Date Published: June 5, 2019
Publisher: Public Library of Science
Author(s): Katharina Marsoner, Andreas Voetsch, Christoph Lierzer, Gottfried H. Sodeck, Sonja Fruhwald, Otto Dapunt, Hans Joerg Mischinger, Peter Kornprat, Chiara Lazzeri.
Gastrointestinal complications following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality. We aimed to assess incidence, perioperative risk factors, treatment modalities and outcomes.
A university medical center audit comprised 4883 consecutive patients (median age 69 [interquartile range IQR 60–76] years, 33% female, median logistic EuroScore 5 [IQR 3–11]) undergoing all types of cardiac surgery including surgery on the thoracic aorta; patients undergoing repair of congenital heart disease, implantation of assist devices or cardiac transplantation were excluded. Coronary artery disease was the leading indication for on-pump cardiac surgery (60%), patients undergoing cardiac surgery under urgency or emergency setting were included in analysis. We identified a total of 142 patients with gastrointestinal complications. To identify intra- and postoperative predictors for gastrointestinal complications, we applied a 1:1 propensity score matching procedure based on a logistic regression model.
Overall, 30-day mortality for the entire cohort was 5.4%; the incidence of gastrointestinal complications was 2.9% and median time to complication 8 days (IQR 4–12). Acute pancreatitis (n = 41), paralytic ileus (n = 14) and acute cholecystitis (n = 18) were the leading pathologies. Mesenteric ischemia and gastrointestinal bleeding accounted for 16 vs. 18 cases, respectively. While 72 patients (51%) could be managed conservatively, 27 patients required endoscopic/radiological (19%) or surgical intervention (43/142 patients, 30%); overall 30-day mortality was 12.1% (p<0.001). Propensity score matching identified prolonged skin-to-skin times (p = 0.026; Odds Ratio OR 1.003, 95% Confidence Interval CI 1.000–1.007) and extended on-pump periods (p = 0.010; OR 1.006, 95%CI 1.001–1.011) as significant perioperative risk factors. Prolonged skin-to-skin times and extended on-pump periods are important perioperative risk factors regardless of preoperative risk factors.
Gastrointestinal complications (GIC) following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality [1–6]. The level of evidence regarding incidence, prevalence, perioperative and postoperative risk factors, treatment options, and outcomes is low, based on a few reports [1–10]. We aimed to provide a systematic and comprehensive report of our institutional 5-year experience in a consecutive series of 4883 patients undergoing on-pump cardiac surgery for all types of cardiac surgery except surgery of congenital heart disease, implantation of ventricular assist devices or cardiac transplantation. As we focused on identifying potentially modifiable perioperative risk factors, we applied a 1:1 propensity score matching (PSM) procedure based on a logistic regression model including all preoperative risk factors according to the EuroScore model .
We performed a university medical center audit between 2008 and 2013 comprising 4883 consecutive adult patients at the Department of Cardiac Surgery, Medical University of Graz, Austria, Europa, who had undergone on-pump-cardiac surgery for all types of cardiac surgery under elective, urgent or emergent setting, with baseline data according to the additive and logistic EuroScore I risk prediction tool. Peri- and postoperative patient data were entered in a prospective cardiac surgical database along with relevant clinical complications and 30-day follow-up data. Patients undergoing off-pump surgery or minimized extracorporeal circulation (MECC) surgery were excluded as well as patients undergoing surgery for congenital heart disease, implantation of ventricular assist devices or cardiac transplantation. Patients undergoing surgery of the thoracic aorta (with or without deep hypothermic circulatory arrest) were included in the study cohort. The dataset was 99% complete.
Between 2008 and 2013, 4883 consecutive patients underwent on-pump cardiac surgery at our institution (median age 69 [interquartile range IQR 60–76] years, 33% female sex, median logistic EuroScore [ES] 5 [IQR 3–11]). Coronary artery and aortic valve disease were the leading indications for surgery (60 and 40%, respectively). Patient’s selection according to EuroScore criterias is presented in Fig 1.
Gastrointestinal complications (GIC) following on-pump cardiac surgery are regarded as orphan but serious risk factors for postoperative morbidity and mortality [1–10]. Our comprehensive university medical center audit of 4883 consecutive adult patients revealed an overall incidence of GIC of 2.9% and a median time to complication of 8 days; 30-day mortality for patients with GIC was 23%.