Predictive Factors of In-Hospital Mortality in Colorectal Surgery

M. PapoulasJune 12th, 2013

“Doctors can do almost anything nowadays, can’t they, unless they kill you while they’re trying to cure you”

Agatha Christie Endless Night (1967)

“The principle task of a conductor is not to put himself in evidence but to disappear behind his functions as much as possible. We are pilots, not servants.”

Franz Liszt

Variables

• Patient related

• Procedure related

• Cancer related

• Hospital

• Surgeon

American Society of Anesthesiologists

I. Normal healthy patient II. Patient with mild systemic disease III. Patient with severe systemic disease IV. Patient with severe systemic disease that is a constant

threat to lifeV. Moribund patient who is not expected to survive without

the operationVI. Declared brain-dead patient whose organs are being

removed for donor purposes

Charlson Criteria

• Upon admission, resident rated the patient’s severity of illness an not ill, mildly ill, moderately ill, severely ill or moribund.

• The prospective rating of illness severity was the most significant predictor of in-hospital morality

Charlson Criteria

• 3-year study period• 1000 hospitals• Almost 1 million patients, colorectal resection

Masoomi et al. J Am Coll Surg 2012

• 52% Nonteaching hospitals

• 58% elective admisions

• 7.4% laparoscopic procedures

In-Hospital Mortality According to Procedure Type

• Overall rate of in-hospital mortality 4.5% (elective surgery 1.42% vs emergent surgery 8.76%; p < 0.01)

Most Potent Predictors of In-Hospital Mortality

• Emergent surgery

• Liver disease, CRF

• Total colectomy

• Age > 65 years

Limitations

• No outpatient follow-up data• Mortality after discharge not included• Unable to evaluate perioperative factors (duration of

operation, anastomotic leak, surgeon’s specialization, hospital volume)

• Unable to evaluate patients with immunosuppressive drugs• Retrospective study

• Single center• Prospective database • 12 years, n = 1245 patients • 81% Elective procedures, 45% ASA ≥3, Malignancy 38%• Mortality 3.3% (41 deaths)

Impact of Systemic Steroid Therapy

• N = 606 patients, 53 on steroids• Equivalent Postoperative Mortality and Anastomotic Leakage • Higher postoperative complications rate in steroid treated

patients, especially infections (38% vs 25%)• Univariate analysis in steroid group, 3 significant risk factors

for complications: 1. Blood transfusion 2. Anticoagulation 3. Chronic Respiratory failure

Tresallet et al. Am J Surg 2008

Corticosteroids and Colonic Anastomoses Strength

• Steroid do have an adverse effect on colonic anastomotic healing

Furst et al. Dis Colon Rectum 1994

Reduced ICAM-1 expression in dexamethasone treated animals

• Reduced leucocytic migration and adhesion• Poor formation of granulation tissue• Inhibition of fibroblastic proliferation and matrix

synthesis• Inhibition of angiogenesis• Inhibition of mRNA expression of type 1 collagen

Polat A et al. Eur J Surg 2002

Impact of Cirrhosis and PHTN

•Key words: Liver cirrhosis, Portal Hypertension, Colorectal surgery, Mortality, Morbidity

•6 retrospective studies (3 small single-center)

Results• Increased in hospital mortality (5% vs 14% vs 29%)

• Higher relative risk of mortality in cirrhotic patients among elective compared with nonelective procedures (1.8% vs7.2% vs 18.6%)

• Absolute mortality difference higher in nonelective procedures (9.1% vs 20.9% vs 35.8%)

• Significantly longer Average Length of Stay (11 vs

13.8 vs 17.8 days)

Postoperative Complications

• Mortality rates in Child’s A, B, and C patients were 6%, 13%, and 28%, respectively .

• Two factors were found to be associated with early postoperative death: increased serum concentration of direct bilirubin (p 0.01), and prolonged prothrombin time (p 0.009)

Gervaz P, et al. J Am Coll Surg 2003

• Chronic liver disease patients (1565) have a nearly 6.5-fold increased risk of mortality following colorectal operations (21,5%)

• MELD > 15 → higher rate of mortality (RR, 8.92)Ghaferi AA, et al. Ann Surg 2010

Impact of Chronic Renal Failure

• Few studies, limited by small sample sizes (the largest included 66 patients)• Only one large population based study

• 1993-2007• NIS database N = 755,343 patients • 3428 hospitals• 5806 Patients with ESRF on dialysis• 22.4% Elective admissions• Dialysis patients more likely to undergo nonelective

procedures (77% vs 65%; p < 0.0001) and more likely to undergo colorectal surgery for vascular insufficiency or infectious colitis

Mortality

Morbidity

• Retrospective study 1997-2005• 138 octogenarians; mean age 84 (80-96years)

The oldest old

• Morbidity 53.6%, SICU admission rate 38.4%

• Emergent surgery highly correlated with mortality (32.3% vs 1.7%)

• No difference between cancer and non cancer operations

• ASA classification was a significant predictor of outcomeThe odds of a major complication increased by a factor of 2.9 for each change in ASA class (P = 0.008).

Laparoscopic vs open Colorectal Resection

• Retrospective study• N = 58,135 patients, 18,8 % Laparoscopic surgery• Results:

Laparoscopic surgery was used less in patients with advanced disease, more comorbidites, or presenting as an emergency. 15,1% conversionReduced 30-day postoperative mortality (OR 0.55; 0.48 to 0.64) and LOS in the laparoscopic group

Conclusion: Laparoscopic surgery was used more frequently in low-risk patients

Taylor EF, et al. Br J Surg 2013

• 145,600 Colorectal surgery

• 32,79% high risk patients

Results• High risk patients had higher mortality

• The use of laparoscopy was lower in the high-risk group

• In high-risk patients, compared to open surgery, laparoscopy was associated with lower mortality (OR=0.60, p = 0.8), shorter hospital stay,decreased respiratory failure (OR=0.53), urinary tract infection (OR=0.64), anastomotic leak (OR=0.69) and wound complications (OR=0.46).

Conclusions: Laparoscopy in high-risk colorectal patients is safe and may demonstrate advantages compared to open surgery

• Prospective study• N= 35 Patients, Laparoscopic Colectomy n= 18• Intradermal injection of recall antigens• Assess cell mediated immune function as measured by

serial delayed-type hypersensitivity (DTH) challenges

Anastomotic Leakage (AL) after Colon Surgery

• Prospective, 5years, 346 institutions Study population: 28,271 – 3% (n=844) with AL

• Predictor of significant morbidity, hospital mortality and greater risk of poor oncological outcome

• Hospital mortality after AL 18.6% vs 2.6% for patients without AL. AL related complications 62.7% vs 19.9% Five-year tumor-free survival rate of 63% (compare 74.6%

without AL; p < 0.001)

• Review two predictive models based on ASA and POSSUM• Three multicentre UK based studies N= 16,006 patients with

malignant or non-malignant bowel pathologies ACPGBI CRC study: 8077 CRC cases MBO study: 1046 patients with malignant LBO

CR-POSSUM study: 6790 patient with benign or malignant disease

Hospital

“Hospitals with specialty expertise can provide complex oncological procedures with lower mortality rates.”

Colin et al. JAMA, 1998

Surgeon

Surgeon’s variables

• Surgeon’s state of mind• Surgical proficiency “An Expert”: Proficient faultless execution in the

automatic unconscious mode consistently well without having to think about it

“Decisions are more important than incisions”

“It is not beyond our skills, it is beyond our expectations”

• 1998-1999• 474,108 Medicare patients• 8 procedures • Aim: Association between surgeon volume

and operative mortality Relation between hospital volume and surgeon’s experience

High Volume Surgeons in High Volume Hospital

• Mortality rate higher among patients of low-volume surgeons regardless of surgical volume of the hospital

• Patients can often improve their chances of survival by selecting surgeons who perform the operations frequently

Is there a safe place for the residents?

• Impact of residents on surgical outcome?• RES (n = 40,474) vs non-RES (n = 20,237)• 92,7% general surgery procedures• Matched study, comparable groups• 30-day mortality, postoperative complications

Kiran et al. Ann Surg 2012

Resident involvement in surgical procedure

• Similar mortality• “Mild” and “surgical” 30-day complications higher in

RES group• Similar individual complications except superficial

wound infection (3.0 vs 2.2%)• Longer operative time in the RES group

CONCLUSION

• Age is a significant predictive factor in emergent operations

• Cirrhosis, ESRF, Steroid treatment are independent predictive factors of mortality

• Emergent surgery

• Hospital and Surgeon Volume: The More the Better..

• Optimize comorbidites

Thank You