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30-Day Mortality After Emergency Surgery for Colorectal Cancer: Who Is At Risk?
Alice Murray*1, 2, Ravi Pasam1, David E. Estrada Trejo1, Anne-Sophie V. Dalen1, Steven Lee-Kong1, 2, Daniel L. Feingold1, 2, Ravi Kiran1, 2
1Colorectal Surgery, New York Presbyterian, New York City, NY; 2Columbia University, New York City, NY
Background: Emergency surgery in patients with colorectal cancer is associated with worse outcomes than elective surgery. Identifying high-risk patients and assessing factors associated with mortality will inform treatment decisions and patient counselling.
Methods: The NSQIP database 2006-2012 was used to examine all patients undergoing colon and rectal resection for malignancy. Factors associated with emergency surgery compared to elective surgery as well as patient demographics, pre-operative and operative factors affecting mortality were assessed. Univariable and multivariable analysis identified independent risk factors for 30-day mortality.
Results: For 62,832 patients with colorectal cancer who underwent colon and rectal resection, 59,986 (95%) of operations were elective and 2, 846 (5%) occurred as an emergency. Emergency surgery was most strongly associated with older age (71 vs. 67 years p<0.0001), lower BMI (24 vs. 32 Kg/m2, p<0.0001), ASA class 4 or 5 (21 vs. 5%, p<0.0001), disseminated cancer (15 vs. 8%, p<0.0001) and serum albumin ≤3.5g/dl (61 vs. 31%, p<0.0001). On univariable and multivariable analysis, factors most associated with an increased risk of mortality in emergency patients included prior sepsis (OR=1.71 (95% CI:1.14-2.56), p=0.009), white cell count ≥11 billion/L (OR=1.51 (95% CI: 1.02-2.23),p=0.04), disseminated cancer (OR=2.25 (95% CI: 1.42-3.57), p=0.0005) and serum albumin ≤3.5g/dl (OR=2.26 (95% CI: 1.45-3.53), p=0.0003). Laparoscopic surgery was associated with reduced odds of mortality even after adjusting for other covariates (OR=0.46 (95% CI: 0.22-0.96), p=0.03).
Conclusion: Specific factors are associated with emergency surgery and risk of mortality. This information guides treatment decisions and patient counselling prior to operation. Laparoscopic colectomy reduces odds of 30-day mortality, thus endorsing its use for emergency colorectal cancer resection. The six-fold increase in mortality after emergency versus elective surgery emphasizes need for early cancer identification through screening, education and surveillance of those at risk.
Characteristics of Emergency and Elective Surgery
| Characteristics | Emergency
(N=2846) | Elective
(N=59986) | p-value | | Age, median (IQR) | 71 (59-82) | 67 (56-77) | <0.0001 | | Sex (male), n (%) | 1375 (48.4) | 31031 (51.8) | 0.0004 | | BMI ≥ 30, n (%) | 636 (24.4) | 18716 (31.5) | <0.0001 | | ASA, n (%) | | | <0.0001 | | 3 | 1424 (50.2) | 30291 (50.5) | | | 4 | 574 (20.2) | 3114 (5.2) | | | Prior sepsis, n (%) | 901 (31.8) | 1574 (2.6) | <0.0001 | | Disseminated cancer, n (%) | 412 (14.5) | 4619 (7.7) | <0.0001 | | Weight loss (>10% body weight), n (%) | 354 (12.4) | 3705 (6.2) | <0.0001 | | Serum albumin (≤3.5 g/dl), n (%) | 1360 (60.5) | 13040 (30.7) | <0.0001 | | WBC, median (IQR) | 9 (6.6-12.5) | 6.7 (5.4-8.4) | <0.0001 | | | | | | Total operation time (≥180 min), n (%) | 606 (21.3) | 23594 (39.3) | <0.0001 | | Laparoscopic surgery, n (%) | 393 (13.8) | 23541 (39.2) | <0.0001 | | | | | | 30-day mortality, n (%) | 280 (9.8) | 1096 (1.8) | <0.0001 | | Length of stay (days), median (IQR) | 8 (6-13) | 6 (4-8) | <0.0001 |
Univariable and Multivariable Analysis for 30-day Mortality | Characteristics | Univariable
OR (95% CI)
p-value | Multivariable
OR (95% CI)
p-value | | Age | 1.04 (1.03-1.05)
<0.0001 | 1.05 (1.03-1.07)
0.0001 | | ASA (≥3) | 5.83 (3.58-9.49)
<0.0001 | 1.61 (0.88-2.97)
0.12 | | | | | Prior sepsis | 3.21 (2.47-4.18)
<0.0001 | 1.71 (1.14-2.56)
0.009 | | WBC (>11 billion cells/L) | 2.00 (1.53-2.60)
<0.0001 | 1.51 (1.02-2.23)
0.039 | | Disseminated cancer | 1.87 (1.36-2.56)
0.0001 | 2.25 (1.42-3.57)
0.0005 | | Serum albumin (≤3.5 g/dl) | 0.28 (0.19-0.40)
<0.0001 | 2.26 (1.45-3.53)
0.0003 | | | | | Laparoscopic surgery | 0.35 (0.21-0.60)
0.0001 | 0.46 (0.22-0.96)
0.03 |
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