Preoperative Functional Health Status Predicts Outcomes After Elective Colorectal Surgery for Malignancy

Nuri Okkabaz, MD, Jeffrey P Hammel, MS, Feza H Remzi, MD, Emre Gorgun, MD. Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic.

Background: The average life expectancy and number of elderly people has been increasing across the world. Age is a significant risk factor for colorectal cancer; thus, surgeons are commonly facing age-related perioperative difficulties while treating these patients. Accurate prediction of the risks for morbidity and mortality can help patients and physicians to have precise expectations; however, surgeons lack easily available bedside parameter.

Hypothesis: Preoperative functional health status may help in predicting the risk of morbidity and mortality in the first appointment for the patients who are candidate for elective colorectal cancer surgery.

Patients and Methods: All patients underwent colectomy for colorectal malignancy between 2006 and 2011 were included in the study with exemption of emergent colectomy and disseminated disease. Patients were classified as independent, partially dependent, and totally dependent as tracked in NSQIP database. Groups were compared in terms of preoperative risk factors and short term outcomes. A secondary comparison was performed after multivariate adjustment for age, wound class, ASA class, and work relative value units.

Results: A total of 25,737 patients were identified: 24,246 (94.2%) independent (IND), 1,307 (5.1%) partially dependent (PDN), and 184 (0.7%) totally dependent (TDN). Both PDN and TDN were older than IND and had more diabetes, chronic obstructive pulmonary disease, congestive heart failure and dialysis dependence (p<.001). On the other hand, IND patients have had more radiotherapy before operation (p<.001). Laparoscopic surgery was less commonly performed in TDN group (p<.001). PDN patients had a higher incidence of all types of surgical site infections (SSI) (p<.05) except organ/space SSI and stroke/CVA (p<.001) compared to both IND and TDN. Both PDN and TDN patients had more respiratory problems (p<.05), urinary problems (p<.05), coma>24 hours (p<.001) and cardiovascular problems (p<.05). Unplanned reoperation, length of postoperative stay (7.4±6.4 vs. 11.4±10.1 vs. 14.4±13.9; p<.001) and death [28 (15.2%) vs. 109 (8.3%) vs. 315 (1.3%); p<.001] were also more common in patients with partial or total dependency. After multivariate adjustment, patients with total dependency were found to have increased risk for most of the postoperative complications including pneumonia [odds ratio (OR)=2.53 (95% confidence interval (CI), 1.56-4.10); p<0.001], unplanned reintubation [OR=2.84 (95% CI, 1.77-4.54); p<.001], acute renal failure [OR=4.00 (95% CI, 1.71-9.39); p=0.001], septic shock [OR=4.04 (95% CI, 2.50-6.54); p<0.001] and cardiac arrest [OR=2.83 (95% CI, 1.20-6.67); p=0.017]. Patients with total dependency also have an increased median incidence of death (12.3%, 95% confidence interval (CI):10.2%-14.5%: p<0.001)

Conclusion: Patients with partial or total dependency in the activities of daily living have been observed to experience more frequent postoperative complications and death following elective colorectal surgery for malignancy. In the setting of major elective colorectal surgery for malignancy, functional health status may be helpful to predict high risk patients for postoperative complications.

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