Impact of Patient and Procedural Factors on Outcomes of Patients Undergoing Mesenteric Bypass
William P Zickler, Benjamin R Zambetti, Saskya Byerly, Edward H Garrett, Jr., Louis J Magnotti
University of Tennessee Health Science Center, Memphis, TN
Introduction: Mesenteric bypass (MB) for acute and chronic mesenteric ischemia carries considerable morbidity and mortality. Antegrade and retrograde bypasses are widely considered comparable procedures with no impact on morbidity. Using a large, national database, this study was designed to identify factors associated with increased cardiovascular (CV) and pulmonary morbidity for patients undergoing MB for acute (AMI) and chronic mesenteric ischemia (CMI).
Methods: Patients with AMI and CMI were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2008-2019. Demographics (age, gender, race, past medical history), operative diagnosis, pre-operative factors (ASA class, wound class, emergency), procedural details (inflow, conduit, operative time, need for bowel resection), morbidity and mortality were recorded. Patients undergoing MB were stratified by diagnosis (AMI vs CMI) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of CV (cardiac arrest, MI, DVT, CVA) and pulmonary (pneumonia, ventilator time>48hrs) morbidities in patients undergoing MB.
Results: 377 patients were identified. Of these, 102 (27%) had AMI. The majority were female (72%) with a median age of 68. There were no significant differences in demographics or comorbidities of patients with respect to diagnosis. Patients with AMI had higher rates of pre-operative SIRS/sepsis (28 vs 12%, p<0.0001), were more likely to be ASA class 4/5 (55 vs 42%, p=0.005), were more likely to require bowel resection (19 vs 3%, p<0.0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, p<0.0001). There were no differences in use of aortic or iliac inflow (p=0.707) nor in return to the OR (24 vs 19%, p=0.282). Both post-operative sepsis (12 vs 2.6%, p=0.003) and mortality (31.4 vs 9.8%, p<0.0001) were significantly increased in patients with AMI. After adjusting for demographics, pre-operative and procedural factors, MLR identified INR (OR 3.16; 95%CI 1.56-6.40, p=0.001) and CHF (OR 5.88; 95%CI 1.15-29.97, p=0.033) to be independent predictors of pulmonary morbidity, while pre-operative sepsis (OR 1.96; 95%CI 1.45-2.66, p<0.0001) alone was predictive of CV morbidity.
Conclusions: MB for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Patients undergoing MB for AMI and CMI have similar baseline demographics and comorbidities. Pre-operative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while patients with elevated INR or underlying CHF carry higher risk of pulmonary morbidity.
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