Associations of postoperative mortality with the time of day, week and year

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study

BACKGROUND

With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.

METHODS

We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons' daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.

RESULTS

Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (OR_adj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (OR_adj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years' practice or surgeons with a preindex volume <700 cases.

CONCLUSIONS

For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.

The influence of summer closure on serious postoperative complications in bariatric surgery

Introduction

Bariatric surgery is an effective method of treating obesity, with gastric bypass and sleeve gastrectomy being the most common techniques used worldwide. Despite the technical challenges in these methods, little is known about the effects of summer closure on the incidence of serious postoperative complications in surgeries performed shortly after summer vacation. This has therefore been studied in our large cohort.

Materials and methods

A retrospective cohort study based on data from the Scandinavian Obesity Surgery Registry was conducted. Patients who underwent a primary gastric bypass or sleeve gastrectomy operation between 2010 and 2019 were included. The rate of serious complications within 30 days after surgery for patients who underwent surgery the first month after summer closure was compared to those who underwent surgery during the rest of the year using the χ² test and adjusted logistic regression.

Results

The study included 42,404 patients, 36,094 of whom underwent gastric bypass and 6310 of whom received sleeve gastrectomy. Summer closure was associated with an increased risk for serious postoperative complications in gastric bypass surgery (adjusted odds ratio (adj-OR) = 1.17; 95% confidence interval (CI): 1.01–1.36). No statistically significant association was seen for sleeve gastrectomy (adj-OR = 1.17; 95% CI: 0.72–1.91), nor in overall complication rate.

Conclusions

Summer closure increases the risk of serious postoperative complications in gastric bypass surgery. No statistically significant association was found for sleeve gastrectomy surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02566-w.

Analysis of 30 anaesthesia-related deaths in Germany between 2006 and 2015: An analysis of a closed claims database

BACKGROUND

Anaesthesiology is one of the safest fields in medicine today in relation to mortality. Deaths directly because of anaesthesia have fortunately now become rare exceptions. Nevertheless, important findings can still be drawn from the rare deaths that still occur.

OBJECTIVE

The aim of this study was to identify and analyse the causes of deaths related to anaesthesia alone over a 10-year period.

DESIGN

Retrospective structured analysis of a database of medical liability claims.

SETTING

Hospitals at all levels of care in Germany.

PATIENTS

The database of a large insurance broker included data for 81 413 completed liability claims over the 10-year period from 2006 to 2015. Among 1914 cases associated with anaesthetic procedures, 56 deaths were identified. Of these, 30 clearly involved anaesthesia (Edwards category 1) and were included in the evaluation.

INTERVENTIONS

None (retrospective database analysis).

MAIN OUTCOME MEASURES

Causes of anaesthesia-related death identified from medical records, court records, expert opinions and autopsy reports.

RESULTS

The 30 deaths were analysed in detail at the case and document level. They included high proportions of 'potentially avoidable' deaths, at 86.6%, and what are termed 'never events', at 66.7%. Problems with the airway were the cause in 40% and problems with correct monitoring in 20%. In addition, communication problems were identified as a 'human factor' in 50% of the cases.

CONCLUSION

The majority of the anaesthesia-related deaths investigated could very probably have been avoided with simple anaesthesiological measures if routine guidelines had been followed and current standards observed. Actions to be taken are inferred from these results, and recommendations are made. In future, greater care must be taken to ensure that the level of safety already achieved in anaesthesiology can be maintained despite demographic developments and increasing economic pressures.

A model-based validation study of postoperative complications with considerations on operative timing

Background

Surgery is a highly technical procedure relying on high mental acuity and manual dexterity. The possibility that surgical outcomes and post-operative complications could be subject to influence by fatigue and/or circadian rhythms in surgeons has been investigated with inconsistent results.

Methods

We conducted a retrospective study to assess the significance of operative timing on classifying surgical complications using an interpretable machine learning approach. We trained various linear, generative as well as tree models on the surgical record data collected from a university-affiliated, tertiary teaching hospital in China by performing parameter tuning using grid search cross-validation for optimizing the F1 score.

Results

The results indicated that XGBoost was the best-performing model overall and its feature importance was shown to provide insight into possible timing-related associations with postoperative complications. We observed that the duration of surgery acted as the strongest indicator, and while surgery initiated at night (between 9 pm and 7 am) also ranked higher on the feature importance scale, it bore less significance than other factors such as the patient's age, gender, and type of surgery performed.

Conclusions

We showed that surgical records could be used to demonstrate that operative timing might affect the occurrence of postoperative complications, but only in a relatively mild way while potentially entangling with multiple factors.

The Weekday Effect on Morbidity of Lung Cancer Surgery: A Real-World Analysis

BACKGROUND

 Many authors have investigated the possible adverse effects among patients who underwent elective surgery on Friday when compared with patients operated earlier in the week. Nonetheless, the weekday effect is still a matter of debate. This study aimed at investigating the postoperative morbidity rates after lung cancer surgery and their relationship with the weekday the surgery took place.

MATERIALS AND METHODS

 We retrospectively reviewed the clinical records of patients who underwent elective thoracotomic lobectomies for lung cancer. Categorical data were analyzed using the chi-square test or Fisher's exact test. Association between predictors and binary outcomes while considering the weekday stratification was determined with Cochran-Mantel-Haenszel statistics. To characterize the typical Friday patient, a multiple logistic regression analysis was performed.

RESULTS

 A total of 817 patients (2015-2019) were identified. Complication rates divided by day of surgery were 164 (20.07%) for patients operated on Mondays, 182 (22.27%) on Tuesdays, 205 (25.09%) on Wednesdays, 172 (21.05%) on Thursdays, and 94 (11.51%) on Fridays. Crude morbidity rates by weekday were Monday 21.53%, Tuesday 20.51%, Wednesday 27.70%, Thursday 20.0%, and Friday 10.26%. No overall association between day of surgery and overall morbidity was found (ρ = 0.095). Median hospital length of stay was 5 days (range: 2-45 days), and there were no statistically significant differences between days. The Cochran-Mantel-Haenszel statistics showed no association between morbidity and the weekday.

CONCLUSION

 In patients undergoing elective lobectomies for lung cancer, the weekday of surgery was not statistically significantly associated with an increase in the risk of postoperative morbidity.

After-hours esophagectomy may pose additional risk to patients with esophageal cancer

Background

The increase in the incidence of esophageal cancers (ECs) combined with fewer surgeons working at large centers will increase the likelihood of surgery for ECs being performed during later hours. This study aimed to compare esophagectomies’ operative outcomes for EC performed at different surgical starting times.

Methods

This was a single-center, retrospective study. Risk-adjusted cumulative sum curve analysis and Cox regression analysis were used to identify the potential change-point of surgical starting times. The participants were then divided into 2 groups according to the change-point time. Propensity score matching was used to control confounding factors between the 2 groups. We compared the short- and long-term outcomes in both groups.

Results

A total of 702 patients who underwent potentially radical esophagectomy from 7 May 2014 to 31 December 2017 in our institute were included. The 3-year all-cause mortality showed a significant change-point at 16:42, with an increment from 56.5% to 76.9% (P=0.043). Esophagectomy that commenced between 17:00–18:59 was associated with significantly lower overall survival (OS) [multivariate hazard ratio (HR): 2.47; 95% confidence interval (CI): 1.25 to 4.90; P=0.010] and disease-free survival (DFS) (multivariate HR: 2.14; 95% CI: 1.08 to 4.21; P=0.028). The participants were allocated to the during-hours group and the after-hours group according to the change-point of 17:00. A total of 84 participants in the during-hours group were matched to 33 participants in the after-hours group. The median operative time was shorter in the after-hours group [309 (during-hours) vs. 239 (after-hours) minutes, P=0.014); the after-hours group had a greater incidence of respiratory complications (22.63% vs. 45.45%, P=0.023) and 90-day mortality (0 vs. 9.09%, P=0.021). The 5-year OS (P=0.042) and DFS (P=0.030) were significantly higher in the during-hours group.

Conclusions

Esophagectomies started during after-hours are correlated with poorer surgical outcomes. It is recommended to cancel selective esophagectomies due to commence after 17:00.

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study

Background

Surgery at night (incision time 17:00 to 07:00 hours) may lead to increased postoperative mortality and morbidity. Mechanisms explaining this association remain unclear.

Methods

We conducted a multicentre retrospective cohort study of adult patients undergoing non-cardiac surgery with general anaesthesia at two major, competing tertiary care hospital networks. In primary analysis, we imputed missing data and determined whether exposure to night surgery affects 30-day mortality using a mixed-effects model with individual anaesthesia and surgical providers as random effects. Secondary outcomes were 30-day morbidity and the mediating effect of blood transfusion rates and provider handovers on the effect of night surgery on outcomes. We further tested for effect modification by surgical setting.

Results

Among 350 235 participants in the primary imputed cohort, the mortality rate was 0.9% (n=2804/322 327) after day and 3.4% (n=940/27 908) after night surgery. Night surgery was associated with an increased risk of mortality (ORadj 1.26, 95% CI 1.15 to 1.38, p<0.001). In secondary analyses, night surgery was associated with increased morbidity (ORadj 1.41, 95% CI 1.33 to 1.48, p<0.001). The proportion of patients receiving intraoperative blood transfusion and anaesthesia handovers were higher during night-time, mediating 9.4% (95% CI 4.7% to 14.2%, p<0.001) of the effect of night surgery on 30-day mortality and 8.4% (95% CI 6.7% to 10.1%, p<0.001) of its effect on morbidity. The primary association was modified by the surgical setting (p-for-interaction<0.001), towards a greater effect in patients undergoing ambulatory/same-day surgery (ORadj 1.81, 95% CI 1.39 to 2.35) compared with inpatients (ORadj 1.17, 95% CI 1.02 to 1.34).

Conclusions

Night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was independent of case acuity and was mediated by potentially preventable factors: higher blood transfusion rates and more frequent provider handovers.

Two open whipples a day: Excessive or efficient

BACKGROUND

Demand for pancreatic surgery is rising, occasionally necessitating consecutive PDs to be performed by a single surgeon in the same workday. The safety of this practice is unknown.

METHODS

Institutional prospective ACS-NSQIP data were reviewed for PDs (2013-2017). Instances where a single surgeon performed two PDs in the same day were a PD pair (PD1, PD2) and compared with univariable analysis. Paired vs. unpaired-PD matched analyses were performed.

RESULTS

661 PDs (25-PD pairs) were performed. PD1 and PD2 revealed similar infectious (12% vs16%), pulmonary (8% vs8%), cardiovascular (12% vs4%), and aggregate (24% vs24%) morbidity (P>0.05). Pancreatic fistula (B + C 0%), delayed gastric emptying (4% vs12%), hospital stay (9.3 vs8.8 days), and 30-day mortality (4% vs4%) were similar (P > 0.05). Matched outcomes were similar except higher cardiovascular morbidity for paired vs. unpaired PD (7% vs0%; P = 0.015).

CONCLUSION

With proper patient selection, and in experienced hands at high-volume centers, two consecutive open PDs may be safely performed.

Surgical timing and presence of a vitreoretinal fellow on postoperative adverse events following pars plana vitrectomy

INTRODUCTION

To evaluate the adverse event rate following pars plana vitrectomy as a function of surgical start time and the presence of a vitreoretinal fellow.

METHODS

Single-institution retrospective cohort study of patients undergoing pars plana vitrectomy from 1 January 2016 to 31 December 2016 at Stanford University School of Medicine (Palo Alto, CA, USA). Records were reviewed for surgical start time, the presence of vitreoretinal fellow, and postoperative adverse events defined as any finding deviating from the expected postoperative course requiring observation or intervention.

RESULTS

A total of 310 pars plana vitrectomies were performed. There was no statistical difference in the rate of any adverse event when comparing cases starting after 16:01 (9/13, 69.2%) and after 12:01 (42/99, 42.4%) to a morning start time (69/198, 34.9%, adjusted p = 0.083). There was a statistically significant increase in the risk of postoperative vitreous hemorrhage with afternoon and evening cases as compared to morning cases (adjusted p = 0.021). In addition, there was no difference in any adverse event with a fellow present (93/244, 38.1%) compared to without (27/66, 40.9%, adjusted p = 0.163). There was a higher risk of postoperative hypotony when a fellow was involved (6.6% vs 0%, p = 0.028), though this difference disappeared after adjusting for confounders (adjusted p = 0.252). There was no difference in the length of surgery with and without a fellow (49 vs 54 min, respectively; p = 0.990).

DISCUSSION

Afternoon start time and the presence of a fellow were not independent risk factors for postoperative adverse events.