Acute colonic ischemia following elective colectomy for cancer: Risk factors and outcomes

Postoperative colonic ischemia is a rare but life-threatening complication after colectomy. High vascular ligation during oncologic resections may predispose patients with limited mesenteric collateralization or vascular comorbidities to ischemia. We sought to describe risk factors, procedure-specific associations, and outcomes of postoperative colonic ischemia in patients undergoing elective colectomy for colorectal cancer.

The National Inpatient Sample (2005-2019) was queried for adults undergoing elective colectomy for colorectal cancer. Demographics, comorbidities, and resection type were compared between patients with and without postoperative colonic ischemia. Univariate and multivariable logistic regression identified independent factors associated with ischemia, mortality, and return to the operating room. Odds ratios with 95% confidence intervals were reported.

Among 192,637 patients (mean age, 65 years; 52% female; 79% White, 10% Black, and 6% Hispanic), Postoperative colonic ischemia occurred in 0.27% (n = 514). Patients with postoperative colonic ischemia had a higher median Charlson Comorbidity Index (3, interquartile range, 2-5) than those without (2, interquartile range, 2-4; P < .001). Incidence varied by resection type, with the highest rates after left hemicolectomy (0.52%), transverse colectomy (0.47%), and ileocecectomy (0.42%), compared with right hemicolectomy (0.28%), sigmoidectomy (0.14%), and low anterior resection (0.19%) (P < .001). On multivariable analysis, higher adjusted odds of postoperative colonic ischemia were observed for left hemicolectomy (adjusted odds ratio, 1.85; 95% confidence interval, 1.46-2.34), transverse colectomy (adjusted odds ratio, 1.69; 95% confidence interval, 1.20-2.37), and ileocecectomy (adjusted odds ratio, 1.63; 95% confidence interval, 1.01-2.61), whereas sigmoidectomy (adjusted odds ratio, 0.54; 95% confidence interval, 0.42-0.70) and low anterior resection (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-0.99) were associated with lower adjusted odds. Comorbidities independently associated with postoperative colonic ischemia included peripheral vascular disease (adjusted odds ratio, 3.79), chronic kidney disease (adjusted odds ratio, 2.03), congestive heart failure (adjusted odds ratio, 1.87), and liver disease (adjusted odds ratio, 1.98). Postoperative colonic ischemia was strongly associated with adverse outcomes: reoperation (20.2% vs 0.96%; adjusted odds ratio, 39.8), prolonged hospitalization (median 15 vs 5 days, P < .001), and in-hospital mortality (23.5% vs 0.95%; adjusted odds ratio, 25.3).

Although uncommon, postoperative colonic ischemia is a catastrophic complication after colectomy for colorectal cancer. Risk is strongly associated with vascular comorbidities and resection type, with left hemicolectomy, transverse colectomy, and ileocecectomy carrying the highest observed incidence. Risk stratification, selective vessel preservation, and intraoperative perfusion assessment may reduce ischemia-related morbidity and mortality.