Abstract
Colon surgery is associated with a high rate of surgical site infection (SSI), and there is an urgent need for strategies to reduce infection rates. To assess whether laparoscopic colon surgery is associated with a lower surgical site infection rate than open-approach laparoscopy, especially in patients with medically complex conditions. This cohort study used previously validated diagnosis and procedure codes from Medicare beneficiaries who underwent colon surgery from January 1, 2009, to November 30, 2013. Analyses were performed from August 1 to December 31, 2018. Outcome measures were SSI events, medical comorbidities, and laparoscopic or open approach procedures. A total of 229 726 patients (mean [SD] age, 74.3 [9.4] years; 128 499 [55.9%] female) underwent colon procedures. There were 105 144 laparoscopic procedures and 124 582 open procedures. The overall mean SSI rate was 6.2%, varying by surgical procedure from 5.8% to 7.6%. Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of SSI (odds ratio, 0.43; 95% CI, 0.41-0.46; P < .001). When stratified by surgical approach, the mean SSI rates were 4.1% (procedure-specific range, 3.9%-5.1%) for the laparoscopic approach and 7.9% (procedure-specific range, 7.4%-10.2%) for the open approach. When stratified by Elixhauser score groups, the mean SSI rates were 6.2% (procedure-specific range, 3.2%-8.7%) for group 1 (0-1 comorbidity), 5.5% (procedure-specific range, 3.6%-11.1%) for group 2 (2 comorbidities), and 6.6% (procedure-specific range, 4.6%-10.6%) for group 3 (3-13 comorbidities). An interaction was also observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure (odds ratio, 1.21; 95% CI, 1.11-1.32) compared with patient groups with fewer comorbidities. The population attributable fraction of SSIs for use of the open approach was 34.2%. A total of 2317 of 3882 hospitals (59.7%) performed few (0%-10%) or most (>50%) procedures laparoscopically. Policy changes that promote surgical education and resources for laparoscopy, especially at low-adoption hospitals, may be associated with reduced colon SSI rates. Support of the development of innovative educational policies may help achieve improvement in patient outcomes and decreased health care use in colon surgery.
Highlights
Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of surgical site infection (SSI)
An interaction was observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure compared with patient groups with fewer comorbidities
Among the remaining 5 paired surgical procedures, 229 726 procedures were identified among 3882 hospitals, including right hemicolectomy, left hemicolectomy, sigmoidectomy, other partial excision of the large intestine or cecectomy, and transverse colectomy, all performed by laparoscopy and an open approach (Table 1)
Summary
Surgical site infections (SSIs) are associated with substantial morbidity, often requiring additional operation and unanticipated hospitalization, with estimated attributable costs of more than $3 billion annually.[1,2] Preventing infection after colon surgery is a national priority for the more than 300 000 procedures performed annually in the United States,[3] with their associated SSI rates being as high as 14% to 25%.4,5 Despite advances in understanding processes for colon SSI prevention and adoption of bundles of processes, the SSI rate after colon surgery continues to be high and varies considerably among hospitals, suggesting that further improvement is possible.[6]Laparoscopic colon surgery, first described in the 1990s, is a safe alternative to traditional open surgery for many patients.[7]. Surgical site infections (SSIs) are associated with substantial morbidity, often requiring additional operation and unanticipated hospitalization, with estimated attributable costs of more than $3 billion annually.[1,2] Preventing infection after colon surgery is a national priority for the more than 300 000 procedures performed annually in the United States,[3] with their associated SSI rates being as high as 14% to 25%.4,5. A patient’s general health may influence the decision regarding surgical approach; patients undergoing a laparoscopic procedure tend to be younger and fitter and have significantly fewer comorbidities.[5] In addition, the complexity of the underlying surgical condition and prior surgical procedures may make laparoscopy more challenging. Many surgeons reliably perform laparoscopic surgery for patients with both medically and surgically complex conditions.[8] The reasons behind and strategies to address the continued variation in uptake of laparoscopic colorectal surgery continue to be debated. Professional societies have developed programs to assist surgeons in practice with transitioning their approach to colon surgery from open to laparoscopic,[9] and general and colorectal residency review committees have prioritized competency in laparoscopy for trainees.[10]
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