title: Reoperative surgery: a critical risk factor for complications inadequately captured by operative reporting and coding of lysis of adhesions.
abstract: BACKGROUND
  Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of "lysis of adhesions."
  
  
  METHODS
  Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ).
  
  
  RESULTS
  In the multispecialty cohort, the non-risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%).
  
  
  CONCLUSIONS
  Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly under reports reoperative surgery and, therefore, is not an adequate surrogate for this important risk factor.
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX. Electronic address: taaloia@mdanderson.org.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Amanda
authors.initials: A
authors.lastname: Cooper
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Weiming
authors.initials: W
authors.lastname: Shi
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D059019:Clinical Coding; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012086:Reoperation / Q000009:adverse effects / Q000706:statistics & numerical data*; D020379:Risk Adjustment / Q000379:methods*; D012307:Risk Factors; D000267:Tissue Adhesions / Q000209:etiology / Q000601:surgery*; D014481:United States; D055815:Young Adult