Highlights
- •This is the first retrospective multivariable analysis exploring trends in surgical outcomes for rectal cancer in the decade prior to NAPRC.
- •Patients are more likely to have major complications undergoing pelvic compared to abdominal procedures.
- •No improvement in complication or mortality rates has occurred.
- •Significant reduction in length of stay may be partly due to increased use of minimally invasive surgery and/or enhanced recovery protocols.
- •NAPRC should help improve surgical and oncologic outcomes including decreasing morbidity and mortality rates over the next decade.
Abstract
Background
There is significant variation in rectal cancer outcomes in the USA, and reported
outcomes have been inferior to those in other countries. In recognition of this fact,
the American College of Surgeons (ACS) recently launched the Commission on Cancer
(CoC) National Accreditation Program for Rectal Cancer (NAPRC) in an effort to further
optimize rectal cancer care. Large surgical databases will play an important role
in tracking surgical and oncologic outcomes. Our study sought to explore the trends
in surgical outcomes over the decade prior to the NAPRC using a large national database.
Methods
The ACS National Surgical Quality Improvement Program (NSQIP) database from 2005 to
2017 was used to select colorectal cancer cases which were divided into abdominal-colonic
(AC) and pelvic-rectal (PR) cohorts based upon the operation performed. Outcomes of
interest were occurrence of any major surgical complication, mortality within 30 days
of procedure, and postoperative length of stay (LOS). Chi-square and two sample t-tests
were used to evaluate association between various risk factors and outcomes. Modified
Poisson regression was used to compare and estimate the unadjusted and adjusted effect
of procedure type on the outcomes. STATA 15.1 was used for analysis and statistical
significance was set at 0.05.
Results
A total of 34,159 patients were analyzed. AC cases constituted 50.7% of the overall
cohort. The two groups were relatively similar in demographic distribution, but the
PR patients had higher rates of hypoalbuminemia and were sicker (ASA class 3 or greater).
Rates of non-sphincter preserving operations ranged from 30 to 34%. Higher complication
rates in the PR cohort were mainly infectious and surgical site complications, while
rates of deep vein thrombosis and pulmonary embolism were similar between the two
cohorts. On bivariate analysis, rates of mortality were similar between the two groups
(AC: 1.02% vs PR: 0.91%, p = 0.395), while PR patients were found to be 1.36 times
(95% CI: 1.32–1.41) more likely to have major complications and 1.40 times (95% CI:
1.35–1.44) more likely to have an extended LOS as compared to the AC patients. After
multivariable analysis, PR patients continued to have a higher likelihood of major
complications (IRR: 1.31, 95% CI 1.25–1.36) and extended LOS (IRR: 1.38, 95% CI: 1.33–1.43).
10-year trends showed a significant reduction in the percentage of patients with prolonged
lengths of hospitalization as well as a reduction of nearly 20% in the mean LOS, but
without improvement in morbidity or mortality.
Conclusions
Patients undergoing PR operations were more likely to have had major complications
than were patients who underwent AC procedures; unfortunately no improvement in the
rate of these complications or in mortality occurred. Perhaps the significant reduction
in LOS is due in part to an increased prevalence of minimally invasive surgery and/or
enhanced recovery protocols. Data were found to be lacking within NSQIP for several
important variables including key oncologic data, stratification by surgical volume,
and patient geographic location. We anticipate that the NAPRC should help improve
PR surgical and oncologic outcomes including decreasing morbidity and mortality rates
during the next decade.
Keywords
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Article info
Publication history
Published online: January 10, 2020
Accepted:
January 4,
2020
Received in revised form:
December 1,
2019
Received:
August 7,
2019
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
