All-cause 30-day postoperative mortality for older patients in highly developed countries having elective colorectal surgery: a systematic review

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Executive summaryBackgroundDeath after surgery is an acknowledged outcome reflecting the safety of a procedure. Death rates after surgery are not often routinely collected, therefore mortality rates can be difficult to quantify. Colorectal surgery is increasingly offered to older patients. The likelihood of postoperative adverse outcomes (including death) may impact decision-making at individual, institutional or health care system levels.ObjectivesThe objective of this review was to provide an estimate of the prevalence of all-cause 30-day postoperative mortality for older patients in highly developed countries undergoing elective colorectal surgery.Inclusion criteriaTypes of participantsThis review considered studies and reports that included patients aged 65 years and over from highly developed countries undergoing elective colorectal surgical resection. Only studies from countries with a very high Human Development Index were included.Types of interventionsStudies and reports including patients having colorectal resection with or without anastamosis were included.Types of studiesThis review considered experimental, analytical and descriptive epidemiological study designs, including randomized controlled trials, prospective and retrospective cohort studies, case series and cross sectional studies and reports. Only studies with a minimum sample size of 150 were included.Types of outcomesThis review included studies and reports that included rates of 30-day all-cause postoperative mortality.Search strategyA three-step search strategy was used in order to find published and unpublished studies and reports in the English language from 1998 to 2013. Databases searched were PubMed, Embase, Scopus, Web of Science, CINAHL, The Cochrane Central Register of Controlled Trials and the website of The Cochrane Colorectal Cancer Group. A search of the grey literature was performed, and hand searching of all retrieved articles was undertaken to identify additional studies or reports.Methodological qualityStudies or reports which met the inclusion criteria were critically appraised by two independent reviewers for methodological quality using the standardized Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Any disagreements between reviewers were resolved by a third reviewer.Data collectionData was extracted from the included studies or reports using a standardized data extraction tool. The tool included details of the study type, the dates covered by the interventions, the setting and model of care, the indication for, as well as the precise intervention(s), the population age range and level of comorbidity, the outcome measure of significance to the systematic review question, and whether the study or report included any qualitative assessment of the safety or acceptability of the surgical outcome.Data synthesisOutcomes for the population of interest were identified and outcome rates over time were analysed. Sub-group analysis was undertaken for mortality rates for age groups 70 years and over, 75 years and over, and 79 years and over. Outcomes were reported separately for countries and regions. Outcome data was reported separately according to the population studied (national-level data, and also data from academic and non-academic centres). Other comparisons examined separately included laparoscopic surgery and open surgery, cancer and non-cancer surgery, rectal and colonic surgery, surgery involving only specialist colorectal surgeons and surgery where non-specialist colorectal surgeons were involved, and surgery where “enhanced recovery” models of care were identified. Any qualitative assessment of the safety or acceptability of surgical outcome was reported.ResultsTwenty-four studies were included in the review. Studies were reported in a range of surgical, medical and educational publications. Twenty-three of the studies were observational. Explicit postoperative mortality rates were often difficult to identify, and data was obtained through direct author contact. Postoperative mortality rates reported and discovered ranged from 0.57-11.3%. The pooled 30-day postoperative mortality rate for all patients across all included studies was 5.34%. Mortality rates for entire countries or systems of care were significantly higher than those reported from single institutions, and particularly from single academic centres. Reported mortality rates due to laparoscopic surgery were lower than those reported from open procedures. There was no clearly identified trend in reported 30-day postoperative colorectal surgical mortality rates for elderly patients in highly developed countries between 1998 and 2011.ConclusionsOutcome data for older patients undergoing elective colorectal surgery is difficult to identify and access. There is considerable variation in reported 30-day postoperative mortality rates after elective colorectal surgery in elderly patients in highly developed countries across whole systems of care, between countries and between institutions. Very few institutional studies report postoperative mortality rates which exceed national averages.

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