Is Patient factor more important than surgeon factor in ...

? IS PATIENT FACTOR MORE IMPORTANT THAN SURGEON FACTOR IN SEPSIS PREVENTION IN COLORECTAL SURGERY

ELROY PATRICK WELEDJI FRCS Edinburgh University of Buea, Cameroon

SEPSIS PREVENTION IN COLORECTAL SURGERYSSI RATES Intraabdominal sepsis is one of the most challenging situations in surgery

Colorectal surgery is associated with a high sepsis rate which may lead to serious complications including death. National Nosocomial Infection surveillane (NNIS )Risk Index (0-3points 1pt- the patent has an operation that is classified as either contaminated or dirty 1pt- Preop assessment score (ASA) of 3,4,5 1pt- duration of operation >75th percent of operation time

Types of operati on

1

1

2

3

Colon surgery

3.2

8.5

16.0

22.0

Vascular 1.6 surgery

2.1

6.1

14.8

Cholecy stectom y

1.4

2.0

7.1

11.5

Organ 0.0 transpla nt

4.4

6.7

18.0

SEPSIS PREVENTION IN COLORECTAL SURGERY? Postoperative infection is an important complication and continued efforts are needed to minimize the risk of surgical site infection (SSI) Dirty/contaminated surgery: SSI >50%

SSIs results in 10 billion dollars in cost /yr in USA  Stays hospitalized 7 days longer  60% more likely to spend time in the ICU  5 times more likely to be readmitted within 30 days of discharge

 twice likely to die

INTRAABDOMINAL SEPSIS IN COLORECTAL SURGERY Spontaneous (at time of colorectal catastrophe) Colonic/rectal perforation Aetiology is wide ranging

Postoperative (later) Anastomtic leak

Inadequate elimination of sepsis Unrecognised perforation Infected haematoma

IS PATIENT FACTOR MORE IMPORTANT THAN SURGEON FACTOR IN SEPSIS PREVENTION IN COLORECTAL SURGERY? SEPSIS PREVENTION IN COLORECTAL SURGERY DEPEND UPON

1) The degree of contamination of

the peritoneal cavity. (Disease Factor) 2) The Preoperative status of the patient (Patient factor) 3) Surgical technique ( Surgeon factor)

EMERGENCY ABDOMINAL SURGERY A reported 12-fold variation in the 30-day mortality rate following emergency abdominal surgery in 21st century Britain ranged from 3.6% in the best performing hospital to 41.7% in the worst.

Elective e.g. damage-limiting surgery/ Hartmann’s for L-sided colonic sepsis) Surgical technique- anastomotic techniques, intraoperative measures to reduce sepsis,

Perioperative( anaesthetic) care (by avoiding hypotension, hypoxia, hypothermia) allow primary resection and anastomosis.

SURGEON FACTOR- POSTOPERATIVE SEPSIS 1 ANASTOMOTIC LEAK

Pathogenesis 5) Multifactorial

Anastomotic leak- independent predictor of mortality due to sepsis (40%) early (3-5 days post operation) as a result of technical failure, or late (weeks) as a result of tissue (biological) failure (common)-due to ischaemia, tissue quality, sepsis: patient or surgeon factor or both?

4) Leak rate ranges 3% - 22%

Surgical technique Impaired microcirculation Life-style related factor ( smoking, alcohol abuse)  post operative NSAIDS?

SURGEON FACTOR (NSAIDS AND ANASTOMOTIC LEAK) Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. Klein M. Postoperative non-steroidal anti-inflammatory drugs and colorectal anastomotic leakage. Dan Med J 2012;59(3):B4420- recommended that NSAIDs be abandoned after

colorectal resection with primary anastomosis (effects on collagen metabolism).

Several clinical studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist.

NSAIDS AND ANASTOMOTIC LEAK Peng F et al. Influence of perioperative nonsteroidal anti-inflammatory drugs on complications after gastrointestinal surgery: A meta-analysis. Acta Anaesthesiol Taiwan 2017;54(4):21-128

 postoperative NSAIDs, especially nonselective NSAIDs, could increase the incidence of anastomotic leak.

Haddadd NN et al.. Perioperative Use of Nonsteroidal Anti-Inflammatory Drugs and the Risk of Anastomotic Failure in Emergency General Surgery. J. Trauma Acute Care Surg. 2017 Epub ahead of print

 safe in emergency general surgery patients undergoing small bowel resection and anastomosis.  use cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. (Therapeutic study level 3)

NSAIDS AND ANASTOMOTIC LEAK Fjederholt KT et al. Ketorolac and other NSAIDS increase the risk of anastomotic leakage after surgery for GEJ cancers: a Cohort study of 557 patients. J Gastrointest Surg. 2017 [Epub ahead of print]

 strong association between the postoperative use of NSAIDS and the risk for anastomotic leakage after surgery for gastro-esophageal-junction cancers.

NSAIDS AND ANASTOMOTIC LEAK Kverneng Hultberg D et al. Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer. Eur J Surg Oncol 2017; 43(10): 1908-1914. Epub 2017 Jun 28

Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.

SURGEON FACTOR: POSTOPERATIVE SEPSIS 2 Postoperative intraabdominal abscess

Surgical otcome

The mortality from post operative intraabdominal abscess is greater than 50% and the mortality increases with each operation to treat recurrent or persistent sepsis.

Therefore, the best opportunity to eradicate infection is the first operation

DISEASE FACTOR Elective

Emergency

Clean-contaminated

Faecal contamination

Mortality 8 predicts mortality (15-18%) P-POSSUM score- wards and HDU patients

C-RP –index of degree of persisting inflammation( 24 hr before surgery,

Admission criteria to HDU or ICU May influence surgical procedure

 presence of organ failure,

 presence of malignancy,  origin of sepsis,  faecal peritonitis  generalized peritonitis

PATIENT FACTOR 1.

Advanced age (>70yrs)(chronological vs physiological)

2.

Comorbidity ( CRF, COAD, Liver failure, Obesity)

3.

Malnutrition (>20% wt loss)

4.

Preexisting remote body site infection

5.

Immune organ response ( host – defence mechm)

6.

Disease process/Shock

7.

Immunosuppression (DM, HIV/AIDS, Steroids)

8.

Perioperative hyperglycaemia ( Insulin resistance) –ERAS –

9.

Lifestyle( smoking, alcohol abuse)

The most important prognostic factor in Emergency colorectal Surgery are:

1. Age 2. Faecal peritonitis

3. Together the mortality is 60% (SIRS, MOF)

PATIENT FACTOR: ADVANCED AGE Emergency surgery

Philips RKL et al. Large bowel cancer: surgical pathology and its relationship to survival. Br J Surg 1986;71:604-610

• >80yr old with malignant large bowel obstruction has a 1 in 3 chance of inhospital mortality Elective surgery • < 80yrs: 8% in-hospital mortality • > 80yrs: 16% mortality for radical rectal cancer surgery

Widdison AL et al. The impact of age on outcome after surgery for colorectal adenocarcinoma. Ann R Coll Surg Engl 2011; 93(6): 445-450

• 30 day mortality; 4% Elective surgery; 14% Emergency surgery (most elderly from medical complications/ comorbidities) • < 59: 1% post op mortality; • Increased by 3% every 10years after elective resection • Increased by 8% every 10yrs after emergency resection • >80yrs: 16 % post op mortality after emergency surgery • Prabability of dying from cancer declined with age: -50 yrs; ½ died from CRC; 70yrs. 1/3 died from CRC; 80yrs: ¼ died from CRC

PATIENT FACTOR: ADVANCED AGE Q: Given the increased post –op mortality in the elderly and reduced likelihood of them dying from CRC. Should all patients undergo a radical resection?

Ans: 1. Selection of those most to gain from radical operation 2. Improved preoperative assessment & optimisation 3. Improved provision of HDU/ICU beds may reduce post operative morbidity and mortality

PATIENT FACTOR (LIFE-STYLE) Sørensen LT et al.

Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999; 86:729e32.

Multiple regression analysis showed that  smokers, compared with non-smokers, had an increased risk of anastomotic leakage (relative risk (RR) 3.18 (95 per cent confidence interval (c. i.) 1.447.00), as did

 alcohol abusers compared with abstainers (RR 7.18 (95 per cent c.i. 1.20-43.01))

PATIENT FACTOR: PATIENTS AND THE DISEASE ARE VARIABLE

It is not possible to practice fully the ideal management of early diagnosis and surgery for the acute abdomen, thus reducing the morbidity and mortality to zero because the patients and the disease are variable.

A pain-free acute abdomen may occur in:

Older people Children Immunocompromised

Last trimester of pregnancy Patients in ICU

PATIENT FACTOR: HOST –DEFENCE MECHANISM 1 Q: Why is it that a patient with

minimal bacterial contamination at surgery may develop a pelvic abscess, whereas another patient with faecal contamination after e.g. stercoral perforation of the colon may not develop infective complications?

A better understanding about susceptibility to endogenous infection. A:

PATIENT FACTOR: HOST-DEFENCE MECHANISM 1 Resistance of patient to infection All surgical wounds will be contaminated with bacteria during surgery but only a small % become infected  patient host defences are capable of controlling and eliminating the offending organisms if  innoculum is small and contaminant not overwhelming

Patient-related surgical site infection risk equation Risk of SSI = Dose of Bacteria contaminant x Virulence of microorganism/ Resistance of patient to infection.

PATIENT FACTOR: HOST DEFENCE MECHANISM 2 Immune balance

Severe SIRS and MOF • Sepsis is an evolving process

balance between excessive and inadequate •Mortality increases with the degree of the responses to infection

excessive or prolonged activation of cellular/humoral mediator pathway (evolution of a cytokine cascade (SIRS) MOF Organ failure amplification

SIRS

Bacteraemia

5%

Sepsis (infection+SIRS)

15%

Septic Shock

50%

Severe SIRS

80%

MOF

90%

PATIENT FACTOR: IMMUNE RESPONSE AND

SURGICAL/METABOLIC STRESS

Immune response and Metabolic regulation are highly integrated  minor operations may stimulate the immune response  effect of major surgery is immunodepression After major surgery cytokine secretion by T lymphocytes are suppressed- increased suceptibility to infection (listeria, mycobacteria)

anti-inflammatory cytokines: PGE2, TGFß- decrease monocyte function TGFß – decrease IL-17- candidiasis , staphylocococus IL-10- down regulates MHCII of monocytes

PATIENT FACTOR: POSTOPERATIVE HYPERGLYCAEMIA AFTER MAJOR COLORECTAL SURGERY Early (within days)- post op complications  Infections;

type 2 diabetes,

Cardiovascular failure;

 CVS effects,

Renal failure;

 Renal failure,

Muscle weakness;

 ventilatory support,

 polyneuropathy

polyneuropathy

Late (years)

PATIENT FACTOR:

IMMUNE RESPONSE AND METABOLIC

REGULATION (ERAS).

 Multimodal approach developed by surgeons in Europe is aimed at reducing metabolic stress after surgery. Using one facet of this protocol will optimize perioperative care.

PATIENT FACTOR: HOST-DEFENCE MECHANISM 3 (IMMUNE DEFICIENCY) HIV/AIDS Heterogenous group:

 > 500 CD4 cells/UL (mild disease) – same risk as non-HIV

Factors influencing morbidity/ mortality 4 factors increase operative morbidity/ mortality

Poor ASA

200-499 CD4 (advanced disease) – caution and if major surgery require ICU,

Physiologically demanding surgery

 < 200 CD4 (AIDS)- life-saving surgery only

Emergency surgery

HAART- improves resistance to infection and nutrition with better surgical outcome

Operations in contaminated field e.g. anorectum, oral cavity)

SUMMARY : SEPSIS SOURCE CONTROL FAILURE  more likely in patients with delayed (> 24 hours) procedural intervention, (Patient /surgeon factor)

 higher severity of illness (Acute physiology and chronic health evaluation score or APACHE >15) - Patient/disease factor)  advanced age (> 70 years), -Patient factor)

 co-morbidity, (patient factor) poor nutritional status, (Patient factor) a higher degree of peritoneal involvement (i.e. a high MPI score)- disease factor

heralded by  persistent or recurrent intra-abdominal infection, anastomotic failure, or  fistula formation

CONCLUSION 1

Interindividual variation in the pattern of mediator release and of end organ responsiveness determine the initial physiological response to major sepsis and may be the key determinant of outcome.

CONCLUSION 2 The most important prognostic factors in emergency colorectal surgery are the preoperative status - age and faecal peritonitis.

Thus, peritoneal sepsis is seldom the sole cause of death, but compounds coincidental cardiovascular, respiratory or renal pathology.

CONCLUSION 3 The empiric choice of the surgical technique/ procedure is predominantly determined by the patient status and the disease

CONCLUSION 5 Perioperative care strives to support as far as possible each organ system to avoid organ failure amplification. The prevention of gut mucosal acidosis in the critically ill patient on ICU may also improve outcome.

CONCLUSION 6 The patient factor has a greater impact than the surgeon-factor on the prognosis of sepsis in emergency colorectal surgery.

CONCLUSION 7 In both elective and emergency colorectal surgery, the surgeon factor remains the single most important factor that can influence the morbidity and mortality from sepsis.

THANK YOU

Mount Cameroon