Using National Surgical Quality Improvement Program (NSQIP) data for risk adjustment to compare Clavien 4 and 5 complications in open and laparoscopic colectomy

Abstract

Laparoscopic colectomy has been associated with fewer postoperative complications than open colectomy. However, it is unclear whether this is true for the most severe complications typically requiring treatment in an intensive care unit (ICU). The authors hypothesized that laparoscopic colectomy patients have fewer of the most severe complications even after adjustment for comorbidity risk. Using the National Surgical Quality Improvement Program (NSQIP) public use files for 2005-2008, the authors identified all laparoscopic (n = 12,455) and open (n = 33,190) colectomies by current procedural terminology (CPT) code. Using the Clavien classification for postoperative complications, they identified NSQIP data points most consistent with Clavien grade 4 complications requiring ICU care (postoperative septic shock, postoperative dialysis, pulmonary embolism, myocardial infarction, cardiac arrest, prolonged ventilatory requirements, need for reintubation) or grade 5 complication (mortality). Statistical analysis was performed using SPSS software. Odds ratios were calculated to compare laparoscopic and open colectomy regarding the probability of having any Clavien class 4 or 5 complication. Logistic regression was performed to account for the effect of preoperative conditions (American Society of Anesthesiology class, wound class, gender, preoperative functional status, preoperative albumin level, azotemia, thrombocytopenia, emergency case, and age >70 years) on complications. The univariate odds ratio showed a 2.27- to 5.52-fold greater likelihood that a patient would have a complication requiring ICU admission if open rather than laparoscopic surgery was performed (p < 0.001). Multivariate logistic regression accounting for preoperative comorbidities that might affect outcome showed persistence of an increase in complications, with an odds ratio range of 1.63 to 2.21. Evaluation of the NSQIP database demonstrated that laparoscopic colectomy confers an independent protective effect on the frequency of ICU-level (Clavien grade 4) complications and mortality. The protective effect remained evident after correction for preoperative conditions that might have affected outcome.