Outcomes of Colorectal Surgery (CRS) at Department of Surgical Gastroenterology, Max Hospital (Saket): International quality at affordable Indian costs

Our team attended annual conference of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) held at Baltimore, USA April 2019. We presented 3 studies including one entitled ‘Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator^’.¹

In the following section we share some of the highlights of this study.

A recent study published in New England Journal of Medicine examined 30 -day readmission data of 479,471 patients from 3004 USA hospitals undergoing six major surgical procedures (colectomy and 5 other surgical procedures). The study concluded that following major surgical procedures, nearly one in seven patients are readmitted to the hospital within 30 days of discharge and readmission data is an indicator of quality of surgical care at any hospital.²

We therefore performed audit of colorectal surgery (CRS) outcomes at our department using American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) risk calculator - one of the most widely utilized and validated universal risk calculator for clinical audits.

The ACS NSQIP risk calculator was developed by utilizing data collected from 4.3 million operations performed across 780 hospitals participating in ACS NSQIP to predict outcomes for 1500 surgical procedures. The risk calculator estimates an individual’s risk of developing 18 different complications within 30 days after surgery.

The risk adjusted scoring systems such as ACS NSQIP risk calculator are important because in heterogeneous cohorts of surgery patients, crude postoperative morbidity and mortality as an outcome measure is misleading. Therefore, for meaningful conclusions from clinical audits and compare outcomes between different units or regions, risk adjusted patient outcomes are essential.

Our single centre observational study included 86 consecutive adult (≥ 18 years) patients who underwent elective or emergency, resective &/or reconstructive CRS from March 2013 to March 2018. Procedures such as appendicectomy, diverting colostomy, laparoscopic rectopexy were excluded from analysis. Data was accessed from institutional electronic health record system and pre-anaesthetic charts. ACS – NSQIP score for each patient was calculated. Actual outcomes were then compared with those predicted by risk calculators.

Of the 86 patients (60 Indians and 26 International) there were 56 males and 30 females with a mean age of 57 (range 18-93) years. Of these 59 (68.6%) underwent elective whereas 27(31.4%) had emergency CRS. We performed complete range of procedures for cancer as well as benign diseases. Sixty-two (72%) and 24 (38%) patients underwent open and minimally invasive procedures (laparoscopic -21 and robotic -3) respectively. The median length of stay was 08 (range 02-40) days. The mortality following elective and emergency operations was 1/59 (1.6%) and 8/27(29.6%) respectively. The readmission rate was 05 (5.8%)

Objective comparison between overall actual outcomes and those predicted by ACS – NSQIP risk calculator revealed no statistically significant difference in any of the parameters studied such as mortality, major complication, anastomotic leak, return to OT, surgical site infection length of stay, and readmission (Figure 1). 

Figure 1. Actual versus predicted outcomes by ACS-NSQIP risk calculator

Additionally there is significant cost advantage - all-inclusive costs of surgery (admission to discharge) were one fifth of the costs incurred for colectomy at comparable US NSQIP hospitals (Figure 2).

Figure 2. Comparison of costs for Colectomy at MSSH & US NSQIP hospitals

In conclusion at Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket outcomes of colorectal surgery are comparable to best of international centres - US NSQIP hospitals at affordable Indian costs.

References:

1. Vashistha N, Verma A and Singhal D. Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator. Surg Endosc. 2019;33:S241

2. Tsai TC, Joynt KE, Orav EJ et al. Variation in surgical readmission rates and quality of hospital care. N Engl J Med 2013;369:1134-42

      

      Authors:

Dr Nitin Vashistha MS, FIAGES, FACS
Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,

Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com