EP336 - Failure-to-Rescue Following Colectomy in Patients ≥65 Years Old: A Nationwide Analysis

Purpose/Background: Failure-to-rescue (FTR) is a well-established metric in general surgery, but data on FTR in colorectal surgery are scarce. Given the complexity of colorectal operations and the growing geriatric patient population, we sought to identify potentially modifiable institutional and system-level factors.

Methods/Interventions: Using the American College of Surgeons NSQIP Database from 2005 to 2021, all patients ≥65 years undergoing colectomy were identified. FTR was defined as patients who died during the admission and experienced at least one serious post-operative complication. Post-operative complications were defined as wound, pulmonary, renal, central nervous system, cardiac, sepsis, bleeding, anastomotic leak, or return to the operating room. Rates of 30-day FTR and complications were calculated. Temporal trends in FTR over the study period were examined. Multivariable logistic models were constructed to identify independent predictors of FTR.

Results/Outcomes: Of 44,271 patients ≥65 years, the overall FTR rate was 9.4%, with 4,177 patients dying after at least one complication within 30 days of surgery. The median age was 74 years, and 54.8% were female. Over the study period, the FTR rate decreased from 17.1% to 7.8%, which reflects a decrease by 59.3%, OR: 0.41 (95%CI 0.25-0.67, p< 0.001). Patients in the FTR group were more often functionally dependent at baseline (15% vs 7%, p< 0.001), and underwent emergency (27% vs 23%, p< 0.001) and open surgery (82% vs 55%, p< 0.001). FTR was associated with surgery for a malignancy (65% vs 60%, p< 0.001) and total colectomy (2.2% vs 1.3%, p< 0.001). The median time from surgery to first complication was 2 days (IQR: 0-6 days), and to death was 12 days (IQR: 6-19 days). The most common complications in the FTR groups were septic shock (43%), bleeding requiring transfusion (36%), and unplanned intubation (35%). For an individual patient, as the number of complications increased, the FTR rate increased incrementally from 4% with one complication to 46% with 7 or more complications. In the FTR group, 75% of patients had >1 complication. On multivariable analyses, post-operative septic shock (OR: 6.1, CI 5.5-6.8, p< 0.001), post-operative stroke (OR: 3.3, CI 2.6-4.1, p< 0.001), and post-operative myocardial infarction (OR:2.0, CI:1.7-2.4, p< 0.001) were most independently associated with FTR. Other independent predictors included increasing age, being functionally dependent at baseline, ascites, steroid use, heart failure, hypertension, weight loss >10% in the last 30 days, emergency presentation, and a longer operative time.

Conclusion/Discussion: Mortality following colectomy in geriatric patients more than halved over the study period, seemingly driven by improvements in "rescue". FTR was strongly associated with early postoperative complications-especially septic shock, stroke, and myocardial infarction-and increased with the number of complications. These findings highlight the critical importance of early postoperative complication management to improve survival in this population.

Figure
Failure-to-rescue rate over the study period