIC STEROID USERS UNDERGOING TOTAL ABDOMINAL COLECTOMIES FOR ULCERATIVE COLITIS
Brian D. Lo*, Miloslawa Stem, Oluseye Oduyale, George Q. Zhang, Tiffany Brocke, Jonathan Efron, Chady Atallah, Bashar Safar
Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
Introduction:
Ulcerative colitis (UC) patients who fail medical therapy often require surgical intervention with a total abdominal colectomy. Though much research has focused on the post-operative complications secondary to pre-operative steroid use, little is known about the impact of surgical approach on outcomes among chronic steroid users. Here, we aim to determine whether laparoscopic surgery reduces the risk of septic shock or sepsis (shock/sepsis) among chronic steroid users with UC.
Methods:
UC patients undergoing an open or laparoscopic (lap) total abdominal colectomy were identified from the American College of Surgeon’s National Surgical Quality Improvement Program database (2006-2018). Patients were stratified based on pre-operative steroid use and operative approach. The primary outcome was 30-day postoperative shock/sepsis. Risk factors for shock/sepsis, and the impact of operative approach on shock/sepsis, were analyzed using multivariable logistic regression. Sub-group analyses were performed for steroid users who required an emergent procedure.
Results:
Of 11,278 UC patients, 10,459 (92.74%) underwent elective and 819 (7.26%) emergent total abdominal colectomies. The elective group consisted of 6,359 (60.80%) steroid users (32.35% open vs. 67.65% lap) and 4,100 (39.20%) non-steroid users (42.44% open vs. 57.56% lap). Lap approach was associated with decreased rates of shock/sepsis regardless of steroid use (Table 1). In addition, lap surgery was associated with shorter lengths of stay and higher readmission rates for both steroid and non-steroid users. In the adjusted analysis, steroid use was identified as an independent risk factor for shock/sepsis (Table 2). Additional risk factors included an open approach, pre-operative shock/sepsis, and pre-operative blood transfusions. Steroid users undergoing an elective lap procedure had a significantly lower risk of shock/sepsis compared to those undergoing an open approach (OR 0.71, 95% CI 0.58-0.86, p=0.001). Sub-group analysis of emergent cases demonstrated that among steroid users (68.49% open vs. 31.51% lap), lap approach was associated with a decreased risk of shock/sepsis in both unadjusted (33.74% open vs. 13.33% lap, p<0.001), and adjusted analyses (OR 0.50, 95% CI 0.28-0.92, p=0.026).
Conclusion:
Though steroid use is an independent risk factor in the development of shock/sepsis among UC patients, the use of lap surgery among steroid users mitigates the post-operative risks associated with this patient population. Further, it is important that we consider operating on these patients before their disease becomes severe enough to require blood transfusions, as pre-operative transfusions are associated with a 2.63-fold increased risk of shock/sepsis. Future studies are needed to determine whether this association holds true for other surgical approaches, most notably robotic surgery.
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