Unplanned hospital readmission and reoperation after colorectal cancer surgery: analysis of risk factors

Abstract

AimUnplanned hospital readmission (UHR) and reoperation following colorectal cancer surgery are associated with increased morbidity, mortality, and healthcare expenditure. This study aimed to determine the rates of UHR and reoperation after colorectal cancer surgery and to identify the predictive clinical and surgical risk factors.MethodsData from patients who underwent surgical resection for colorectal cancer between January 2015 and December 2018 were retrospectively analyzed from a prospectively maintained database. Univariate and multivariate logistic regression analyses were performed to identify factors independently associated with UHR and reoperation.ResultsA total of 344 patients were included; 220 (64.0%) were male, and 124 (36.0%) were female. The mean age was 60.88 ± 12.4 years, and the mean body mass index was 26.2 ± 4.7 kg/m². The UHR and reoperation rates were 13.1% (n = 45) and 6.4% (n = 22), respectively. The most frequent causes of UHR were surgical site infection (33.3%) and bowel obstruction (31.1%), whereas anastomotic leakage was the leading indication for reoperation (54.5%). In univariate analysis, stoma formation, conversion to open surgery, and the presence of intra- and postoperative complications were significantly associated with UHR (P < .05). A history of prior abdominal surgery, stoma formation, and postoperative complications were significant risk factors for reoperation (P < .05). On multivariate analysis, hypoalbuminemia emerged as an independent predictor of UHR (P = .034; OR = 0.111; 95% CI: 0.014–0.851).ConclusionUHR and reoperation rates following colorectal cancer surgery are meaningful and are predominantly driven by postoperative complications. Hypoalbuminemia is an independent predictor of UHR and may serve as a biomarker for preoperative risk stratification. Preoperative optimization and postoperative surveillance of high-risk patients may contribute to reducing both readmission and reoperation rates.

Keywords

Introduction

Colorectal cancer represents the third most common malignancy in developed countries, and surgical resection remains the cornerstone of curative-intent treatment. Despite significant advances in surgical technique and perioperative care, postoperative complications continue to represent a major source of morbidity in this patient population.
Complications arising after hospital discharge may precipitate unplanned hospital readmissions (UHR). In contemporary surgical practice, readmission rates have emerged as an important quality-of-care indicator alongside traditional outcome measures such as mortality and morbidity.¹
The incidence of postoperative readmission varies according to the surgical discipline and the complexity of the procedure. Readmission rates of 5–15% have been reported following abdominal surgery in general, while rates of 10–27% have been documented specifically after colorectal surgery.^2-6 The most frequently cited reasons include ileus, gastrointestinal complications, surgical site infection (SSI), dehydration, poor oral intake, and postoperative pain.^7,8 Identified risk factors for readmission in the literature include the presence of comorbid conditions, emergency surgery, male sex, stoma formation, and an open surgical approach.^9,10
A subset of postoperative complications necessitates reoperation. Prior studies have identified intra-abdominal hemorrhage, intra-abdominal abscess, anastomotic leakage, evisceration, and ileus as the most common indications, with reoperation rates ranging from 6.5% to 12.8%.^11,12 Reported risk factors include high ASA classification, male sex, SSI, chronic obstructive pulmonary disease (COPD), steroid use, anemia, and obesity.
Beyond being a consequence of surgical complications, reoperation is associated with increased perioperative mortality, elevated risk of local recurrence, and diminished overall survival. Furthermore, reoperation may delay the initiation of adjuvant therapy, thereby adversely affecting oncological outcomes.^13,14 As such, reoperation rates are recognized as a meaningful surrogate indicator of surgical quality when evaluated alongside other established outcome parameters.¹⁵
Readmissions impose a substantial economic burden on healthcare systems. In a large series of 93,913 colectomy patients reported by Bliss et al., the readmission rate was 14.7%, with a mean readmission cost of $7,030 per patient.¹⁶
Early identification of patients at elevated risk for readmission and reoperation is essential to implement targeted preventive strategies. The present study aimed to determine the rates of UHR and reoperation following colorectal cancer surgery and to identify the clinical and surgical predictors of these outcomes.

Materials and Methods

Study Design and Patient PopulationThis retrospective study analyzed data from patients who underwent surgical resection for colorectal cancer between January 2015 and December 2018 at our institution. Data were extracted from a prospectively maintained institutional database.
Patients who underwent elective or emergency surgical resection for colorectal cancer were eligible for inclusion. Those with incomplete data were excluded from analysis.Data CollectionThe following variables were recorded for each patient: demographic characteristics (age, sex, body mass index [BMI]); clinical features (ASA physical status score, comorbid conditions, history of prior abdominal surgery, clinical TNM stage); laboratory parameters (preoperative hemoglobin and serum albumin levels); and operative data (type of procedure, surgical approach, conversion to open surgery, stoma formation, operative time).
Postoperative data included intraoperative complications, postoperative complications (SSI, intra-abdominal abscess, evisceration, ileus, hemorrhage), length of hospital stay (LOS), requirement for reoperation, and occurrence of UHR.DefinitionsUHR was defined as any unplanned return visit to the study center's emergency department or inpatient admission within 30 days of discharge for any reason. Hypoalbuminemia was defined as a serum albumin level below 3.5 g/dL. Reoperation was defined as any unplanned surgical intervention performed at the index institution following the index colorectal resection.Ethical ApprovalThis study was approved by the Çukurova University Faculty of Medicine Ethics Committee (Date: 08.05.2026; Decision No: 166/51).Statistical AnalysisStatistical analyses were performed using SPSS software (Statistical Package for the Social Sciences). Continuous variables are expressed as mean ± standard deviation (SD); categorical variables are reported as frequency and percentage. Group comparisons for categorical variables were performed using the chi-square test or Fisher's exact test, as appropriate. Student's t-test or the Mann–Whitney U test was applied for continuous variables. Univariate analyses were followed by multivariate logistic regression analysis to identify independent predictors of UHR and reoperation. Variables achieving P < .05 in univariate analysis were entered into the multivariate model. Statistical significance was set at P < .05.Reporting GuidelinesThis study was reported in accordance with the STROBE guideline.

Results

Patient Demographics and Overall OutcomesA total of 344 patients were enrolled. Of these, 220 (64.0%) were male, and 124 (36.0%) were female, with a male-to-female ratio of 1.77. The mean age was 60.88 ± 12.4 years (range: 20–107), and the mean BMI was 26.2 ± 4.7 kg/m² (range: 14–51). Reoperation was required in 22 patients (6.4%), and UHR occurred in 45 patients (13.1%). Demographic data are summarized in Table 1.Reoperation: Comorbidity ComparisonsHypertension and diabetes mellitus were the most prevalent comorbidities in both groups. No statistically significant intergroup differences were observed for any comorbidity (P > .05; Table 3).Reoperation: Operative and Postoperative ComparisonsNo significant differences were noted between groups with respect to tumor localization, concomitant surgical procedures, or operative time (P > .05). The conversion rate to open surgery was 9.1% in the reoperation group vs. 4.65% in the non-reoperation group, with a borderline significant difference (P = .050). Stoma formation was significantly more frequent in the reoperation group (72.6% vs. 40.9%; P = .004). The intraoperative complication rate was significantly higher in the reoperation group (18.2% vs. 2.48%; P = .005), with ureteral and small bowel injuries as the most common intraoperative events. Mean postoperative LOS was significantly longer in the reoperation group (22.36 ± 16.1 days vs. 8.75 ± 5.1 days; P = .001). Rates of SSI (68.1% vs. 10.2%; P = .001), intra-abdominal abscess (54.5% vs. 3.4%; P = .001), evisceration (18.2% vs. 2.2%; P = .003), and ileus (27.2% vs. 9.0%; P = .016) were all significantly higher in the reoperation group. No significant difference was observed for intra-abdominal hemorrhage (P = .087). Detailed data are presented in Table 4.Indications for ReoperationThe most common indication for reoperation was anastomotic leakage, accounting for 54.5% of cases. A complete distribution of reoperation indications is provided in Table 5.UHR: Demographic and Clinical ComparisonsOf the 344 patients, 45 (13.1%) experienced UHR. Comparison of patients with and without UHR revealed no significant differences in age, sex, ASA score, BMI, preoperative hemoglobin, preoperative albumin, clinical TNM stage, or history of prior abdominal surgery (P > .05). However, on multivariate logistic regression analysis, hypoalbuminemia was identified as an independent predictor of UHR (P = .034; OR = 0.111; 95% CI: 0.014–0.851). Demographic and clinical characteristics are summarized in Table 6.UHR: Comorbidity ComparisonsHypertension and diabetes mellitus were the most common comorbidities in both groups. The prevalence of diabetes mellitus in the UHR group was 31.1%. No statistically significant intergroup differences were observed for any comorbidity (P > .05; Table 7).UHR: Operative and Postoperative ComparisonsThe proportion of patients undergoing emergency surgery was significantly higher in the non-UHR group (P = .024). No significant differences were observed between groups in surgical approach, tumor localization, concomitant procedures, intraoperative complications, or conversion rate (P > .05). Mean operative time was 180.89 ± 32.2 minutes in the UHR group vs. 170.15 ± 36.5 minutes in the non-UHR group (P = .063). Stoma formation was significantly more common in the UHR group (64.4% vs. 39.7%; P = .002). Postoperative LOS did not differ significantly between groups (11.22 ± 8.8 vs. 9.41 ± 6.9 days; P = .119). Rates of SSI (37.8% vs. 10.4%; P = .001), intra-abdominal abscess (22.2% vs. 4.3%; P = .001), evisceration (11.1% vs. 2.0%; P = .008), and ileus (28.8% vs. 7.4%; P = .001) were all significantly elevated in the UHR group. Intra-abdominal hemorrhage rates did not differ significantly (P = .718). Data are presented in Table 8.Reasons for UHRThe most frequent reasons for readmission were SSI (33.3%), ileus (31.1%), and poor oral intake (17.9%). The complete distribution of UHR causes is shown in Table 9.

Discussion

Reoperation following colorectal surgery is a clinically significant event associated with increased morbidity, mortality, and healthcare costs. Prior studies have consistently demonstrated that reoperation rates after colorectal resection are higher than those observed in other general surgical procedures.^17,18 In the current literature, reoperation rates following colorectal surgery range from 6.5% to 12.8%;^13,14 our observed rate of 6.4% falls within this range, suggesting that the surgical and perioperative care standards at our institution are consistent with published benchmarks.
Established risk factors for reoperation in the literature include elevated ASA classification, hypoalbuminemia, and obesity.¹⁹ Ricciardi et al. identified these as independent predictors of reoperation in a large series. In our cohort, the predominance of ASA class I–II patients may account for the absence of ASA score as a significant predictor. Similarly, while albumin levels appeared lower in the reoperation group, statistical significance was not reached, likely reflecting limited statistical power due to the relatively small sample size or the homogeneity of the study population.
A history of prior abdominal surgery increases operative complexity through adhesion-related technical challenges and has been associated with higher rates of surgical morbidity in the literature.^20,21 Consistent with these findings, prior abdominal surgery was significantly more prevalent in our reoperation group (P = .021), underscoring the importance of detailed preoperative assessment of surgical history.
The relationship between surgical approach and reoperation risk remains a subject of debate in the literature. While some studies have reported a higher reoperation risk associated with laparoscopic surgery ²⁰, others have found no significant difference between open and laparoscopic approaches.²² Our analysis similarly identified no significant association between surgical approach and reoperation. However, the borderline significance observed for conversion to open surgery (P = .050) may reflect the additional tissue trauma and technical complexity inherent to converted procedures.
The markedly elevated rates of postoperative complications in the reoperation group are clinically noteworthy. The significantly higher rates of SSI, intra-abdominal abscess, evisceration, and ileus in this group confirm that the majority of reoperations were directly attributable to these complications. This is consistent with the broader literature, in which anastomotic leakage and infectious complications are recognized as the leading indications for reoperation.²³ Anastomotic leakage was likewise the most common indication for reoperation in our series (54.5%).
Stoma formation emerged as a significant predictor of both reoperation and UHR in our study. The literature documents a wide clinical spectrum of stoma-related complications, including those severe enough to necessitate reoperation.²⁴ Our findings of significantly higher stoma formation rates in the reoperation group (P = .004) support the conclusion that ostomy creation independently contributes to increased surgical morbidity.
Unplanned hospital readmission is widely recognized as a quality-of-care indicator in contemporary surgical practice.⁶ Published UHR rates following colorectal surgery range from 7% to 27%.^2-6 Our observed rate of 13.1% is consistent with this range. A counterintuitive finding in our study was the higher proportion of emergency surgery in the non-UHR group (P = .024). This may be explained by selection bias: patients undergoing emergency operations typically have longer hospital stays and more intensive postoperative surveillance, which may reduce the probability of discharge during a vulnerable period and thereby lower the likelihood of 30-day readmission.
The primacy of postoperative complications as drivers of UHR has been established in multiple studies.^25-28 SSI, intra-abdominal complications, and ileus have been consistently identified as the most frequent causes of readmission.²⁷ In line with these reports, SSI, evisceration, and ileus were all identified as significant risk factors for UHR in our analysis, supporting the premise that a substantial proportion of readmissions are complication-driven and potentially preventable.
One of the most clinically meaningful findings of this study was the identification of hypoalbuminemia as an independent predictor of UHR on multivariate analysis. Serum albumin (normal: ≥3.5 g/dL) reflects not only nutritional status but also systemic inflammatory burden and overall physiologic reserve. Recent evidence has demonstrated that preoperative hypoalbuminemia is associated with increased postoperative complications and prolonged hospital stay following colorectal surgery.^29,30 Our findings suggest that hypoalbuminemia may predispose patients to postoperative complications and, through this mechanism, indirectly elevate the risk of UHR. This study thus highlights that readmissions after colorectal surgery are determined not only by postoperative events but also by preoperative patient-level factors, most notably nutritional and metabolic status.
Stoma formation was also a significant independent risk factor for UHR in our cohort. High-output stoma, dehydration, and electrolyte imbalances are well-established causes of early readmission in patients with ostomies.^28,31-34 These findings collectively emphasize the need for structured preoperative ostomy education, enhanced outpatient nursing support, and close outpatient follow-up for patients undergoing stoma formation.
The most common causes of UHR in our series were SSI (33.3%), ileus (31.1%), and poor oral intake (17.9%), consistent with previously published data.^6,35,36 This pattern underscores that a majority of readmissions are attributable to manageable postoperative complications, many of which may be amenable to targeted prevention strategies.

Limitations

This study has several limitations that merit consideration. The retrospective design introduces inherent limitations regarding data completeness. The single-center nature of the study may limit generalizability. The relatively small size of the reoperation group (n = 22) constrains statistical power for certain analyses. The four-year study period may have introduced heterogeneity in perioperative care protocols. Furthermore, the definition of reoperation was restricted to interventions performed at the index institution, potentially underestimating the true reoperation rate for patients who may have been reoperated at other centers.

Conclusion

Unplanned hospital readmission and reoperation following colorectal cancer surgery occur at clinically significant rates and are predominantly attributable to postoperative complications. Hypoalbuminemia is an independent predictor of UHR and represents a modifiable preoperative risk factor amenable to nutritional optimization. Similarly, stoma formation is a key determinant of both reoperation and readmission, highlighting the importance of meticulous perioperative patient counseling and follow-up. Preoperative identification of high-risk patients based on these factors, combined with targeted optimization strategies and intensified postoperative surveillance, may help reduce the burden of readmission and reoperation, improving both individual patient outcomes and healthcare resource utilization.

Declarations

References

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