OUTCOME AFTER PROCTECTOMY FOR RECTAL-CANCER IN DEPARTMENT-OF-VETERANS-AFFAIRS HOSPITALS - A REPORT FROM THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM

Objective To define risk factors that predict adverse outcomes after p roctectomy for cancer in Department of Veterans Affairs Medical Center s. Summary Background Data Accurate presurgical assessment of the risk of perioperative complications and death is important in planning sur gical therapy. Methods The National VA Surgical Quality Improvement Pr ogram contains prospectively collected and extensively validated data on >287,000 patients. All patients undergoing proctectomy for rectal c ancer from 1991 to 1995 who were registered in this data base were sel ected for study. Independent variables examined included 68 presurgica l and 12 intraoperative clinical risk factors; dependent variables wer e 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting 30-day morbidity rates for eac h of the 10 most common complications and the 30-day mortality rate. R esults Five hundred ninety-one patients were identified; 467 (79%) und erwent abdominoperineal resection and 124 (21%) were treated with sphi ncter-saving procedures. Thirty percent of patients had one or more co mplications after proctectomy. Prolonged ileus, urinary tract infectio n, pneumonia, and deep wound infection were the most frequently report ed complications. The 30-day mortality rate was 3.2% (19 deaths). For most complications, 30-day mortality rates were significantly higher f or patients with complications than for those without. Thirty-day mort ality rates for several complications exceeded 50%: cardiac arrest req uiring cardiopulmonary resuscitation, deep venous thrombosis or thromb ophlebitis, coma lasting >24 hours, acute renal failure, cerebrovascul ar accident, and pulmonary embolism. Four presurgical factors predicte d a high risk of 30-day mortality in the logistic regression analysis: elevated blood urea nitrogen level, impaired sensorium. low serum alb umin concentration, and partial thromboplastin time less than or equal to 25 seconds. Conclusions Mortality rates after proctectomy in VA ho spitals are comparable to those reported in other large series. Most p ostsurgical complications are associated with an increased 30-day mort ality rate. Elevated presurgical blood urea nitrogen level, impaired s ensorium, low serum albumin concentration, and partial thromboplastin time less than or equal to 25 seconds predict a high risk of 30-day mo rtality.