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Original Investigation
December 07, 2016

Associations of Specific Postoperative Complications With Outcomes After Elective Colon ResectionA Procedure-Targeted Approach Toward Surgical Quality Improvement

Author Affiliations
  • 1Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
JAMA Surg. Published online December 7, 2016. doi:10.1001/jamasurg.2016.4681
Key Points

Question  Which postoperative complications have the greatest effect on clinical and economic outcomes after elective colorectal surgery?

Findings  In this cohort study using American College of Surgeons National Surgical Quality Improvement Program data, anastomotic leak and postoperative ileus had significantly higher associations with 30-day patient and health care resource use outcomes than complications such as surgical site infection, urinary tract infection, or venous thromboembolism.

Meaning  Existing federal quality improvement programs are not targeting the complications that matter the most in colorectal surgery.


Importance  Numerous quality initiatives have been implemented in an effort to minimize the onus of postoperative complications on clinical and economic outcomes after major surgery. It is unknown which complications have the greatest overall effect on these outcomes.

Objective  To quantify the associations of specific postoperative complications with outcomes after elective colon resection.

Design, Setting, and Participants  Patients undergoing elective colon resection between January 1, 2012, and December 31, 2013, who were included in the Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program were assessed for the development of specific types of postoperative complications. The overall contributions of these complications to subsequent clinical and resource use outcomes were assessed.

Main Outcomes and Measures  The main outcomes were 30-day mortality, end-organ dysfunction, reoperation, prolonged hospitalization, nonroutine discharge status, and hospital readmission. Risk-adjusted population attributable fractions were estimated for each complication-outcome pair. The population attributable fractions for a specific complication represented the percentage reduction in a given outcome that would be expected if exposure to that complication was completely eliminated.

Results  A total of 26 682 patients undergoing elective colon resection were included for analysis; 13 870 patients were women (52.0%) and 15 088 (56.5%) were younger than 65 years. The most common index complications were ileus (n = 3140; 11.8%), bleeding (n = 2032; 7.6%), and incisional surgical site infection (n = 1873; 7.0%). Anastomotic leak was associated with the incidence of end-organ dysfunction, mortality, reoperation, and hospital readmission, with estimated population attributable fractions of 33.3% (95% CI, 29.6-36.8), 20.0% (95% CI, 14.0-25.7), 48.4% (95% CI, 45.7-51.0), and 20.6% (95% CI, 19.1-22.1) for each of these respective outcomes. The effect of complications, such as urinary tract infection, venous thromboembolism, and myocardial infarction, on these outcomes was comparatively small.

Conclusions and Relevance  Anastomotic leak has a large overall effect on 30-day clinical and economic outcomes after elective colon resection. The findings of our study support the adoption of a procedure-targeted approach to surgical quality improvement and describe a practical method for assessing complication effect.