UNEXPECTED FINDINGS DURING LAPAROTOMY SURGERY AND URGENT SURGICAL INDICATIONS ARE ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN’S DISEASE

TEIXEIRA, Guilherme Zupo; TEIXEIRA, Magaly Gemio; GIMENEZ, Marina Carla; RIBEIRO, Silvia Caroline Neves; CHIMELLO, Nathacia Bernardo; LEANDRO-MERHI, Vania Aparecida

doi:10.1590/0102-6720202400073e1867

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Original Article • ABCD, arq. bras. cir. dig. 37 • 2024 • https://doi.org/10.1590/0102-6720202400073e1867 linkcopy

UNEXPECTED FINDINGS DURING LAPAROTOMY SURGERY AND URGENT SURGICAL INDICATIONS ARE ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN’S DISEASE

ACHADOS INESPERADOS DURANTE LAPAROTOMIAS E INDICAçãO CIRúRGICA DE URGêNCIA ESTãO ASSOCIADOS COM COMPLICAçõES PóS-OPERATóRIAS EM PACIENTES COM DOENçA DE CROHN

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND: Patients undergoing Crohn’s disease (CD) surgery may develop a higher rate of postoperative complications (POC) than other patients.

AIMS: The aim of this study was to investigate factors determining POC in patients with CD undergoing urgent laparotomy.

METHODS: This is a retrospective cohort study conducted on adult patients undergoing urgent laparotomy for CD. Clinical and surgical variables, medication history, American Society of Anesthesiologists classification, and POC were investigated. Data collection and management were carried out using the REDCap software (REDCap electronic data capture tools) hosted at the hospital institution. For statistical analysis, the χ² (or Fisher’s exact) test, Student’s t-test, Mann-Whitney test, and simple and multiple multilevel logistic regression analyses were used.

RESULTS: There was an association regarding the history of adalimumab use (p=0.04, OR 2.8, 95%CI 1.03-7.65), previous use of prednisone (p<0.01, OR 2.03, 95%CI 2.00-2.05), urgent surgery indications (p<0.01, OR=4.32, 95% CI=1.58-11.82), mechanical anastomosis (p=0.02, OR=0.22, 95%CI 0.06-0.80), unexpected intraoperative findings (p=0.02, OR 10.46, 95%CI 1.50-72.99), length of hospital stay greater than 10 days (p<0.01, OR 16.86, 95%CI 2.99-94.96), unplanned intensive care unit (ICU) admission (p=0.01, OR 15.06, 95%CI 1.96-115.70), and planned ICU admission (p<0.01, OR 18.46, 95%CI 3.60-94.51). On multivariate analysis, there was an association between the indication of urgent surgery (or emergency) (p=0.01, OR 4.38, 95%CI 1.43-13.37) and unexpected intraoperative findings (p=0.03, OR 8.11, 95%CI 1.21-54.50).

CONCLUSIONS: Unexpected changes and urgent surgical indications are considered risk factors for POC in patients with CD.

HEADINGS:
Crohn’s Disease; Laparotomy; Postoperative Complications; Risk Factors.

Variables	n	%
Gender
Female	28	38.9
Male	44	61.1
Education
Completed primary education	2	2.7
Completed high school	13	18.0
Completed higher education	43	59.7
No registry	14	19.4
Comorbidities
No	52	72.2
Yes	13	18.0
No registry	7	9.7
Family history of IBD
No	59	81.9
Yes	3	4.1
No registry	10	13.9
Family history of autoimmune diseases
No	62	86.1
Yes	0	0
No registry	10	13.9
ASA surgical risk classification
I	0	0
II	64	88.9
III	8	11.1
IV	0	0
V	0	0
Previous surgery for CD in another service
No	48	66.6
Yes	24	33.3
Previous abdominal surgery for another reason
No	63	87.5
Yes	9	12.5
Location of the disease
Small intestine	93	74.4
Colon	60	48.0
Perianal	20	16.0
Disease pattern
Stenosing	48	38.4
Fistulizing	33	26.4
Inflammatory	30	24.0
Stenosing and fistulizing	14	11.2
Extra-intestinal manifestations
No	116	92.8
Yes	9	7.2
Drug treatment
No	16	12.7
Yes	109	87.3

Variables	n	%
POC
No	100	80.0
Yes	25	20.0
Clavien-Dindo classification
I	9	7.2
II	9	7.2
IIIa	0	0
IIIb	6	4.8
IVa	0	0
IVb	1	0.8
V	0	0
Degree I
Adynamic ileum	6	4.8
Superficial abdominal wall collection	1	0.8
Enterorrhagia with spontaneous resolution	1	0.8
Central venous access infection	1	0.8
Degree II
Postoperative blood transfusion	5	4
Abdominal wall infection with antibiotic therapy	1	0.8
Parental nutrition due to adynamic ileus	1	0.8
Pulmonary thromboembolism	1	0.8
Enterocutaneous fistula with antibiotic therapy	1	0.8
Degree IIIb
Anastomotic leakage	3	2.4
Laparotomy for anastomosis revision	2	1.6
Intracavitary infection	1	0.8
Degree IVb
Marrow aplasia	1	0.8

Variables	p-value	OR	95%CI
Male	0.96	0.99	0.35-2.71
University education	0.09	4.07	0.77-21.35
Comorbidities	0.24	1.98	0.63-6.18
Smoking	0.17	0.97	0.93-1.01
ASA III	0.27	2.13	0.55-8.23
Previous surgery for CD in another service	0.47	0.67	0.23-1.98
Previous abdominal surgery	0.86	1.14	0.26-5.00
Albumin<3.2 (ROC)	0.27	1.91	0.60-6.09
Mild hypoalbuminemia (3-3.5)	0.91	0.92	0.22-3.88
Moderate hypoalbuminemia (2.4-2.9)	0.99	1.01	0.24-4.32
Severe hypoalbuminemia (<2.4)	0.13	6.73	0.56-81.39
Anemia (literature)	0.73	0.83	0.28-2.42
Hemoglobin<10.95 (ROC)	0.13	2.17	0.80-5.85
Low hematocrit (literature)	0.01	1.24	1.23-1.26
Hematocrit<32.5 (ROC)	0.13	0.46	0.17-1.27
Preoperative parenteral nutrition	0.09	2.85	0.85-9.52
Preoperative enteral nutrition	0.17	5.09	0.50-51.64
Underweight (BMI<18.5)	0.71	1.26	0.58-2.78
Overweight (BMI=25-29.9)	0.87	0.87	0.15-4.95
Obesity (BMI=30)	0.11	5.12	0.67-39.08
BMI=23.5 (ROC)	0.38	0.59	0.19-1.89
Two surgeries	0.82	1.11	0.38-3.23
Three surgeries	0.62	0.65	0.11-3.47
Four surgeries	0.86	1.24	0.11-14.18
Five surgeries	0.38	3.82	0.19-77.58
Six surgeries	0.38	3.82	0.19-77.58
Age=60 years	0.57	0.52	0.06-4.86
Age at symptom onset	0.36	1.03	0.96-1.11
Age at diagnosis	0.6	1.02	0.95-1. 08
Interval between symptom onset and surgery (=18.86)	0.08	3.16	0.87-11.43
Interval between diagnosis and surgery (=14.88)	0.24	1.99	0.63-6.31

Variables	Previous treatment			Current treatment
Variables	p-value	OR	95% CI	p-value	OR	95% CI
No treatment	0.51	0.57	0.10-3.14	0.24	2.01	0.62-6.53
Prednisone	<0.01	2.03	2.00-2.05	0.95	1.03	0.41-2.66
Aminosalicylates
Mesalazine PO	0.88	1.08	0.40-3.03	0.89	0.92	0.30-2.81
Sulfasalazine	0.96	0.97	0.30-3.10	0.66	0.79	0.28-2.24
Ciprofloxacin	0.62	0.73	0.20-2.69	0.85	1.11	0.38-3.14
Immunosuppressants	0.65	1.27	0.45-3.49	0.72	0.86	0.28-2.59
Azathioprine	0.24	0.52	0.18-1.61	0.8	0.87	0.29-2.63
Methotrexate	0.99	1.02	0.08-12.49	-	-	-
Immunobiologicals	0.4	0.64	0.22-1.85	0.64	0.79	0.29-2.14
Adalimumab	0.04	2.8	1.03-7.65	0.4	0.51	0.11-2.45
Certolizumab	0.56	2.28	0.14-37.93	0.33	4.05	0.24-68.20
Infliximab	0.09	2.37	0.85-6.73	0.51	1.52	0.43-5.31
Vedolizumab	0.91	1.09	0.24-4.87	0.42	2.05	0.35-12.14
Ustekinumab	-	-	-	0.81	1.32	0.13-13.48

Variables	p-value	OR	95%CI
Indication of urgency (or emergency)	<0.01	4.32	1.58-11.82
Time of surgery (ROC)	0.12	3.31	0.73-15.04
Anastomosis creation	0.51	1.73	0.34-8.88
Mechanical anastomosis	0.02	0.22	0.06-0.80
Terminal stoma creation	0.10	5.87	0.96-35.98
Protective ileostomy	0.29	2.40	0.48-12.14
Unexpected findings	0.02	10.46	1.50-72.99
Drain placement	0.83	0.82	0.14-4.94
Preoperative blood transfusion	0.07	4.93	0.86-28.44
Length of stay greater than 10 days (ROC)	<0.01	16.86	2.99-94.96
Unplanned ICU admission	0.01	15.06	1.96-115.70
Planned ICU admission	<0.01	18.46	3.60-94.51

Variables	p-value	OR	95%CI
Surgical indications of urgency (or emergency)	0.01	4.38	1.43-13.37
Unexpected findings	0.03	8.11	1.21-54.50

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