The Laryngoscope

The Effect of Transoral Robotic Surgery on

Short-Term Outcomes and Cost of Care after

Oropharyngeal Cancer Surgery

1
Jeremy Richmon, M.D.
1,2
Harry Quon, M.D., M.S.
1
Christine G. Gourin, M.D., M.P.H.

1. Department of Otolaryngology-Head and Neck Surgery

2. Department of Radiation Oncology and Molecular Radiation Sciences

Johns Hopkins Medical Institutions

Baltimore, MD

Running Title: transoral robotic surgery and short-term outcomes

Key words: transoral robotic surgery, TORS, complications, head and neck neoplasms, surgery,
Nationwide Inpatient Sample

Financial disclosures; nothing to disclose

Conflict of interest: none

Address for correspondence:

Jeremy D. Richmon, M.D., F.A.C.S.
Johns Hopkins Outpatient Center
Department of Otolaryngology- Head and Neck Surgery
601 N. Caroline Street
Baltimore, MD 21287
Phone: (410) 955-6420
Fax: (410) 955-8510
Email: jrichmo7@jhmi.edu

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to l

differences between this version and the Version of Record. Please cite this article as doi:
10.1002/lary.24358

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Abstract

Background: Transoral surgery is an increasingly frequent treatment modality for tumors of the

upper aerodigestive tract. This is in large part related to the introduction of transoral robotic

surgery (TORS) for oropharyngeal cancer resection, which has demonstrated excellent oncologic

and functional outcomes. There is limited data, however, on how TORS compares to traditional

open surgery in overall costs and length of hospitalization. With increasing pressure to contain

and reduce the costs of medical care, we sought to evaluate the impact of TORS on a national

sample of patients undergoing surgery for oropharyngeal cancer.

Study design: Retrospective cross-sectional study.

Methods: A cross-sectional analysis of 9,601 patients who underwent an extirpative procedure

for a malignant oropharyngeal neoplasm in 2008-2009 was performed using discharge data from

the Nationwide Inpatient Sample.

Results: TORS was performed in 116 (1.2%) of cases. TORS patients had a lower rate of

gastrostomy tube placement (0% vs 19%), tracheotomy tube placement (0% vs 36%), and

nonroutine discharge (0% vs 44%) compared to patients undergoing non-TORS procedures.

After controlling for all other variables, including comorbidity, extent of surgery and teaching

hospital status, TORS was associated with significantly decreased length of hospitalization

(mean, -1.5 days) and hospital-related costs (mean, -$4285).

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Conclusions: TORS is becoming an increasingly frequent technique to

treat tumors of the upper aerodigestive tract. These data demonstrate

that TORS is associated with a decreased length of hospitalization and

hospital-related costs compared to other surgical techniques.

Level of Evidence: 2c

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Introduction

In 2005, the da Vinci robot was initially introduced for transoral surgery1 and since that

time it has emerged as an attractive treatment option for select neoplasms of the upper

aerodigestive tract. In particular, transoral robotic surgery (TORS) has shown to be most useful

for oropharyngeal tumors as it provides non-invasive surgical exposure to an otherwise

challenging anatomic area with reduced surgical morbidity compared to traditional transcervical

open approaches. Oropharyngeal cancer has traditionally been treated with surgery followed by

radiation therapy for advanced primary site disease or nodal disease, resulting in superior

survival rates compared with radiotherapy with or without chemotherapy,2 but results in poorer

functional outcomes, particularly with respect to speech and swallowing. The success of organ

preservation protocols in laryngeal cancer has led to an increase in the use of nonoperative

treatment for head and neck cancer, despite a lack of randomized controlled clinical trial data

comparing primary surgical approaches to organ preservation.

In the past decade, there has been an epidemic increase in oropharyngeal cancer

associated with the human-papilloma virus (HPV), which affects a younger population of

patients and is associated with improved long-term survival.3,4 These observations have led to a

surge of interest in treatment deintensification to minimize long-term treatment related toxicity.5

The advantage of primary surgical approaches are the possibility of avoiding the use of

chemotherapy or permitting reduced doses of radiation in the postoperative setting and

dosimetric benefits, which may reduce the incidence of long-term dysphagia.6-8 These

observations have led to a renewed interest in primary surgical approaches to head and neck

cancer using TORS to reduce surgical morbidity. As TORS emerges as a surgical approach for

head and neck cancer, it is important to compare the cost of TORS to traditional open surgery

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given the increasing pressure to contain and reduce the costs of medical care

in this era of health care reform. We sought to evaluate the impact of TORS

on in-hospital mortality, postoperative complications, length of stay, and costs

in patients undergoing oropharyngeal cancer surgery using a national hospital

discharge database.

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Methods

A cross-sectional analysis of patients with a diagnosis of oropharyngeal cancer was

performed using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost

and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ). The NIS

is the largest all-payer inpatient care database in the United States, containing data from

approximately 8 million hospital stays each year from a stratified sample of 20% of non-federal

U.S. hospitals from participating states.9 The NIS database provides information regarding the

index hospital admission and includes patient demographic data, primary and secondary

diagnoses, primary and secondary procedures, hospital characteristics, and inpatient and

discharge mortality rates. The International Classification of Disease, 9th revision (ICD-9) codes

were used to identify adult patients (≥18 years of age) who underwent an ablative procedure for a

malignant oropharyngeal neoplasm for the years 2008 and 2009, as codes for TORS do not

appear in the NIS prior to 2008. (Supplemental Table 1). Reconstructive procedures were

obtained from codes for pedicled or free flap reconstruction, and surgical complications were

derived from codes for complications directly resulting from surgical procedures assigned at the

time of hospital discharge. Prior irradiation was obtained from the codes for previous exposure to

therapeutic radiation.

Comorbidity was graded using the Romano adaptation of the Charlson comorbidity
10-12
index, excluding ICD-9 codes for the index cancer diagnosis from the solid tumor category.

Cancer staging information is not available in the NIS, and as a result ICD-9 codes for

metastases were excluded as these have not been shown to be a reliable surrogate for disease
13
stage. Acute medical complications were derived from codes for acute cardiac events, acute

pulmonary edema or failure, acute renal failure, acute hepatic failure, acute cerebrovascular
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events, sepsis, pneumonia, and UTI assigned at the time of hospital discharge, and surgical

complications were derived from codes for complications directly resulting from surgical

procedures assigned at the time of hospital discharge. (Supplemental Table 2)

Postoperative complications, length of hospitalization and cost were examined as

dependent variables. Secondary independent variables included were age, sex, race, payer source

(commercial or health maintenance organization [HMO], Medicare, Medicaid, self-pay, or

other), comorbidity, procedure, nature of admission (emergent/urgent, or other), inpatient death,

postoperative surgical complications, and acute medical complications. Procedures were

categorized by severity as minor (excision/destruction of lesion, tonsillectomy, and partial

glossectomy, with or without neck dissection, and major (partial or total laryngectomy, total

glossectomy, pharyngectomy, mandibulectomy, and maxillectomy, with or without neck

dissection). American Joint Commission on Cancer (AJCC) tumor stage, tumor grade,

histological subtype, and outcome after discharge were not available from the NIS database.

Hospital-related charges for each index admission were converted to the organizational

cost of providing care using cost to charge ratios for individual hospitals. Cost to charge ratios

were calculated using information from the detailed reports by hospitals to the Centers for

Medicare and Medicaid Services, providing an estimate of the all-payer inpatient cost-to-charge

ratio by hospital.14 This ratio was multiplied by each patient's charge to obtain the cost per
15
admission. All costs were adjusted for inflation based on U.S. Bureau of Labor Statistics indices,

with results converted to 2012 USD.16 To obtain national cost estimates, all discharges were re-

weighted to account for cases where cost estimates were missing for hospitals that did not

provide head and neck cancer surgical care.12

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Data were analyzed using Stata 12 (StataCorp, College Station, TX). Associations

between variables were analyzed using cross-tabulations, multivariate logistic regression, and

multinomial logistic regression modeling. Non-zero discharge counts with fewer than 11

observations were masked in accordance with the HCUP data use agreement. Data were

weighted, and modified hospital and discharge weights to correct for changes in sampling over

time were applied.9 Variance estimation was performed using procedures for survey data

analysis with replacement. Strata with one sampling unit were centered at the population mean.

Variables with missing data for more than 10% of the population were coded with a dummy

variable to represent the missing data in regression analysis. The primary clinical endpoints were

evaluated using multiple logistic regression analysis. Generalized linear regression modeling

with a log link was used to analyze costs and length of stay because these variables were not

normally distributed. This protocol was reviewed and approved by the Johns Hopkins Medical

Institutions Institutional Review Board.

Results

There were 9,601 oropharyngeal cancer surgical cases in 2008-2009 with TORS reported

in 116 (1.2%) (Table 1). The majority of patients were white (66%), male (75%) and between

40-64 years of age (63%). The majority of TORS surgery was elective in nature with routine

disposition from the hospital in all patients. Patients undergoing TORS were more likely to

undergo surgery at small hospitals, did not have a history of prior radiation, and were less likely

to have advanced comorbidity, although significance could not be demonstrated due to small

numbers. There was no significant difference in the incidence of postoperative surgical

complications between TORS and non-TORS patients; however, no patient undergoing TORS

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had an acute medical complication or received a tracheostomy or gastrostomy tube

compared to the non-TORS group, although this did not reach statistical significance

secondary to the small number of patients in the TORS group.

Multiple logistic regression analysis of independent variables associated with the risk of

postoperative complications is shown in Table 2. After controlling for the effects of all

variables, the only independently significant factors predictive of postoperative surgical

complications were advanced age, advanced comorbidity, and extent of surgery, while acute

medical complications were associated with urgent or emergent admission, flap reconstruction,

Medicaid payor status, and comorbidity.. TORS procedures were not associated with significant

differences in acute postoperative morbidity or mortality.

Multivariate generalized linear regression analyses of independent variables predictive of

length of hospital stay and hospital-related costs are shown in Table 3, with mean values

representing the change in the value of the intercept mean. Urgent or emergent admission, major

surgical procedures, pedicled or free flap reconstruction, Medicare or Medicaid, payor status,

comorbidity, black race and surgery performed at a teaching hospital were significantly

associated with greater length of hospitalization. Major surgical procedures, pedicled or free flap

reconstruction, Medicaid payor status, comorbidity, and surgery performed at a teaching hospital

were significantly associated with increased hospital costs, while age <65 years was associated

with decreased hospital-related costs. After controlling for all other variables, the use of

TORS was associated with significantly decreased length of hospitalization (-1.5 days) and

hospital-
related costs (-$4285).
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Discussion

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TORS offers a minimally invasive approach to tumors of the upper aerodigestive tract. In

contrast to non-TORS surgical approaches in which pharyngotomy and mandibulotomy are

frequently required for access, multiple institutional series have demonstrated TORS to have

short hospital length of stays (LOS) and decreased morbidity and mortality.17-21 Our

analysis of nationwide inpatient data demonstrates that TORS is associated with a decreased

length of hospital stay and hospital-related costs and is associated with a lower rate of

gastrostomy tube and tracheotomy tube placement compared to other surgical techniques.

Furthermore, we found that TORS is not associated with acute morbidity and mortality. It is

noteworthy that the period covered in this study represents the earliest available data with TORS

(2008-2009) with most cases occurring in small, non-teaching hospitals when this technique was

in its infancy. Thus, these data suggest that TORS may be a more generalizable surgical

approach with a lower risk of immediate complications seen even in the early years of adoption

into clinical practice concurrent with a learning curve.

Critics of TORS have cited the expense of the da Vinci robot as unwarranted in today’s heath

care cost-containment environment. One should keep in mind that the robot is a capital

investment made by the hospital, usually to support the urology, cardiac and gynecology services

as the surgical volume from otolaryngology would not justify the purchase. The additional cost

per case for TORS is minimal, approximately $500 for disposable equipment, comparable

to other endoscopic, laser, or harmonic technologies. Compared to non-TORS surgical

procedures, these cases tend to be shorter (2-4 hours), rarely require complex reconstruction,

tracheotomy, or gastrostromy, and have shorter hospital LOS, less acute morbidity and therefore

less hospitalrelated costs. Although the complexities of surgical versus non-surgical treatment of

oropharyngeal cancer exceed the scope of this paper, Moore et al. 22 have shown that transoral

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surgical treatment of oropharyngeal cancer with directed adjuvant treatment based on pathology

represents a cost savings when compared to non-surgical approaches with chemoradiation.

Therefore, for hospitals that own the da Vinci robot, the surgical treatment of oropharyngeal

cancer with TORS may the least expensive treatment option.

Dysphagia is one of the primary determinants of quality of life (QOL) and has been shown to

be associated with depression after treatment of head and neck cancer.23,24 Dysphagia may result

from local tissue destruction from the primary tumor, loss of normal tissue from surgery and

scarring, and the long-term neuromuscular dysfunction sustained from radiation and

chemotherapy. The cumulative dose and volume of radiation delivered to the pharynx is

predictive of long-term swallow function and QOL.25-27 TORS offers a minimally invasive

approach to remove tumors of the oropharynx that allows for the tailored use of radiation and

chemotherapy, as well as a lower dose of radiation in the postoperative setting.28 Although our

data is limited to the immediate post-operative setting, we found a very low gastrostomy tube

rate compared to open surgical approaches which supports the functional advantages of this

surgical approach. While gastrostomy tube placement is only a rough surrogate measure for

overall swallow function, other studies have demonstrated excellent long-term swallow function

after TORS with directed adjuvant therapy29-31 with superior function compared to that observed

with non-operative treatment.32 This is likely the result of reduced tissue toxicity when radiation

and chemotherapy are delivered in the adjuvant setting, which favorably impacts long-term

swallow function.

There are several limitations to the use of hospital discharge data that may influence our

findings. The NIS database provides no follow-up data beyond the index admission and is

limited to a 30-day postoperative window, and contains no information on stage of disease,

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grade, subtype, HPV status, or survival. Thus, analysis of long-term outcomes is not possible

from the available data. The NIS database does not contain information regarding readmission,

previous surgical procedures or prior chemotherapy, which could potentially affect results with

regard to the extent of surgery, length of hospital stay, or perioperative morbidity. There may be

differences in the type of patient or disease that are not adequately captured, which is particularly

important for TORS as patient selection is key in the use of this approach, and there are likely

differences in tumor stage and characteristics in patients selected for TORS that cannot measured

using administrative data. Additionally, information regarding the use of adjuvant therapy or

long-term complications following TORS or non-TORS procedures is not available from this

inpatient database. While comorbidity scores were used for risk adjustment, the ability to

adequately control for case mix is limited when discharge diagnoses from administrative

databases are used. Postoperative complications may not be apparent at the time of discharge,

and as a result the incidence of complications may be underreported. Another potential limitation

is that the cost analysis was based on hospital-related charges, adjusted for institutional

expenseto-revenue ratios, and did not include physician-related costs, as these data are not

contained in the NIS database.

Nevertheless, the data presented demonstrate that the adoption of TORS as a surgical

approach for oropharynx cancer appears to be a valid option given its low immediate

complication rates during the early years of its adoption, and is associated with significantly

reduced length of hospitalization and hospital-related costs. These data suggest that TORS,

when feasible, may be preferable to traditional surgical approaches for oropharynx cancers. The

cost savings associated with TORS is particularly relevant in an era of increasing scrutiny for

cost-effective treatment approaches. While this analysis cannot comment on the oncologic

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outcomes of the patients analyzed, it is reassuring that various institutional

series have reported comparable if not favorable oncologic outcomes when

31,33,34
treatments. compared to non-surgical

Two prospective randomized controlled trials (Radiation Therapy Oncology

Group 1221 and Eastern Cooperative Oncology Group 3311) will soon be

initiated and further define the role of TORS in the treatment of

Conclusions oropharyngeal cancer.

National data demonstrates that TORS is associated with a lower

incidence of perioperative gastrostomy and tracheostomy tube placement

with significantly decreased length of hospitalization and hospital-related

costs compared to other surgical techniques. TORS appears to be a safer

and more generalizable surgical technique for oropharyngeal cancer

treatment. Further investigation into the use and adoption of TORS in the

multidisciplinary management of head and neck cancer is warranted.

Page 14 of 22

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robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc. 2012
Mar;87(3):219-25.

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oropharyngeal cancer. Otolaryngol Clin North Am. 2012 Aug;45(4):823-

44.
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Table 1. Demographic characteristics.

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All Patients Non-TORS TORS P value
(N=9,601) (N=9,485) (N=116)
Age Group 0.6890

≤40 years 3.9% 4.0% 0%

40-64 years 62.5% 62.5% 61.0%

65-80 years 29.9% 29.8% 39.0%

>80 years 3.7% 3.7% 0%

Race 0.1080

White 65.7% 66.1% 28.6%

Black 5.5% 5.6% 0%

Hispanic 3.6% 3.7% 0%

Asian or Pacific Islander 1.8% 1.9% 0%

Native American 0.3% 0.3% 0%

Other 2.3% 2.3% 0%

Unknown 20.8% 20.1% 71.4%

Sex 0.5857

Male 75.4% 75.4% 71.8%

Female 24.6% 24.6% 28.2%

Payor <0.0001

Private 49.8% 50.0% 33.1%

Medicare 32.6% 32.6% 33.6%

Medicaid 10.5% 10.6% *

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Self-pay/Other 7.1% 6.8% 28.5%

Nature of Admission 0.5256

Elective 85.7% 85.5% 100%

Emergency/Urgent 14.3% 14.5% 0%

Comorbidity 0.1681

0 67.0% 67.2% 57.1%

1 22.9% 22.7% 33.3%

2 6.3% 6.4% *

≥3 3.8% 3.7% *

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Procedure Severity 0.7129
Minor 72.6% 72.6% 76.0%
Major 27.4% 27.4% 24.0%
Procedure
Excision/destruction 31.5% 30.9% 80.9% 0.0005
Tonsillectomy 20.7% 20.0% 76.3% <0.0001
Partial glossectomy 33.1% 33.0% 34.4% 0.8798
Total glossectomy 6.5% 6.5% 0% 0.6492
Pharyngectomy 13.1% 12.9% 24.0% 0.1089
Maxillectomy 0% 0% 0% ---
Mandibulectomy 8.2% 8.3% 0% 0.6306
Partial laryngectomy 1.1% 1.2% 0% 0.8287 Laryngectomy 4.7% 4.8% 0% 0.6947
Neck dissection 74.9% 74.8% 80.5% 0.6097
Pedicled or free flap reconstruction 10.6% 10.8% 0% 0.5770
Prior radiation 0.6360
No 92.8% 92.7% 100%
Yes 7.2% 7.3% 0%
Hospital Bedsize <0.0001
Small 12.1% 11.4% 71.4%
Medium 19.6% 19.7% 10.1%
Large 68.3% 68.9% 18.5%
Hospital Teaching Status 0.1121
Non-teaching hospital 19.5% 19.7% *
Teaching hospital 80.5% 80.3% 95.8%
Hospital Ownership/Control 0.1940
Government, nonfederal 28.0% 27.5% 71,4%
Private, nonprofit 64.9% 65.3% 28.6%
Private, for profit 7.1% 7.2% 0%
Hospital location 0.7291
Rural 4.1% 4.1% 0% Urban 95.9% 95.9% 100%
Postoperative complications
Acute cardiac event 7.1% 7.2% 0% 0.6429

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 The Laryngoscope
Page 20 of
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*fewer than 11 observations

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 The Laryngoscope
Acute pulmonary edema/failure 3.1% 3.1% 0% 0.7469
Acute cerebrovascular event 0.8% 0.8% 0% 0.8443
Acute renal failure 1.5% 1.5% 0% 0.8012
Acute hepatic failure 0.1% 0.1% 0% 0.9030
Pneumonia 5.1% 5.2% 0% 0.6911
Sepsis 1.3% 1.3% 0% 0.8184
Urinary tract infection 1.6% 1.6% 0% 0.7965
Surgical complications 10.0% 9.9% 14.4% 0.9816
Dysphagia 9.3% 8.7% 9.4% 0.9792
Gastrostomy tube 21.0% 19.4% 0% 0.4110
Tracheostomy 30.1% 36.1% 0% 0.3057
Disposition 0.4777
Routine 66.0% 65.6% 100%
Short-term hospital care 0.6% 0.6% 0%
Other facility 7.7% 7.8% 0%
Home health care 24.6% 24.9% 0%
AMA 0.2% 0.2% 0%
Died in hospital 0.9% 0.9% 0%

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Table 2. Multivariate logistic regression analysis of variables associated with risk of postoperative
complications.
Variable Odds Ratio 95% CI P value
Postoperative surgical complications Major
procedure 3.38 2.31-4.95 <0.001
Pedicled or free flap reconstruction 1.65 1.08-2.51 0.019
Comorbidity score ≥3 2.24 1.13-4.46 0.021
Age 40-64 years 0.36 0.18-0.71 0.003
Age 65-79 years 0.36 0.16-0.81 0.014

Acute medical complications

Urgent/emergent admission 1.57 1.02-2.40 0.039
Pedicled or free flap reconstruction 1.89 1.28-2.79 0.001
Medicaid 2.04 1.33-3.12 0.001
Comorbidity score 1 1.67 1.15-2.42 0.007
Comorbidity score 2 5.25 3.47-7.95 <0.001
Comorbidity score ≥3 9.27 5.63-15.27 <0.001
Page 22 of 22

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 The Laryngoscope
Table 3. Generalized linear regression analysis of length of stay and hospital costs.
Variable Estimate 95% CI P value Mean

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 The Laryngoscope
Length of stay (days)
Intercept 0.9819 0.5508-1.4130 <0.001 5.8
Urgent/emergent admission 0.2267 0.0748-0.3785 0.004 1.4
Pedicled or free flap reconstruction 0.4833 0.3493-0.6175 <0.001 3.5
Major procedure 0.6645 0.5522-0.7768 <0.001 4.6
Medicare 0.2228 0.0545-0.3911 0.010 1.4
Medicaid 0.3537 0.1908-0.5166 <0.001 2.4
Comorbidity score 1 0.1280 0.0207-0.2352 0.019 0.8
Comorbidity score 2 0.4173 0.1907-0.6439 <0.001 2.9
Comorbidity score ≥3 0.5324 0.2621-0.8027 <0.001 4.0
Black race 0.2005 0.0346-0.3665 0.018 1.3
Teaching hospital 0.2243 0.0677-0.3809 0.005 1.2
TORS -0.2902 -0.4712- -0.1091 0.002 -1.5

Hospital costs (2012 USD)

Intercept 9.3977 8.9574-9.8380 <0.001 $20,547
Age 40-64 years -0.2181 -0.3972- -0.0390 0.017 -$4,613
Pedicled or free flap reconstruction 0.5200 0.3902-0.6498 <0.001 $13,251
Major procedure 0.5731 0.4731-0.6731 <0.001 $13,647
Medicaid 0.3101 0.1575-0.4628 <0.001 $7,227
Comorbidity score 1 0.1030 0.0090-0.1970 0.032 $2,178
Comorbidity score 2 0.3480 0.1579-0.5380 <0.001 $8,363
Comorbidity score ≥3 0.5546 0.2217-0.8876 0.001 $14,915
Teaching hospital 0.3112 0.1499-0.4725 <0.001 $5,847
TORS -0.2330 -0.3854- -0.0807 0.003 -$4,285

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Variable ICD-9 Code

DIAGNOSIS CODES
Neoplasms
Oropharyngeal neoplasm (malignant) 141.0, 141.5, 141.6, 141.8, 145.3, 145.4,
146.0, 146.1, 146.2, 146.3, 146.6, 146.7,
146.8, 146.9, 149.0, 149.1

PROCEDURE CODES
Excision/destruction of lesion 25.1, 27.72, 27.79, 28.5, 28.91, 29.39
Tonsillectomy 28.2
Partial glossectomy 25.2
Total glossectomy 25.3, 25.4
Pharyngectomy 29.33
Mandibulectomy 76.31, 76.41, 76.42
Maxillectomy 27.32
Partial laryngectomy 30.1, 30.29
Total laryngectomy/laryngopharyngectomy 30.3, 30.4

Non-site specific procedures

Neck dissection 40.40, 40.41, 40.42, 40.3
Pedicled or free flap reconstruction 86.7, 86.70, 86.71, 86.72, 86.73, 86.74,
86.75, 86.8, 86.89
Robotic-assisted procedure 17.41, 17.44, 17.49
 SupplementalTable 1. ICD-9 diagnosis and procedure codes for
included cases.
 The American Laryngological, Rhinological and Otological Society, Inc.

Variable ICD-9 Code

Surgical complications Shock
998.0
Hemorrhage, hematoma, or seroma 998.1, 998.11, 998.12, 998.13
Accidental perforation or laceration of 998.2
blood vessel, nerve, or organ
Wound dehiscence 998.3, 998.30, 998.31, 998.32, 998.33
Foreign body 998.4
Postoperative infection 998.5, 998.51, 998.59
Postoperative fistula 998.6
Non-healing surgical wound 998.83
998.8, 998.81, 998.89, 998.9
Other unspecified procedural complications

Medical complications Acute

cardiac event 410.0-410.9, 411.1, 411.8, 415.0, 420.0,
420.9, 421.0, 421.1, 421.9, 422.0, 422.9,
427.0-427.5, 428.0-428.9
Acute pulmonary edema/failure 518.4, 518.81, 518.82, 518.84
Acute cerebrovascular event 997.00, 997.01, 997.02, 997.09, , 434.91,
430, 431, 432.0, 432.1, 432.9, 434.11
Acute renal failure 584.5-584.9
Acute hepatic failure 570
Pneumonia 480,480.0, 480.1, 480.2, 480.3, 480.8,
480.9, 481, 482, 482.0, 482.1, 482.3,
482.30, 482.31, 482.32, 482.39, 482.40,
482.41, 482.42, 482.49, 482.8, 482.81,
482,82, 482.83, 482.84, 482.89, 482.9,
483, 483.1, 483.8, 484, 484.1, 484.3,
484.5, 484.6, 484.7, 484.8, 485, 487.0,
V12.61, 507.0, 514, 518.4, 518.5, 516,
516.8, 997.31
Sepsis 995.9, 038.0-038.4, 999.3
Urinary tract infection 599.0, 996.64, 996.31, V13.02
SupplementalTable 2. ICD-9 diagnosis codes for
medical and surgical complications.

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