Outcomes of Right and Left Colectomy at Academic Centers
By Hinojosa, Marcelo W Konyalian, Viken R; Murrell, Zuri A; Varela, J Esteban; Stamos, Michael J; Nguyen, Ninh T
Few studies have compared outcomes of right colectomy (RC) and left colectomy (LC) with respect to both benign and malignant disease. The objective of this study was to compare outcomes of RC versus LC for benign and malignant disease using a national administrative database of academic medical centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, data was obtained from the University HealthSystem Consortium Clinical Data Base for patients that underwent RC and LC for benign and malignant disease between 2002 and 2006. The main outcomes compared were demographics, length of hospital stay, observed to expected in-hospital mortality, complications, 30-day readmission, and mean cost. There were a total of 27,483 patients; 12,971 patients (47.2%) underwent RC. Compared with LC for benign disease, RC was associated with a shorter length of stay, lower overall complications, lower wound infections, lower 30-day readmissions, and lower cost. Compared with LC for malignant disease, RC was associated with lower overall complications, lower wound infections, and lower cost. In this analysis of academic centers, RC was associated with a lower length of stay, lower morbidity, and lower cost when compared with LC for benign and malignant disease. IN THE UNITED STATES THERE are approximately 600,000 colorectal procedures performed each year, making it one of the most common types of operations.1 Many surgeons believe that left-sided colon surgery is associated with more complications and is technically more challenging than right-sided colon surgery. Colocolonic and colorectal anastomoses have also been found to have a higher postoperative leak rate when compared with ileocolic anastomoses.2,3 We hypothesized that right colon operations would have improved outcomes when compared with leftsided colon operations. To test this hypothesis we compared the outcomes of right and left colectomy using a national administrative database of academic medical centers.
Methods
Database
The University HealthSystem Consortium (UHC) Clinical Data Base is a source of patient-level, hospital, and discharge abstract data from affiliated academic medical centers and community hospitals in the United States. The discharge abstract data contains information regarding patient demographics, length of stay, 30-day readmission rates, and in-hospital morbidity and mortality. The database also provides riskadjusted data for comparison of institutions. Approval for the use of the UHC patient-level data in this study was obtained from the Institutional Review Board of the University of California, Irvine Medical Center and the UHC.
We identified patients who underwent right and left colectomy for both benign and malignant disease between January 1, 2002 and June 30, 2006 using appropriate diagnoses and procedural codes (Table 1) as specified by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM). The left colectomy group included patients with left colectomy and sigmoid colectomy ICD-9- CM codes. The right colectomy group included patients with right colectomy ICD-9-CM code (Table 1). Patients undergoing emergent procedures were excluded. Right and left colectomy groups were compared with regards to patient characteristics (age, sex, race, and severity class), perioperative outcomes, and inhospital mortality.
Patient severity scores were based on the severity and complexity of the secondary diagnoses (comorbidities and complications). In- hospital mortality was defined as the percentage of patients who died before being discharged from the hospital and does not reflect those patients in which death occurred after discharge. Length of stay was defined as the number of days from the index procedure to hospital discharge.
Table 1. ICD-9 CM Diagnosis and Procedural Codes for Right and Left Colectomy.
Data Analysis
Statistical analysis was performed using Statistix software, version 8 (Analytical Software, Tallahassee, FL). Analyses of differences between groups for categorical data were performed using the khgr;^sup 2^ analysis. Differences in length of stay and cost between groups were determined by two-sample t tests. Data are expressed as mean +- standard deviation and proportions. A P value of equal to or less than 0.05 was considered statistically significant.
Results
During the 4-year study period, 27,483 patients underwent colon resections, including 12,971 (47%) right colectomies and 14,512 (53%) left colectomies. Twelve thousand, four hundred and three (45%) cases were performed for benign pathology and 15,080 (55%) performed for malignant pathology. Table 2 lists the demographic data of patients who underwent right and left colectomy.
Analysis of data for both benign and malignant disease revealed that the right colectomy group was associated with a lower rate of wound infection (4% vs 6%, P < 0.01), a lower 30-day readmission rate (7% and 8%, P < 0.01), and lower cost (15,403 +- 17,378 vs 16,595 +- 23,105, P < 0.01) compared with the left colectomy group. Amongst the subset of patients with benign disease, right colectomy was additionally associated with a shorter length of stay and a lower overall rate of complications (Table 3). Amongst the subset of patients with malignant disease, right colectomy was also found to have lower overall complications, lower wound infections, and lower cost (Table 4). The observed in-hospital mortality and observed to expected in-hospital mortality ratio was similar amongst all groups.
Discussion
In this study, we hypothesize that right colectomy would be associated with less perioperative morbidity and mortality than left colectomy. In general, left colectomy, with or without splenic flexure mobilization, can provide more technical challenges and may require more operative time compared with right colectomy. Additionally, colocolonic or colorectal anastomoses have also been found to be at an increased risk of developing postoperative leaks compared with ileocolonic anastomosis.2-3 In this study of national administrative data with a large volume of cases over a 4-year period, we found that patients who underwent right colectomy showed better outcomes when compared with patients who underwent left colectomy for both benign and malignant disease.
Table 2. Demographics of Patients Who Underwent Right and Left Colectomy for Benign and Malignant Disease.
TABLE 3. Outcomes of Right and Left Colectomy for Benign Disease.
For benign disease, we found that length of stay was significantly lower for patients who underwent a right colectomy. Overall complication and wound infection rate was also lower in patients that underwent right colectomy for benign or malignant disease. The lower morbidity after right colectomy may be, in part due to the higher overall leak rate that has been reported in patients who underwent a colocolonic or colorectal anastomosis.2-3 The leak rates for colorectal operations have been reported to be from 1.2 per cent to 15 per cent.2^6 Hospital stay costs were also found to be significantly lower in patients who underwent right colectomy. This finding was likely related to the observed lower morbidity and lower length of stay in the right colectomy group. There was no significant difference in in-hospital mortality or risk- adjusted observed to expected in-hospital mortality ratio between the two groups. This finding suggests that observed mortality was lower than that of the expected mortality based on risk adjustment methodology. Finally, we found that the 30-day readmission rate was lower in those patients who underwent a right colectomy compared with those who underwent a left colectomy for benign disease. This may be due to the larger proportion of left colectomy patients that were operated on for diverticular disease and the increased in- hospital morbidity seen in these patients.
TABLE 4. Outcomes of Right and Left Colectomy for Malignant Disease.
Our study has some limitations. The UHC database only contains inpatient data and does not provide follow-up data, such as postdischarge complications or deaths. We were also not able to accurately describe the proportion of colectomy performed laparoscopically, as there is presently no ICD-9 procedural code(s) for laparoscopic colectomy. Using ICD-9-CM codes for diagnostic laparoscopy and laparoscopic lysis of adhesion, we estimate that 5 to 10 per cent of the cases within our study were performed laparoscopically. Several studies have suggested improved perioperative outcomes associated with minimally invasive techniques, which could have some influence on our findings.7 14 The population groups in our study were not comparable. There were a larger proportion of younger patients in the left colectomy group. More patients in our study underwent left compared with right colectomy for diverticular disease, substantiating prior reports showing the incidence of operative rightsided diverticular disease to be about two per cent of all right-sided diverticular cases.15- 16 Surprisingly, in the patients with malignant disease, there was a greater proportion of patients that underwent right colectomy as compared with those that underwent left colectomy. It has been suggested that there has been an increasing trend in diagnosis of right-sided colon cancer,17 however, this was not the focus of our study and may be better addressed in a future study. In summary, this analysis of academic centers shows that right colectomy was associated with improved morbidity and cost when compared with left colectomy for both benign and malignant disease. However, we did not find any differences with regard to in-hospital mortality between the two groups. With the growing trend in the utilization of laparoscopy in colon surgery, outcome data on the impact of laparoscopic colectomy should be examined.
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MARCELO W. HINOJOSA, M.D., VIKEN R. KONYALIAN, M.D., ZURI A. MURRELL, M.D.,
J. ESTEBAN VARELA, M.D., M.P.H., MICHAEL J. ST AMOS, M.D., NINH T. NGUYEN, M.D.
From the Department of Surgery, University of California Irvine School of Medicine, Irvine, California
Presented at the 18th Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, CA, January 19-21, 2007.
The information contained in this article was based on the Clinical Data Base provided by the University HealthSystem Consortium.
Address correspondence and reprint request to Ninh T. Nguyen, M.D., Department of Surgery, 333 City Boulevard, West, Suite 850, Orange, CA 92868. E-mail: ninhn@uci.edu.
Copyright Southeastern Surgical Congress Oct 2007
(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.