Complications following General Surgery

Patients discharged from the hospital are at risk in the immediate postdischarge (PD) period. In the 6 months following an index hospitalization, nearly 1 in 7 surgical patients who were accounted for in the Medicare fee-for-service program experienced adverse events that required readmission to the hospital. As a means for reduction in healthcare costs, the Patient Protection and Affordable Care Act has targeted the reduction of avoidable hospital readmissions. Beginning in 2013, hospitals with high risk-standardized readmission rates will be subject to a Medicare reimbursement penalty.

Noting that data on the burden of PD complications and their association with more serious adverse events among surgical patients are essential to the development of appropriate quality improvement interventions, researchers recently conducted an analysis of risk factors for PD complications. The retrospective cohort study was designed to identify procedure-specific types, rates, and risk factors for PD complications that occurred within 30 days by following 21 groups of inpatient general surgery procedures. Study results were reported in Archives of Surgery [2012;147(11):1000-1007].

The researchers utilized information from the American College of Surgeons National Surgical Quality Improvement Program 2005-2010 Participant Use Data Files. The files provided data on 551,510 adult patients who underwent 1 of 21 general surgery procedures in an inpatient setting. The primary outcome measures were PD complications, reoperation, and mortality.

Mean age of the study sample was 54.6 years, 60.5% were female, 74.4% were white, 95.9% were admitted from home, and 92.9% were of independent functional status prior to surgery. Colectomy, bariatric procedures, and appendectomy were the most common procedures in the study (17.1%, 11.3%, and 10.8%, respectively).

The overall complication rate within 30 days was 16.7% and the overall rate of PD complications was 6.9%. Nearly 42% of postoperative complications occurred PD.

There was variation in the rate of PD complications among the 21 procedures included in the study, ranging from 1 in 7 proctectomy patients to 1 in 67 endocrine patients. Proctectomy, enteric fistula repair, and pancreatic operations had the highest rates of PD complications. Breast surgery, bariatric procedures, and ventral hernia repair had the highest proportions of complications that occurred in the postdischarge period.

Analyses of the relative contribution of each procedure to the overall occurrence of PD complications found that the top 10 procedures accounted for 82.5% of PD complications. In decreasing order of relative contribution, the 10 procedures were (1) colectomy (26.2%), (2) small-bowel procedures (13.3%), (3) bariatric procedures (6.6%), (4) ventral hernia repair (6.6%), (5) appendectomy (6.4%), (6) cholecystectomy (5.9%), (7) pancreatic procedures (4.9%), (8) exploratory laparotomy (4.7%), (9) breast procedures (4.3%), and (10) gastrectomy (3.6%).

Overall, 25%, 50%, and 75% of PD complications occurred within 5, 9, and 14 days. Ten complications accounted for 90.9% of all PD complications: (1) surgical site infections (31.1%); (2) organ space infection (13.9%); (3) severe sepsis (11.4%); (4) urinary tract infection (9.7%); (5) deep surgical site infection (7.3%); (6) wound dehiscence (4.7%); (7) deep venous thrombosis (4.0%); (8) pneumonia (3.7%); (9) septic shock (2.7%); and (10) pulmonary embolism (2.4%).

Patients who had an inpatient complication were more likely to have a PD complication (12.5% vs 6.2% without an inpatient complication; P<.001). Patients with a postdischarge complication had higher rates of reoperation compared with those without a PD complication (17.9% vs 4.6%; P<.001); patients with a PD complication also had higher rates of death (6.9% vs 2.0%; P<.001) within 30 days after surgery.

Patients with a PD complication who also had an inpatient complication had the highest rates of reoperation and death (33.7% and 24.7%, respectively; P<.001 for both comparisons).

Following adjustment for >20 risk factors, multivariate analysis revealed that factors associated with an occurrence of a PD complication included procedure type, prolonged operation time, inpatient complication, American Society of Anesthesiologists class >3, and patient steroid use.