L. Gregorian1, E. Vo1, L. Haubert1,2, E. Choi1,2, S. S. Awad1,3, A. Artinyan1,2 1Baylor College Of Medicine,Houston, TX, USA 2Baylor St. Lukes Medical Center,Houston, TX, USA 3Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA
Introduction:
Colorectal cancer is a leading cause of cancer death in the US. We have previously described changes in cancer-specific rectal cancer treatment and long-term survival over the last 4 decades. The aim of our current study was to describe changes in early postoperative outcomes after curative-intent surgery for rectal cancer in the US. We hypothesized that postoperative outcomes such as length of stay (LOS), mortality, and postoperative complications have improved over time.
Methods:
The National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality data were queried in 5 year intervals from 1993-2013 for patients with rectal adenocarcinoma, older than 18 years of age, who had undergone curative-intent surgery (n=16,419). Baseline characteristics (age, gender, type of operation) and postoperative outcomes (LOS, inpatient mortality, discharge disposition, and postoperative complications) were described. Clinical/demographic characteristics and postoperative outcomes were compared by discharge year. Continuous variables were compared using the 1-way analysis of variance (ANOVA) or non-parametric tests, and categorical variables were compared using the chi-square test.
Results:
The mean age of the entire population was 65.6±13.1 years. 58.7% of patients were male and median LOS was 8 (IQR 4-11) days. Mean age of diagnosis has decreased with time (68.3±12.1 in 1993 to 62.6±13.0 years in 2013, p<0.001). The proportion of male patients has increased in the same time period (56% to 62%, p<0.001). As in our prior study, sphincter-preserving operations increased significantly over time (51% in 1993 to 60.5% in 2013, p<0.001). During the same time period, perioperative hemorrhage and inpatient mortality decreased from 3.6% to 1.6% (p<0.001) and 1.9% to 0.7% (p<0.001), respectively. There was no clinically significant change in the surgical site infection (SSI) rate (4.3% to 4.6%, p<0.001), whereas anastomotic leak and digestive complications increased over time (9.8% to 12.7%, p<0.001). Median LOS decreased significantly from 10 (IQR 7-13) to 6 (IQR 4-9) days (p<0.001). However, non-home discharges and home-health use increased from 8.3% to 11.4% and 23.5% to 42.7%, respectively (p<0.001).
Conclusion:
The treatment of rectal cancer continues to evolve, with a greater emphasis on sphincter-preserving surgery, as well as decreases in perioperative hemorrhage and inpatient mortality. However, the rate of SSIs has not changed meaningfully and the risk of anastomotic and other digestive complications has increased, potentially secondary to anatomically lower pelvic anastomoses. Although LOS has decreased, there has been an increase in transitional care and home-health service needs. A shift toward organ-preserving strategies is likely necessary to further improve post-operative outcomes from rectal cancer surgery.