Editorial on “Impact of complications on length of stay in elective laparoscopic colectomies”

Colectomy is one of the most common surgical procedures performed in the United States, with greater than 300,000 procedures performed in 2014 (1), the majority of these are performed laparoscopically (2,3). These procedures are at high risk of complication, and it is known that complications affect length of stay (LOS).

Using, the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) database the authors evaluated the impact of individual complications on LOS after elective laparoscopic colectomy. The study included over 42,000 patients (from 2011 to 2014) and evaluated thirty-day postoperative morbidity and mortality. Authors looked specifically at individual postoperative complications and their effect on LOS. The postoperative complications included in this cohort were bleeding requiring transfusion <72 h, superficial surgical site infection (SSI), organ space SSI, postoperative sepsis, UTI, wound occurrences (deep SSI and/or fascial disruption), pneumonia, unplanned intubation, ventilator dependence >48 h, PE, DVT, MI, acute renal failure (ARF). For this cohort, median LOS was 4 days. After adjustment for patient demographics and other complications; unplanned reoperation had the greatest impact on LOS with increase of 1.6 times. The most frequent postoperative complications included bleeding requiring transfusion <72 h (N=1,765, 4.2% of patients), superficial SSI (N=1,673, 3.9% of patients), unplanned reoperation (N=1,389, 3.3% of patients), and organ space SSI (N=1,003, 2.4% of patients). Postoperative sepsis and UTI each occurred in <2% of patients. Wound occurrences, pneumonia, unplanned intubation, ventilator dependence >48 h, PE, DVT, MI, and ARF each occurred in <1% of patients. Overall, 30-d mortality was (N=188, 0.4% of patients) and overall readmission (N=2,416, 6.9% of patients). In addition, authors estimated that 12,195 addition hospital days could be attributed to the complications, leading to a burden in excess of $150 million on the healthcare system.

The relationship between complications and LOS is well documented. As some studies reported two-fold increase in LOS with postoperative complications (4,5). Overall, this study is similar to the other literature. It would have been helpful to look at some of the other known risk factors for complications such as surgeon or institutional volume or cumulative complication risk. Also, given the increased push towards eras, it would have been interesting if they could have adjusted for the use of early recovery protocols as it is clear that LOS can be markedly reduced with proper postoperative care (6,7).

Overall, this retrospective study of large database confirmed prior data showing the impact of complications on postoperative outcomes. In addition, to that it presented the financial burden and costs of these complications, looking to improve health care and to decrease institutional costs.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2018.04.08). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. HCUPnet: A tool for identifying, tracking, and analyzing national hospital statistics. Available online: https://hcupnet.ahrq.gov (April. 3. 2018).
2. Bardakcioglu O, Khan A, Aldridge C, et al. Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time. Ann Surg 2013;258:270-4. [Crossref] [PubMed]
3. Yeo HL, Isaacs AJ, Abelson JS, et al. Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume. Dis Colon Rectum 2016;59:535-42. [Crossref] [PubMed]
4. Flynn DN, Speck RM, Mahmoud NN, et al. The impact of complications following open colectomy on hospital finances: a retrospective cohort study. Perioper Med (Lond) 2014;3:1. [Crossref] [PubMed]
5. McAleese P, Odling-Smee W. The effect of complications on length of stay. Ann Surg 1994;220:740-4. [Crossref] [PubMed]
6. Bardram L, Funch-Jensen P, Jensen P, et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995;345:763-4. [Crossref] [PubMed]
7. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 1999;86:227-30. [Crossref] [PubMed]