BRIEF REPORT

Changing Patterns in the Morbidity and Mortality of Colorectal Surgery

Jonathan Nwiloh, MD, New York, New York, Herbert Dardik, MD, FACS, Michael Dardik, ~nglewood, NOW Jersey, Luke Aneke, MD, NOW York, NOW York, Ibrahim M. Ibrahim, MD, FACS, ~nglewood, NOW Jersey

C olorectal surgery in the preantibiotic era was often associated with prohibitive morbidity and mortality

rates ranging from 13% to 28% in elective surgery [I,Z]. With the availability of broad-spectrum antibiotics, the development of improved surgical techniques, and ad- vances in critical care, perioperative management of pa- tients undergoing all types of surgical procedures im- proved to such a degree that mortality rates for elective colorectal surgery fell to a range of 1.7% to 6% [3-51. Despite these improvements, colorectal surgery continues to present a challenge, particularly in the elderly patient with underlying cardiac and respiratory risk factors, It is estimated that by the year 2000, 35 million people, or 13% of the United States population, will be 65 years or older, compared with 16.7 million or 9.2% in 1960 [a. Therefore, as the absolute number of geriatric patients increases, a corresponding increase in those requiring sur- gical intervention for colorectal diseases is predictable. The present study was undertaken to assess the patterns of complications in colorectal surgery during two sepa- rate time periods in order to understand the impact of antibiotics, improved surgical techniques, and critical care management on morbidity and mortality rates. It was also our intention to identify those risk factors predic- tive for an unfavorable outcome.

The records of 362 patients who underwent surgery for colorectal diseases over a lo-year period at Engle- wood Hospital, a 547~bed institution in a suburban com- munity, were reviewed. There were 167 men (46.1%) and 195 women (53.9%) with a median age of 65.5 years (range: 17 to 99 years). The patients were divided into two groups. Group 1 consisted of 136 patients treated between 1970 and 1975 of whom 81% (n = 110) under- went elective surgery and 19% (n = 26) emergency proce- dures. Group 2 consisted of 226 patients treated between 1984 and 1987 with a comparable distribution of elective (n = 194, 86%) and emergency (n = 32, 14%) proce- dures. The diagnoses and procedures are indicated in Table I. Each patient was graded according to the Amer- ican Society of Anesthesiologists Physical Status (ASA) rating [n, which was then used as a measure of physic+ logic reserve and to develop a rating scale for predicting postoperative morbidity and mortality. The &i-square test was used to perform statistical analysis.

Age and ASA distribution of the patients demon-

From the Departments of Surgery, Harlem Hospital (JN, LA), New York, New York, and Englewood Hospital (HD, MD, IMI), Engle wood, New Jersey.

Requests for reprints should be addressed to Herbert Dardik, MD, 375 Engle Street, Englewood, New Jersey 0763 1.

Manuscript submitted May 11,1990, and accepted in revised form September 19,199O.

strated significant differences (p X0.05) between the two groups, Group 2 having a higher percentage of older (53% versus 38%) and higher risk patients (48% versus 76% for ASA I and II; 52% versus 24% for ASA III and IV). Morbidity rates were comparable in both groups (42%, Group 1 and 40%, Group 2). The rate of complica- tions following elective surgery were also similar in both groups (39%, Group 1 and 36%, Group 2), but complica- tions were more frequent following emergency surgery in Group 2 (66% versus 54%, p KO.05). Abdominal compli- cations showed a dramatic decrease in Group 2 (15% versus 33%) but systemic complications doubled (47% versus 26%). Cardiac and respiratory complications were more common in Group 2 patients (Table II).

A shift in type of complications after colorectal sur- gery has been noted, that is, wound infection, septicemia and multiple organ failure are now being superceded by myocardial infarction and pulmonary insufficiency. In this study, the surgical complications of wound infection, anastomotic leakage, enterocutaneous futula, intraabdo- minal abscess, intestinal obstruction, and gastrointestinal bleeding occurred in 33% of patients in Group 1 and medical complications occurred in 26%. In Group 2, how- ever, medical complications were the predominant causes of morbidity and occur& in 47%, with surgical compli- cations occurring in only 15% of the patients.

The mortality rate in Group 1 was 11% compared with 3% for Group 2 (p <O.OOl). After elective surgery, the mortality rate in Group 1 was 9% compared with 3% in Group 2 (p <0.05), with an increase to 19% and 6%, respectively, after emergency procedures (p <O.OOl)

TABLE I Diagnosis and Procedures in 362 Patients Undergolng

Colorectal Surgery

No. of Patients (%) Group 1 Group 2 (n = 136) (n = 226)

Diagnosis Colon cancer Diverticulitis Ulceratiie wliiis Crohn’s disease Miscellaneous (volvulus, ischemic

Procedure Right hemicolectomy Traverse colectomy Left hemiwlectomy Sigmoid and anterior resection Abdominoperineal resection Subtotal wlectomy Total wlectomy

colitis)

72 (53) 55 (40)

3 (2) 2 (2) 4 (3)

26 (20) 4 (3)

16 (12) 73 (54) 10 (7) 3 (2) 2 (2)

153 (66) 51 (22)

2 (1) 13 (6) 7 (3)

69 (39) 9 (4)

27 (12) 93 (41)

5 (2) 2 (1) 1 (11

THE AMERICAN JOURNAL OF SURGERY VOLUME 162 JULY 1991 83

TABLE II Complications In 362 Patients Undergoing Colorectal Surgery

Complications

Abdominal

Wound infection lntraabdominal

abscess Anastomotic leak Enterocutaneous

fistula

Intestinal obstruction

Gastrointestinal bleeding

Subtotal

Systemic

Cardiac Respiratory Renal Cerebrovascular

accident

Elective

15 6

5 6

2

0

34

5 9 7 2

Group 1 (n = 136) Group 2 (n = 226) Total Total

Emergency (% of group) Elective Emergency (% of group)

5 20 (15) 15 6 21 (9) 4 10 (7) 1 0 1 (1)

2 7 (5) 0 0 0

0 6 (4) 3 0 3 (1)

0 2 (2) 5 1 6 (3)

0 0 2 1 3 (1)

11 45 (33) 26 6 34 (15)

5 lO(7) 30 13 43 (19) 5 14 (10) 26 13 39 (17) 2 9 (7) 16 5 23 (10)

0 2 (2) 1 1 2 (1)

Subtotal 23 12 35 (26) 75 32 107 (47)

TABLE III Correlation of Age and Physiological Status

with Mortality

No. of Patients (%)* Group 1 Group 2

Variable (n=136) (n = 226)

ASA physical status I o/22 (0) O/l 0 (0) II 7161 (9) O/96 (0) Ill 7/30 (23) 4/101 (4) IV II3 (33) 3117 (16)

Age (YES) <70 9/65 (11) O/l 07 (0) >70 6151 (12) 7/l 19 (6)

‘Value indicates number of patients who died/number of patients in group.

Specific causes of death in both groups were also differ- ent. In Group 1, the most common cause of death was sepsis (7%, n = 10) which decreased significantly (p <O.Ol) in Group 2 to 1% (n = 3). Cardiopulmonary and renal causes for death accounted for a low percentage in either group (2% or less). The likelihood for a postopera- tive fatality increased with progressively higher ASA class in both groups, with advanced age a factor only in Group 2 (Table III).

As a result of the improved safety of colorectal sur- gery, an increasing number of elderly patients who might have been considered poor surgical candidates in the past are now undergoing operative intervention with good re- sults. Despite these improvements, the physiologic de mands of surgery and anesthesia remain formidable, es- pecially in the elderly, exposing them to a higher risk for

postoperative complications. In 1968, Cole [8] reported a two to five times higher operative mortality for elderly patients with approximately half due to myocardial dis- ease. It is now recognized that physiologic factors rather than chronologic age are most crucial for determining outcome. High-risk groups can now be identified and appropriately treated to produce decreased morbidity and mortality rates [9]. Nevertheless, emergency colon surgery continues to be associated with a significantly higher mortality rate than that following elective surgery. Irvin et al [5], in a study of 693 patients from 1978 to 1981, reported a mortality rate of 28% for emergency operations, compared with 6% for elective surgery. Scott- Connor and Scher [4] similarly reported mortality rates of 38% and 5% for emergency and elective colorectal surgery, respectively. In our study, the overall mortality rate following elective surgery was 5% compared with 12% for emergency surgery.

Most of the patients in Group 1(76%) were classified in ASA classes I and II. Fifty-two percent of patients in Group 2 were classified in ASA classes III and IV. De- spite this greater percentage of high-risk patients in Group 2, mortality rates for both elective and emergency procedures have significantly improved compared with Group 1, based on advances in perioperative critical care. Del Guercio and Cohn [9] have advocated preoperative staging by invasive monitoring in order to further reduce operative mortality in the elderly patient, since specific physiologic defects could not be identified by using ASA status alone. In particular, perioperative invasive moni- toring might prove beneficial in ASA classes III and IV where significant risks were present and where prolonged and extensive surgery under general anesthesia is re- quired. Gur experience supports this thesis in that the

84 THE AMERICAN JOURNAL OF SURGERY VOLUME 162 JULY 1991

highest number of cardiopulmonary complications and fatalities occurred in ASA classes III and IV.

Despite the significant decrease seen in the mortality rates between Group 1 and 2 (11% versus 3%), the overall morbidity rates remain unchanged (42% versus 40%). However, as sepsis, previously the most common compli- cation of colorectal surgery, is brought under control with improvements in surgical techniques and availability of broad-spectrum antibiotics, derangements in other vital organs and systems have assumed increasingly important roles as determinants of survival. This is especially true for the geriatric population with limited physiologic re- serve and multiple underlying medical problems. Recom- mended measures to further improve the safety of colo- rectal surgery include comprehensive preoperative preparation by stabilizing underlying medical problems and possibly inserting a pulmonary arterial catheter to aid in optimizing hemodynamic status, performing elec- tive rather than emergency procedures, and aggressive postoperative surveillance in intensive care units.

REFERENCES 1. Allen AW, Welch CE. Malignant disease of the colon: factors influencing the operability, morbidity and mortality. Am J Surg 1939; 46: 171-80. 2. Macfee WF. Resection with aseptic end to end anastomosis for carcinoma of the colon. Ann Surg 1937; 106: 701-13. 3. Localio S, Eng K, Grouche T, et al. Abdominosacral resection for carcinoma of the midrectum: ten year experience. Ann Surg 1978; 33: 475-80. 4. Scott-Conner CE, Scher KS. Implications of emergency opera- tions on the colon. Am J Surg 1987; 153: 535-40. 5. Irvin GL, Horsley JS, Caruana JA, Jr. The morbidity and mortality of emergent operations for colorectal disease. Ann Surg 1984; 199: 598-603. 6. Bureau of the Cermrs. Statistical abstract of the United States, 107th edition. Washington DC US ti emment Priming Gflice, 1987. 7. Tinker J, Roberts S. Anesthesia risk. In: Miller RD, ed. Text- book of anesthesia. New York: Churchill Livingstone, 1986; 1: 359-80. 8. Cole WH. Prediction of operative reserve in the elderly patient. Ann Surg 1968; 168: 310-l. 9. Del Guercio LRM, Cohn JD. Monitoring operative risk in the elderly. JAMA 1980; 243: 1350-5.

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