Preoperative Gastroesophageal Reflux Disorder Is Associated With Increased Morbidity in Patients Undergoing Abdominal Surgery.

BACKGROUND: In North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. METHOD: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP-targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP-targeted procedure groups, and open versus laparoscopic surgery. RESULTS: Of 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P < 0.001). CONCLUSIONS: Preoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

Congestive Heart Failure and Noncardiac Operations: Risk of Serious Morbidity, Readmission, Reoperation, and Mortality.

BACKGROUND: Congestive heart failure (CHF) predicts surgical morbidity and mortality. However, few studies evaluate CHF's impact on noncardiac operations. Because of CHFs serious threat to health and survival, surgeons must understand risks CHF poses to patients undergoing a diverse array of operations. STUDY DESIGN: We used 2009 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Files to estimate the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications associated with preoperative diagnosis of CHF. Multivariable logistic regression analysis provided odds ratios (OR) and 95% confidence intervals (CI) for outcomes in 34 ACS NSQIP procedure groups, controlling for age, sex, race, emergency surgery status, American Society of Anesthesiologists Classification, body mass index, and selected laboratory values. RESULTS: Unadjusted ORs indicate adverse effects of CHF on surgical outcomes for most procedures considered. When adjusted for age and other confounders, CHF persists with adverse effects on most outcomes, including serious morbidity (OR 1.52, 95% CI, 1.44 to 1.61; p < 0.001); reoperation (OR 1.29, 95% CI, 1.17 to 1.42; p < 0.001); readmission (OR 1.39, 95% CI, 1.29 to 1.50; p < 0.001); and 30-day mortality (OR 1.96, 95% CI 1.80 to 2.13; p < 0.001). The impact of CHF on morbidity and mortality substantially affected those undergoing carotid endarterectomy and lower extremity endovascular repair. Cardiac arrest, mortality, unplanned intubation, and ventilator > 48 hours were complications most affected by CHF. CONCLUSIONS: Congestive heart failure strongly predicts serious morbidity, unplanned reoperation, readmission, and surgical mortality for noncardiac operations. Surgeons must pay particular attention to recognizing CHF and optimizing perioperative management when considering surgery.

Thirty-day postoperative death rate at an academic medical center.

OBJECTIVE: To improve understanding of perioperative deaths at an academic medical center. SUMMARY BACKGROUND DATA: Because published data have typically focused on specific patient populations, diagnoses, or procedures, there are few data regarding surgical deaths and complications in institutional or regional studies. Specifically, surgical adverse events and errors are generally not studied comprehensively. This limits the overall understanding of complications and deaths. METHODS: Data from all operations performed in the main operating suite of the University of Virginia Health Sciences Center from January 1 to June 30, 1999, were compared with state death records to gain a dataset of patients dying within 30 days of surgery. All clinical records from patients who died were screened for adverse events and subsequently reviewed by three surgeons who identified adverse events and errors and performed comparisons with survivors. RESULTS: One hundred nineteen deaths followed 7,379 operations performed on 6,296 patients, yielding a patient death rate of 1.9%. Patients dying within 30 days of surgery were older and had higher American Society of Anesthesiologists scores. Of 119 deaths, 86 (72.3%) were attributable to the patient's primary disease. Twenty-three patient deaths (19.3% of all deaths, 0.37% of all patients) could not be attributed to the patient's primary disease and thus were suspicious for an adverse event (AE) as the cause of the death. Of the 23 deaths suspicious for AE, 15 (12.6% of all deaths, and 65.2% of AE deaths) followed an error in care and thus were classified as potentially preventable, affecting 0.24% of the study population. CONCLUSIONS: Overall, the 30-day postoperative death rate was low in the total surgical population at an academic medical center. Errors and AEs were associated with 12.6% and 19.3% of deaths, respectively. Retrospective review inadequately characterized the nature of AEs and failed to determine causality. Prospective audits of outcomes will enhance our understanding of surgical AEs.