Associations of specific postoperative complications with outcomes after elective colon resection: A procedure-targeted approach toward surgical quality improvement

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, whowere included in the Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Programwere assessed for the development of specific types of postoperative complications. The overall contributions of these complications to subsequent clinical and resource use outcomeswere assessed. Main Outcomes and Measures: The main outcomeswere 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, andmyocardial 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.