Ira L Leeds, MD, MBA, ScM, Christian D Jones, MD, MS, Elliott R Haut, MD, PhD, Joseph V Sakran, MD, MPA, MPH, Sandra R Dibrito, MD, PhD, Ryan Fransman, MD, Alistair J Kent, MD, MPH. Johns Hopkins University School of Medicine
Introduction: The purpose of this study was to determine if variation in the practice of deferring surgery for preoperative optimization or surgeon availability impacts surgical outcomes.
Methods: The national NSQIP databases from 2011-2016 were queried for emergent surgeries for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Diaphragmatic hernias, elective cases and cases without the specific designation emergent were also excluded. Patients were grouped by time in days from date of admission to date of surgery: Same day, next day, and second day or longer. These groups were then examined for differences in NSQIP defined major morbidities and mortality. We used a multinomial propensity score weighting for covariates’ clustering across the timing groups then performed weight-adjusted multivariate logistic regression.
Results: The effective population size was 79,145; selected unadjusted characteristics are shown (Table). After adjusted analysis, the odds of major complication were increased by 25% (aOR = 1.25, 95% CI 1.07-1.47, p=0.005) for delays to the next day, and 50% for delays to the second day or longer (aOR = 1.50, 95% CI 1.22-1.86, p<0.001). There was no difference of risk of 30-day mortality when adjusting for other factors for next day surgery (aOR 1.37, CI 0.52-3.60, p=0.51) or surgery deferred ≥2 days (aOR 1.79, CI 0.56-5.74, p=0.32).
Conclusions: Delay in surgery for emergent hernias substantially and progressively increased odds of major morbidity but not mortality in a propensity adjusted analysis of NSQIP data, though limitations exist based on NSQIP structure and reporting mechanisms. Patients presenting with hernia and indications for urgent surgical intervention be taken to the operating room as soon as physiologically feasible. Delays for resuscitation and optimization beyond physiologic tolerance of the procedure may increase the risk of major morbidity.
|
Variable (%) n = 79,145 |
Same-day | Next-day | Further Delayed | p |
|---|---|---|---|---|
|
Preoperative Sepsis |
21.3 | 21.6 | 22.1 | 0.6 |
| Diabetes | 16.9 | 17.1 | 19.2 | 0.08 |
| Hypertension | 51.6 | 51.6 | 57.5 | <0.001 |
| Dyspnea | 7.0 | 7.1 | 8.2 | 0.2 |
| COPD | 7.9 | 7.7 | 9.9 | 0.07 |
| Active smoker | 20.8 | 20.5 | 18.4 | 0.06 |
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93241
Program Number: P001
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster