![Page 1: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/1.jpg)
Predictive Factors of In-Hospital Mortality in Colorectal Surgery
M. PapoulasJune 12th, 2013
![Page 2: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/2.jpg)
“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)
![Page 3: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/3.jpg)
“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
![Page 4: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/4.jpg)
Variables
• Patient related
• Procedure related
• Cancer related
• Hospital
• Surgeon
![Page 5: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/5.jpg)
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
![Page 6: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/6.jpg)
Charlson Criteria
![Page 7: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/7.jpg)
• 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
![Page 8: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/8.jpg)
![Page 9: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/9.jpg)
![Page 10: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/10.jpg)
• 3-year study period• 1000 hospitals• Almost 1 million patients, colorectal resection
Masoomi et al. J Am Coll Surg 2012
![Page 11: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/11.jpg)
• 52% Nonteaching hospitals
• 58% elective admisions
• 7.4% laparoscopic procedures
![Page 12: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/12.jpg)
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)
![Page 13: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/13.jpg)
![Page 14: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/14.jpg)
Most Potent Predictors of In-Hospital Mortality
• Emergent surgery
• Liver disease, CRF
• Total colectomy
• Age > 65 years
![Page 15: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/15.jpg)
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
![Page 16: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/16.jpg)
• Single center• Prospective database • 12 years, n = 1245 patients • 81% Elective procedures, 45% ASA ≥3, Malignancy 38%• Mortality 3.3% (41 deaths)
![Page 17: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/17.jpg)
![Page 18: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/18.jpg)
Impact of Systemic Steroid Therapy
![Page 19: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/19.jpg)
• 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
![Page 20: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/20.jpg)
Corticosteroids and Colonic Anastomoses Strength
• Steroid do have an adverse effect on colonic anastomotic healing
Furst et al. Dis Colon Rectum 1994
![Page 21: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/21.jpg)
![Page 22: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/22.jpg)
![Page 23: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/23.jpg)
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
![Page 24: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/24.jpg)
Impact of Cirrhosis and PHTN
•Key words: Liver cirrhosis, Portal Hypertension, Colorectal surgery, Mortality, Morbidity
•6 retrospective studies (3 small single-center)
![Page 25: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/25.jpg)
![Page 26: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/26.jpg)
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)
![Page 27: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/27.jpg)
Postoperative Complications
![Page 28: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/28.jpg)
![Page 29: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/29.jpg)
• 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
![Page 30: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/30.jpg)
Impact of Chronic Renal Failure
• Few studies, limited by small sample sizes (the largest included 66 patients)• Only one large population based study
![Page 31: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/31.jpg)
• 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
![Page 32: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/32.jpg)
![Page 33: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/33.jpg)
![Page 34: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/34.jpg)
Mortality
![Page 35: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/35.jpg)
Morbidity
![Page 36: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/36.jpg)
• Retrospective study 1997-2005• 138 octogenarians; mean age 84 (80-96years)
The oldest old
![Page 37: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/37.jpg)
![Page 38: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/38.jpg)
• 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).
![Page 39: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/39.jpg)
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
![Page 40: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/40.jpg)
• 145,600 Colorectal surgery
• 32,79% high risk patients
![Page 41: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/41.jpg)
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
![Page 42: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/42.jpg)
• 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
![Page 43: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/43.jpg)
![Page 44: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/44.jpg)
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)
![Page 45: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/45.jpg)
![Page 46: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/46.jpg)
• 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
![Page 47: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/47.jpg)
![Page 48: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/48.jpg)
![Page 49: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/49.jpg)
![Page 50: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/50.jpg)
Hospital
![Page 51: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/51.jpg)
![Page 52: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/52.jpg)
![Page 53: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/53.jpg)
“Hospitals with specialty expertise can provide complex oncological procedures with lower mortality rates.”
Colin et al. JAMA, 1998
![Page 54: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/54.jpg)
Surgeon
![Page 55: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/55.jpg)
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”
![Page 56: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/56.jpg)
• 1998-1999• 474,108 Medicare patients• 8 procedures • Aim: Association between surgeon volume
and operative mortality Relation between hospital volume and surgeon’s experience
![Page 57: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/57.jpg)
![Page 58: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/58.jpg)
![Page 59: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/59.jpg)
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
![Page 60: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/60.jpg)
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
![Page 61: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/61.jpg)
![Page 62: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/62.jpg)
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
![Page 63: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/63.jpg)
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
![Page 64: Predictive factors of in-hospital mortality in colorectal surgery](https://reader035.vdocument.in/reader035/viewer/2022070318/55746474d8b42a146f8b4c73/html5/thumbnails/64.jpg)
Thank You