Increased Mortality After Surgical Complications
Every year, more than 230 million major surgeries occur [1]. Perioperative complications can be common, with major complications potentially occurring in as many as 20% of surgeries according to some data, irrespective of individual patient profiles and surgical discipline [2]. Not only can complications directly cause death during operations, but they are also associated with a higher rate of death after them [1]. Accordingly, perioperative complications are a major indicator of postoperative mortality. Despite the general acceptance of this fact among the medical community, the extent to which surgical complications affect postoperative mortality remains a point of ongoing investigation.
Traditionally, healthcare systems, practitioners, and hospitals have relied on 30-day mortality as a measure of success following operations [2]. The association between surgical complications and 30-day mortality is well-documented. In 2005, Khuri and colleagues found that surgical complications were the “most important determinant of decreased postoperative survival” in the 30 days following an operation, based on data from a cohort of veteran patients who underwent major surgery [3]. The researchers focused on the 22 types of complications listed in the National Surgical Quality Improvement Program (NSQIP) [3]. These complications predicted mortality more accurately than intraoperative factors and preoperative patient risk, demonstrating the strength of the association [3].
Recent research indicates that a focus on only the first 30 days following surgery may fail to capture the strength of the connection between surgical complications and increased mortality [2]. A study conducted by Fowler et al. indicated that perioperative complications “cast a ‘long shadow’ of mortality beyond the 30-day time frame” [2]. Compared to patients who did not suffer complications, those who did experienced a nearly doubled risk of death in the 12-month postoperative period [2]. Indeed, more than 80% of the deaths among patients with complications occurred outside of the 30-day time frame, further demonstrating the limitations of this measure [2].
In response to similar evidence, researchers have proposed expanding the observation period to the first 60 or even 90 days following surgery [2]. While analyzing the data of 40,474 cancer surgery patients, Damhuis and colleagues found that the internationally recommended 30-day standard did capture most surgery-related deaths, contrary to the Fowler study [4]. However, a 90-day observation period allowed the researchers to identify more deaths, which may have been indirectly linked to surgery [4]. Consequently, the 90-day observation period, while not necessarily more informative for surgeons, can help patients make more informed decisions and, as such, is valuable.
On the other hand, Hirji et al. published a study more in line with Fowler’s discoveries [5]. Their experiment centered on Medicare beneficiaries undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) [5]. They considered 90-day mortality more “robustly informative” about patients’ first-year outcomes than 30-day mortality [5]. Additionally, it was more reliable as a measurement of hospital performance [5].
All in all, it appears undeniable that complications increase postoperative mortality. By widening the postsurgical observation period, medical providers will have a more informed look into the link between surgical complications and postoperative success.
References
[1] R. M. Pearse et al., “Mortality after surgery in Europe: a 7 day cohort study,” The Lancet, vol. 380, no. 9847, p. 1059-1065, September 2012. [Online]. Available: DOI: 10.1016/S0140-6736(12)61148-9.
[2] O. Stundner and P. S. Myles, “The ‘long shadow’ of perioperative complications: association with increased risk of death up to 1 year after surgery,” British Journal of Anaesthesia, vol. 35, no. 4, p. 410-417, April 2022. [Online]. Available: DOI: 10.1016/j.bja.2022.03.014.
[3] S. F. Khuri et al., “Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications,” Annals of Surgery, vol. 242, no. 3, p. 326-343, September 2005. [Online]. Available: DOI: 10.1097/01.sla.0000179621.33268.83.
[4] R. Damhuis et al., “Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types,” British Journal of Surgery, vol. 99, no. 8, p. 1149-1154, August 2012. [Online]. Available: DOI: 10.1002/bjs.8813.
[5] S. Hirji et al., “Utility of 90-Day Mortality vs 30-Day Mortality as a Quality Metric for Transcatheter and Surgical Aortic Valve Replacement Outcomes,” JAMA Cardiology, vol. 5, no. 2, p. 156-165, December 2019. [Online]. Available: DOI: 10.1001/jamacardio.2019.4657.