Nancy A. Melville

January 21, 2013

SAN JUAN, Puerto Rico — Older patients and those with chronic obstructive pulmonary disease (COPD) are at the greatest risk for death, according to the largest series of colectomies performed for Clostridium difficile.

The results were presented here at the Society of Critical Care Medicine 42nd Critical Care Congress.

According to the lead investigator, the risk associated with COPD was unexpected.

"One of the surprising findings of the study was the association of COPD with mortality," David Lee, MD, from the Institute for Bariatric and Minimally Invasive Surgery at St. Luke's–Roosevelt Hospital Center in New York City, told Medscape Medical News. "The finding...suggests that patients with decreased pulmonary reserves have a difficult time recovering from an emergency subtotal colectomy," he said.

The multivariate analysis involved 335 patients from the American College of Surgeons National Surgical Quality Improvement Program database who received emergency open colectomies. The researchers found an overall mortality rate of 33%, with a median time to death of 8 days.

Patients 80 years and older had the highest mortality risk within 30 days, with a 9-fold increase in the odds of death (95% confidence interval, 3.0 - 13.0).

Other leading factors associated with an increased risk for mortality after COPD were preoperative shock, dialysis, and contaminated wounds.

Risk Factors for Death After Colectomy

Risk Factor Odds Ratio 95% Confidence Interval
COPD 3.7 2.0 - 7.1
Preoperative shock 2.8 1.6 - 5.4
Dialysis 2.3 1.1 - 4.8
Class III wound 2.1 3.0 - 13.0

Patients with thrombocytopenia (platelet count, <150 × 10³/mm³), coagulopathy (international normalized ratio, >2.0), and renal insufficiency (blood urea nitrogen, >40 mg/dL) also had higher mortality rates.

Dr. Lee pointed out that the incidence of and mortality from C difficile colitis are, in general, on the rise.

More Fatal Cases of Colitis

"The rise is probably due to the increase in antibiotic usage," Dr. Lee said. "Fulminant C difficile colitis requiring colectomy or ICU admission occurs in 1% to 8% of patients," he reported.

The study's findings could be useful in guiding decision making in such cases, Dr. Lee noted.

"This study confirms that patients who are in multiorgan failure, who are elderly, and who have severe COPD are not good operative candidates," he explained. "Before these patients are offered surgery, a careful discussion needs to take place between the family and the medical team."

Roy Brower, MD, professor of medicine at Johns Hopkins University in Baltimore, Maryland, who was asked by Medscape Medical News to comment on the study, said that age as a predictor of mortality is no surprise and, considering the gravity of the surgery, COPD as a predictor also makes sense.

"I guess it's a little surprising that the COPD odds ratio is as high as 3.7, but it's no surprise that COPD is associated with a bad outcome," he said. "When you have a person with a bad disease like C difficile colitis that is out of control, having a chronic breathing condition like COPD makes it very difficult to go into an operation," he noted.

"The patient has to go on a ventilator for the operation. With COPD, it can take longer to get off the ventilator, increasing the risk for complications, such as pneumonia or blood clots," he said.

Dr. Brower pointed out, however, that there are few options other than surgery.

Surgery Last Resort

"A surgeon usually won't recommend surgery for C difficile unless the patient really is on the verge of a very bad outcome and likely can't survive without it," he noted. "The only alternative to surgery is usually to stick with the antibiotics and hope the patient can turn around despite the odds."

Dr. Brower agrees that the study's findings are valuable in providing clinicians with the ability to counsel patients and families about the risk associated with surgery.

"In some cases, patients who are told of the high risk related to age or COPD may indeed find that information valuable and opt to say, 'Thanks, but I want to be with my family and am accepting death'."

The study had no outside funding. Dr. Lee and Dr. Brower have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 42nd Critical Care Congress: Abstract 40. Presented January 20, 2013.