Safety of Elective Colorectal Cancer Surgery: Non-Surgical Complications and Colectomies are Targets for Quality Improvement DANIEL HENNEMAN, MD, 1 * MARTIJN G. TEN BERGE, MD, 1 HELEEN S. SNIJDERS, MD, 1 NICOLINE J. VAN LEERSUM, MD, 1 MARTA FIOCCO, PhD, 2 THEO WIGGERS, MD, PhD, 3 ROB A.E.M. TOLLENAAR, MD, PhD, 1 MICHEL W.J.M. WOUTERS, MD, 1,4 AND ON BEHALF OF THE DUTCH SURGICAL COLORECTAL AUDIT GROUP † 1 Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands 2 Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands 3 Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands 4 Department of Surgical Oncology, Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands Background: Mortality following severe complications (failure‐to‐rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon‐ and rectal cancer resections. Methods: Analysis of patients undergoing elective colon and rectal cancer resections registered in the Dutch Surgical Colorectal Audit in 2011– 2012. Severe complication‐ and FTR rates were compared between the groups in univariate and multivariate analysis. Results: Colon cancer (CC) patients (n ¼ 10,184) were older and had more comorbidity. Rectal cancer (RC) patients (n ¼ 4,906) less often received an anastomosis and had more diverting stomas. Complication rates were higher in RC patients (24.8% vs. 18.3%, P < 0.001). However, FTR rates were higher in CC patients (18.6% vs. 9.4%, P < 0.001). Particularly, FTR associated with anastomotic leakage, postoperative bleeding, and infections was higher in CC patients. Adjusted for casemix, CC patients had a twofold risk of FTR compared to RC patients (OR 1.89, 95% CI 1.06–3.37). Conclusions: Severe complication rates were lower in CC patients than in RC patients; however, the risk of dying following a severe complication was twice as high in CC patients, regardless of differences in characteristics between the groups. Efforts should be made to improve recognition and management of postoperative (non‐)surgical complications, especially in colon cancer surgery. J. Surg. Oncol. . ß 2013 Wiley Periodicals, Inc. KEY WORDS: failure to rescue; colon cancer; rectal cancer; postoperative complications; postoperative mortality INTRODUCTION Ever since the Institute of Medicines report “to err is human,” patient safety is a number one priority in many western healthcare systems. Colorectal cancer surgery is performed commonly, though it remains associated with relatively high morbidity and mortality rates [1,2], in part because colorectal cancer patients often have a high age and comorbid illnesses [3]. As a result, colorectal cancer surgery is the subject of many national quality improvement programs in Europe [4] and the United States [5], with complication‐ and mortality rates being widely used outcomes for comparisons of quality of surgical care. Failure‐to‐rescue (FTR)—the mortality rate in patients with a severe complication—is another outcome measure that indicates the ability of a surgical team to keep patients alive when severe complications occur [6– 8]. FTR is seen as a good quality indicator as it evaluates both complication recognition and treatment. Following the example of audits in other European countries, the nationwide Dutch Surgical Colorectal Audit (DSCA) was introduced in the Netherlands in 2009 [9]. One of the main objectives of these audit programs is to reduce morbidity and mortality after colorectal surgery. To reach this objective, it is important to understand the mechanisms behind the development of adverse events and the way they lead to fatal outcomes. In the DSCA, postoperative mortality appears to be higher after colon cancer resections than after rectal cancer resections, despite higher complication rates in the latter [9], suggesting higher FTR rates in colon cancer surgery. These differences in FTR may be partly due to a higher proportion of non‐elective surgery in colon cancer patients, which carries a higher risk of adverse events [10], though may also exist in elective cases. A similar pattern was observed in the British National Bowel Cancer Audit Program, with higher postoperative mortality rates after colon resections than after rectal cancer resections, both in elective and non‐elective cases, despite higher reoperation rates in rectal cancer patients [11]. Differences in patient characteristics, such as age, comorbidity, and tumor stage between colon and rectal cancer patients may also play a role in the differences in outcomes between the two patient groups. Moreover, possible differences in treatment characteristics, such as The authors declared that they have no conflicts of interest. y A. Aalbers, W.A. Bemelman, D. Boerma, R.M. van Dam, J.W. Dekker, E.H. Eddes, M. Elferink, E. de Graaf, E. van der Harst, M.L.E.A. Jansen‐ Landheer, T.M. Karsten, J.H.J.M. van Krieken, V.E. Lemmens, E.R. Manusama, W.J.H.J. Meijerink, M. de Noo, H.J.T. Rutten, P.J. Tanis, C.J.H. van de Velde (the members of the Dutch Surgical Colorectal Audit group are collaborators of the study). *Correspondence to: Daniel Henneman, MD, Department of Surgery, K‐6, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands. Fax: 31‐71‐526‐6750. E‐mail: d.henneman@lumc.nl Received 20 September 2013; Accepted 22 November 2013 DOI 10.1002/jso.23532 Published online in Wiley Online Library (wileyonlinelibrary.com). Journal of Surgical Oncology ß 2013 Wiley Periodicals, Inc.