Abstract
PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, “do not resuscitate” status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.
Article PDF
Similar content being viewed by others
References
Brown SC, Abraham JS, Walsh S, Sykes PA. Risk factors and operative mortality in surgery for colorectal cancer. Ann R Coll Surg Engl 1991;73:269–72.
Turunen MJ, Peltokallio P. Surgical results in 657 patients with colorectal cancer. Dis Colon Rectum 1983;26:606–12.
Canivet JL, Damas P, Desaive C, Lamy M. Operative mortality following surgery for colorectal cancer. Br J Surg 1989;76:745–7.
Keighley MR. Prevention of wound sepsis in gastrointestinal surgery. Br J Surg 1977;64:315–21.
Polk HC, Ausobsky JR. Preoperative preparation and antibiotic utilization in operations for carcinoma of the colon and rectum. In: Spratt JS, ed. Neoplasms of the colon, rectum and anus. Philadelphia: WB Saunders, 1984:114.
Nichols RL, Condon RE. Preoperative preparation of the colon. Surg Gynecol Obstet 1971;132:323–9.
Gordon PH. Malignant neoplasms of the colon. In: Gordon PH, Nivitavongs S, eds. Principles and practice of surgery of the colon, rectum and anus. St. Louis: Quality Medical Publishing, 1996:556–9.
Anderson JH, Hole D, McArdle CS. Elective versus emergency surgery for patients with colorectal cancer. Br J Surg 1992;79:701–9.
Nwiloh J, Dardik H, Dardik M, Aneke L, Ibrahim IM. Changing patterns in the morbidity and mortality of colorectal surgery. Am J Surg 1991;162:83–5.
Copeland GP, Sagar P, Brennan J,et al. Risk adjusted analysis of surgeon performance: a 1-year study. Br J Surg 1995;82:408–11.
Rosen L, Stasik JJ Jr, Reed JF III, Olenwine JA, Aronoff JS, Sherman D. Variations in colon and rectal surgical mortality: comparison of specialties with a state-legislated database. Dis Colon Rectum 1996;39:129–35.
Longo WE, Virgo KS, Johnson FE,et al. Outcome of proctectomy for rectal cancer in the Department of Veterans Affairs: a report from the National Surgical Quality Improvement Program. Ann Surg 1998;228:64–70.
Khuri SF, Daley J, Henderson WG,et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995;180:519–31.
Nagelkerke NJ. A note on a general definition of the coefficient of determination. Biometrika 1991;78:691–2.
Wiggers T, Arends JW, Volovics A. Regression analysis of prognostic factors in colorectal cancer after curative resections. Dis Colon Rectum 1988;31:33–41.
Griffin MR, Bergstralh EJ, Coffey RJ,et al. Predictors of survival after curative resection of carcinoma of the colon and rectum. Cancer 1987;60:2318–24.
Hannisdal E, Thorsen G. Regression analyses of prognostic factors in colorectal cancer. J Surg Oncol 1988;37:109–12.
Pihl E, Hughes ES, McDermott FT, Milne BJ, Korner JM, Price AB. Carcinoma of the colon: cancer specific survival. Ann Surg 1980;192:114–7.
Abrams JS. Elective resection for colorectal cancer in Vermont 1971–1975. Am J Surg 1980;139:78–83.
Bokey EL, Chapuis PH, Fung C,et al. Postoperative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 1995;38:480–7.
Canivet JL, Damas P, Desaive C, Lamy M. Operative mortality following surgery for colorectal cancer. Br J Surg 1989;76:745–7.
Wied U, Nilsson T, Knudsen JB, Sprechler M, Johansen AA. Postoperative survival of patients with potentially curable cancer of the colon. Dis Colon Rectum 1985;28:333–5.
Thompson GA, Cocks JR, Collopy BT,et al. Colorectal resection in Victoria: a comparison of hospital based and individual audit. Aust N Z J Surg 1996;66:520–4.
Khuri SF, Daley J, Henderson,et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk study. J Am Col Surg 1997;185:315–27.
Bates EW, Berki SE, Homan RK, Lindenauer SM. The challenge of benchmarking: surgical volume and operative mortality in Veterans Administration Medical Centers. Best Pract Benchmarking Healthc 1996;1:34–42.
Ondrula DP, Nelson RL, Prasad ML, Coyle BW, Abcarian H. Multifactorial index of preoperative risk factors in colon resections. Dis Colon Rectum 1992;35:117–22.
Daley J, Khuri SF, Henderson WG,et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care. J Am Coll Surg 1997;185:328–40.
Author information
Authors and Affiliations
Additional information
Supported by the Veterans Health Administration of the U.S. Department of Veterans Affairs, Washington, D.C.
Dr. Daley is a Senior Research Associate in the Career Development Program of Health Services Research and Development Service in the Department of Veterans Affairs.
About this article
Cite this article
Longo, W.E., Virgo, K.S., Johnson, F.E. et al. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum 43, 83–91 (2000). https://doi.org/10.1007/BF02237249
Issue Date:
DOI: https://doi.org/10.1007/BF02237249