WASHINGTON – Although general surgeons perform the majority of rectal resections in the United States, their patients have more severe postoperative complications, longer lengths of stay, higher hospital costs, and higher mortality rates than do those of colorectal surgeons.
A review of more than 60,000 cases over a 6-year period found that patients who had been operated on by a general surgeon had a 42% increase in the risk of mortality. They stayed in the hospital an average 1 day longer than the patients of colorectal surgeons, and had bills more than $1,000 higher. Although their overall complication rate was lower, general surgeons’ patients tended to have more severe complications, including pulmonary complications and surgical site infections, Dr. Marc Casasanta said at the annual clinical congress of the American College of Surgeons.
Dr. Casasanta of the University of Texas, Houston, extracted his data from the Premier Perspective database, the largest inpatient database in the United States. His analysis included 60,412 nonemergent rectal resections performed from 2005 to 2011.
Most of these (74%) were performed by general surgeons, with colorectal surgeons performing the remainder. Adverse outcomes examined included length and cost of hospital admission, overall complications and severe complications, and mortality.
There were several significant differences in the patient populations. General surgeons had older patients (63 vs. 61 years), and their patients tended to be sicker, with less minor disease severity (31% vs. 35%) and more major (29% vs. 17%) and extreme disease severity (8% vs. 6%).
Colorectal surgeons treated significantly more patients with inflammatory bowel disease (10% vs. 4%). They worked exclusively in urban hospitals, compared with 87% of general surgeons. Half of colorectal surgeons worked in teaching hospitals versus 37% of general surgeons.
The mean overall length of stay was a little more than 8 days. The mean hospital cost was $19,093.The overall complication rate was 29%, and mortality was 1.5%.
Complications varied significantly by surgeon specialty. General surgeons had significantly higher rates of digestive complications (including anastomotic problems), as well as pulmonary complications, lower-extremity thromboembolism, shock, and surgical site infections, including intra-abdominal infections.
The univariate analysis identified several patient characteristics significantly associated with poor outcomes, including age older than 62 years (odds ratio, 1.43), female gender (OR, 1.23), major disease severity (OR, 4.7), extreme disease severity (OR, 23), and a diagnosis of inflammatory bowel disease (OR, 1.41).
Other significant risk factors were being treated in a rural hospital (OR 1.29), being treated in a teaching hospital (OR, 1.08), and having a general surgeon (OR, 1.16). Having a colorectal surgeon decreased the risk of a poor outcome by 14%.
In the multivariate analysis, patients of general surgeons were 13% less likely to have any complication and 20% less likely to have ileus. But these patients were also significantly more likely to have severe complications, including pulmonary problems (13%) and surgical site infections (11%).
The length of stay was about 1 day longer, and hospitals costs were $1,122 more expensive. Patients of general surgeons were 42% more likely to die.
Dr. Casasanta said he had no relevant financial disclosures. However, Dr. Eric Haas, the primary investigator, said he has been a consultant for Applied Medical; and has received consulting fees, research funding, and honoraria from Intuitive Surgical.