Impact of frailty on approach to colonic resection: Laparoscopy vs open surgery

Table 1 Patient characteristics, tumor factors and postoperative outcomes by type of procedure for patients undergoing colorectal resection, ACS-NSQIP 2005-2012

Characteristics, mean (± SD), (n)	Open colectomy n (%)	Lap colectomy n (%)	P value
Age 61.3 ± 15.17	61.89 ± 15.31	60.55 ± 14.93	< 0.0001
Race
AA (8778)	5823 (10.46)	2955 (7.55)	< 0.0001
White (73879)	42801 (76.90)	31087 (79.38)
Other (3808)	2043 (3.67)	1765 (4.51)
Unknown (8346)	4992 (8.97)	3354 (8.57)
Gender			0.62
Male (45383)	26606 (47.08)	18777 (47.96)
Female (49428)	29053 (52.50)	20375 (52.04)
ASA
Unknown (84)	60 (0.11)	24 (0.06)	< 0.0001
1 (2962)	1276 (2.30)	1686 (4.31)
2 (46287)	23687 (42.50)	22600 (57.72)
3 (40773)	26898 (48.30)	13875 (35.44)
4 (4627)	3664 (6.58)	963 (2.46)
5 (78)	74 (0.13)	4 (0.01)
Frailty index
0 (42507)	23651 (42.49)	18856 (48.16)	< 0.0001
1 (35596)	20838 (37.44)	14759 (37.69)
2 (11774)	7562 (13.59)	4212 (10.76)
≥ 3 (4934)	3608 (6.48)	1326 (3.39)
Type of intervention			< 0.0001
APR (524)	524 (100)	0 (0)
LAR (21300)	12056 (21.66)	9244 (23.61)
TPC (3760)	2514 (4.52)	1246 (3.18)
Total colectomy (3210)	2556 (4.59)	654 (1.67)
Partial colectomy (61646)	34311 (61.65)	27335 (69.82)
Sigmoid colectomy (4371)	3698 (6.64)	673 (1.72)
Complication
Yes (23755)	17241 (30.98)	6514 (16.64)	< 0.0001
No (71056)	38418 (69.02)	32638 (83.36)
Complication by severity
Minor (9,996)	6884 (12.37)	3112 (7.95)	< 0.0001
Mayor (13759)	10357 (18.61)	3402 (8.69)
No complication (71056)	38418 (69.02)	32638 (83.36)
LOS, 8.32 ± 9.28	9.88 ± 10.37	5.89 ± 6.40	< 0.0001
Prolonged LOS
Yes (4472)	3768 (10.42)	704 (3.19)	< 0.0001
No (53755)	32397 (89.58)	21358 (96.81)
Mortality (30 d)
Yes (1766)	1463 (2.63)	303 (0.77)	< 0.0001
No (93045)	54196 (97.37)	38849 (99.23)
Total patients	55659 (58.7)	39152 (41.3)	94811

Lap: Laparoscopic; ACS-NSQIP: American College of Surgeons National Surgical Quality Improvement Program; AA: African Americans; APR: Abdominoperineal resection; LAR: Low anterior resection; TPC: Total abdominal proctocolectomy; LOS: Length of stay.

Table 2 Univariate and multivariate mortality analysis by frailty group patients undergoing colon resection, ACS-NSQIP 2005-2012

Characteristic	Mortality n (%)	P value	OR (95%CI), P value
Non frail (n = 42507)
Age	Yes: 65.22 ± 15.23	< 0.0001	0.94 (0.95-1.05), < 0.0001
	No: 53.84 ± 15.09
Race
AA	20 (0.71)	0.60	-
White	186 (0.55)
Other	10 (0.54)
Unknown	20 (0.47)
Gender
Male	122 (0.60)	0.20	1.34 (1.03-1.75), 0.028
Female	114 (0.51)		Ref
Type of intervention		< 0.0001
APR	1 (0.40)		0.45 (0.02-2.04), 0.36
LAR	31 (0.31)		0.53 (0.35-0.77), 0.0008
TPC	8 (0.32)		0.81 (0.36-1.57), 0.56
Total colectomy	15 (0.89)		1.82 (1.02-3.04), 0.04
Partial colectomy	162 (0.62)		Ref
Sigmoid colectomy	19 (1.16)		1.18 (0.66-1.96), 0.54
Procedure
Open	204 (0.86)	< 0.0001	4.65 (3.16-6.82), < 0.0001
Lap	32 (0.17)		Ref
Characteristic mildly frail (n = 35596)
Age	Yes: 72.84 ± 12.25	< 0.0001	0.94 (0.95-1.05), < 0.0001
	No: 65.75 ± 12.36
Race		0.59
AA	68 (1.64)
White	453 (1.67)
Other	20 (1.38)
Unknown	57 (1.92)
Gender		0.006
Male	302 (1.89)		1.58 (1.33-1.88), < 0.0001
Female	296 (1.51)		Ref
Type of intervention		< 0.0001
APR	5 (2.55)		1.14 (0.34-2.73), 0.79
LAR	85 (1.05)		0.68 (0.53-1.87), 0.0018
TPC	14 (1.54)		1.07 (0.58-1.81), 0.79
Total colectomy	31 (3.27)		1.94 (1.28-2.84), 0.00025
Partial colectomy	405 (1.70)		Ref
Sigmoid colectomy	58 (3.48)		1.77 (1.30-2.36), 0.0003
Procedure
Open	470 (2.26)	< 0.0001	2.35 (1.92-2.91), < 0.0001
Lap	128 (0.87)		Ref
Characteristic moderately frail (n = 11744)
Age	Yes: 74.7 ± 10.95	< 0.0001	0.96 (0.11-17.47), < 0.0001
	No: 70.28 ± 11.2
Race
AA	49 (3.86)	0.65	-
White	368 (3.96)
Other	13 (3.53)
Unknown	40 (4.76)
Gender		0.34
Male	265 (4.15)		-
Female	205 (3.81)
Type of intervention		< 0.0001
APR	29 (3.77)		0.89 (0.14-2.92), 0.87
LAR	54 (2.39)		0.68 (0.49-0.91), 0.018
TPC	13 (5.94)		1.70 (0.88-2.98), 0.10
Total colectomy	28 (7.78)		2.29 (1.48-3.40), 0.0003
Partial colectomy	317 (3.86)		Ref
Sigmoid colectomy	56 (8.41)		2.08 (1.50-2.83), < 0.001
Procedure
Open	395 (5.22)	< 0.0001	2.70 (2.08-3.54), < 0.0001
Lap	75 (1.78)		Ref
Characteristic: Severely frail (n = 4934)
Age	Yes: 75.92 ± 9.51	< 0.0001	0.96 (0.15-13.07), < 0.0001
	No: 71.94 ± 10.02
Race
AA	50 (8.80)	0.42	-
White	381 (9.61)
Other	7 (5.79)
Unknown	24 (8.54)
Gender
Male	281 (10.16)	0.03	1.42 (1.16-1.75), 0.0006
Female	181 (8.35)		Ref
Type of intervention		< 0.0001
APR	2 (8.33)		0.75 (0.12-2.62), 0.69
LAR	46 (5.67)		0.63 (0.45-0.88), 0.0058
TPC	10 (10.10)		1.15 (0.55-2.15), 0.68
Total colectomy	35 (16.67)		2.07 (1.38-3.03), 0.0006
Partial colectomy	299 (8.82)		Ref
Sigmoid colectomy	70 (17.59)		1.94 (1.41-2.62), < 0.0004
Procedure
Open	394 (10.92)	< 0.0001	2.13 (1.62-2.84), < 0.0001
Lap	68 (5.13)		Ref

Lap: Laparoscopic; ACS-NSQIP: American College of surgeons National surgical Quality improvement program; AA: African Americans; APR: Abdominoperineal resection; LAR: Low anterior resection; TPC: Total abdominal proctocolectomy; LOS: Length of stay.

Table 3 Univariate and multivariate complication analysis by frailty group patients undergoing colorectal resection, ACS-NSQIP 2005-2012

Characteristic	Complication n (%)	P value	OR (95%CI), P value
Non frail (n = 42507)
Age	Yes: 53.74 ± 15.81	< 0.0001	0.94 (0.95-1.05), < 0.001
	No: 53.94 ± 14.93
Race
AA	719 (25.63)	< 0.0001	1.29 (1.18-1.41), < 0.0001
White	6736 (20.07)		Ref
Other	362 (19.37)		0.98 (0.87-1.10), 0.77
Unknown	906 (21.24)		1.06 (0.98-1.15), 0.11
Gender
Male	4191 (20.73)	0.30
Female	4532 (20.33)
Type of intervention			< 0.0001
APR	55 (21.91)		0.87 (0.64-1.18), 0.37
LAR	1858 (18.32)		0.97 (0.91-1.03), 0.34
TPC	733 (28.95)		1.71 (1.55-1.87), < 0.0001
Total colectomy	536 (31.66)		1.77 (1.59-1.98), < 0.0001
Partial colectomy	18.58 (18.32)		Ref
Sigmoid colectomy	573 (34.90)		1.88 (1.69-2.10), < 0.0001
Procedure
Open	6143 (25.97)	< 0.0001	2.07 (1.97-2.18), < 0.0001
Lap	2580 (13.68)		Ref
Characteristic, mildly frail (n = 35596)
Age	Yes: 65.81 ± 13.06	< 0.0001	0.94 (0.94-0.95), < 0.0001
	No: 65.00 ± 12.17
Race
AA	1154 (27.90)	< 0.0001	1.15 (1.07-1.24), 0.0002
White	6637 (24.54)		Ref
Other	291 (20.07)		0.81 (0.70-0.93), 0.0026
Unknown	734 (25.78)		1.06 (0.97-1.16), 0.18
Gender		0.34
Male	4017 (25.09)		-
Female	4829 (24.66)
Type of intervention		< 0.0001
APR	61 (31.12)		1.09 (0.80-1.48), 0.55
LAR	1918 (23.72)		1.01 (0.95-1.08), 0.58
TPC	341 (37.47)		1.78 (1.54-2.05), < 0.0001
Total colectomy	370 (39.07)		1.75 (1.53-2.01), < 0.0001
Partial colectomy	5500 (23.12)		Ref
Sigmoid colectomy	656 (39.40)		1.78 (1.60-1.98), < 0.0001
Procedure
Open	6360 (30.52)	< 0.0001	2.05 (1.94-2.16), < 0.00001
Lap	2486 (16.85)		Ref
Characteristic moderately frail (n = 11774)
Age	Yes: 70.480 ± 11.81	< 0.0001	0.99 (0.99-1.00), < 0.0001
	No: 70.42 ± 10.82
Race
AA	472 (37.19)	0.0013	1.20 (1.06-1.37), 0.003
White	2996 (32.21)		Ref
Other	118 (32.07)		1.01 (0.80-1.26), 0.93
Unknown	299 (35.81)		1.12 (0.96-1.31), 0.13
Gender
Male	2029 (31.75)	0.0017	0.92 (00.85-1.00), 0.06
Female	1856 (34.48)		Ref
Type of intervention		< 0.0001
APR	19 (35.85)		0.97 (0.52-1.70), 0.92
LAR	726 (32.12)		1.05 (0.95-1.17), 0.28
TPC	110 (50.23)		2.10 (1.49-2.63), < 0.0001
Total colectomy	182 (50.56)		2.05 (1.65-2.55), < 0.0001
Partial colectomy	2522 (30.70)		Ref
Sigmoid colectomy	326 (48.95)		1.96 (1.66-2.31), < 0.0001
Procedure
Open	2896 (38.38)	< 0.0001	1.89 (1.73-2.07), < 0.0001
Lap	989 (23.48)		Ref
Characteristic severely frail (n = 4934)
Age	Yes: 71.89 ± 10.50	0.02	0.96 (0.040-0.17), < 0.0001
	No: 72.54 ± 9.57
Race
AA	295 (51.94)	0.042	1.18 (0.98-1.42), 0.06
White	1822 (45.96)		Ref
Other	51 (42.15)		0.90 (0.682-1.33), 0.61
Unknown	133 (45.96)		1.02 (0.79-1.32), 0.84
Gender
Male	1308 (42.27)	0.31	-
Female	993 (45.82)
Type of intervention		< 0.0001
APR	12 (50)		1.05 (0.46-2.38), 0.89
LAR	350 (43.10)		0.98 (0.84-1.15), 0.85
TPC	53 (53.54)		1.27 (0.85-1.91), 0.23
Total colectomy	134 (63.81)		1.96 (1.46-2.64), < 0.0001
Partial colectomy	1499 (44.21)		Ref
Sigmoid colectomy	253 (63.57)		1.94 (1.56-2.44), < 0.0001
Procedure
Open	1842 (51.05)	< 0.0001	1.83 (1.60-2.09), < 0.0001
Lap	459 (3462)		Ref

Lap: Laparoscopic; ACS-NSQIP: American College of Surgeons National Surgical Quality Improvement Program; AA: African Americans; APR: Abdominoperineal resection; LAR: Low anterior resection; TPC: Total abdominal proctocolectomy; LOS: Length of stay.