title: Additional procedures performed during elective colon surgery and their adverse impact on postoperative outcomes.
abstract: BACKGROUND
  The need for additional procedures during a segmental elective colectomy is considered to lead to increased postoperative morbidity, but there have been few data that have validated and quantified this risk.
  
  
  OBJECTIVE
  We hypothesized that patients having additional procedures performed during a segmental colectomy have worse outcomes compared to patients undergoing a colectomy alone.
  
  
  METHODS
  All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent an elective open or laparoscopic segmental colectomy during 2005-2009 and met the inclusion criteria were analyzed. Using current procedural terminology (CPT) codes, patients were stratified into three groups. Group 1 only had CPT codes for a colectomy. Group 2 had additional CPT codes for procedures that were considered related to the colectomy, such as splenic flexure mobilization and endoscopy or a relatively minor procedure such as an appendectomy. Group 3 included patients that had additional procedures performed along with a segmental colectomy. Serious morbidity, overall morbidity, return to the operating room, and death were calculated and compared for each group.
  
  
  RESULTS
  There were 25,996 patients in the open and 20,396 patients in the laparoscopic colectomy group. Thirty-six percent of patients in the open colectomy group vs. 18 % in the laparoscopic colectomy group had additional procedures performed. After adjustment for available differences in the groups, patients undergoing open and laparoscopic segmental colectomy along with an additional procedure had worse postoperative outcomes compared to patients undergoing a colectomy alone.
  
  
  CONCLUSIONS
  The study is limited by the possibility of coding errors in the ACS NSQIP database leading to a case ascertainment bias and a selection bias given the observational nature of the study. It also could not differentiate between additional procedures that were planned or incidental at the time of surgery.
  
  
  CONCLUSIONS
  A proportion of patients undergoing elective open and laparoscopic segmental colon resections undergo additional procedures that adversely impact postoperative outcomes. This is mainly related to the type of additional procedures performed and therefore should be accounted for when counseling patients about the risks of surgery and in comparisons of outcomes.
authors.affiliation: Department of Surgery, University of Iowa, Iowa City, IA, USA, imran-hassan@uiowa.edu.
authors.forename: Imran
authors.initials: I
authors.lastname: Hassan
authors.forename: Paul E
authors.initials: PE
authors.lastname: Pacheco
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Markwell
authors.forename: Sajida
authors.initials: S
authors.lastname: Ahad
mesh_terms: D000328:Adult; D000368:Aged; D001062:Appendectomy; D003082:Colectomy / Q000009:adverse effects* / Q000379:methods; D003108:Colonic Diseases / Q000150:complications / Q000473:pathology / Q000601:surgery*; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D017063:Outcome Assessment, Health Care; D058996:Quality Improvement