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It's Later Than We Think

Brendan C. Visser, MD; Hugh Keegan, BS; Molinda Martin, BSN; Sherry M. Wren, MD

Arch Surg. 2009;144(11):1021-1027.

Background  Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk.

Design  Prospective cohort.

Setting  University-affiliated Veterans Affairs Medical Center.

Patients  All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006.

Main Outcome Measures  Mortality at 30 days and 90 days.

Results  The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively.

Conclusion  The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

Author Affiliations: Department of Surgery, Stanford University School of Medicine, Stanford (Dr Visser), and Palo Alto Veterans Health Care System, Palo Alto, California (Drs Visser and Wren, Mr Keegan, and Ms Martin).

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