title: Morbidity related to concomitant adhesions in abdominal surgery.
abstract: BACKGROUND
  We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery.
  
  
  METHODS
  Using the American College of Surgeons National Surgical Quality Improvement Program data, we created a uniform data set of all gastrectomies, enterectomies, hepatectomies, and pancreatectomies performed between 2007 and 2012 at our tertiary academic center. American College of Surgeons National Surgical Quality Improvement Program data were supplemented with additional variables (e.g., procedure complexity-relative value unit). The presence of CAs was detected using the Current Procedural Terminology codes for adhesiolysis (44005, 44180, 50715, 58660, and 58740). Cases where adhesiolysis was the primary procedure (e.g., bowel obstruction) were excluded. Multivariable logistic regression analyses were performed to assess the independent effect of CAs on 30-d morbidity and mortality, while controlling for age, comorbidities and the type/complexity/approach/emergency nature of surgery.
  
  
  RESULTS
  Adhesiolysis was performed in 875 of 5940 operations (14.7%). Operations with CAs were longer (median duration 3.2 versus 2.7 h, P < 0.001), more complex (median relative value unit 37.5 versus 33.4, P < 0.001), performed in sicker patients (American Society for Anesthesiologists class ≥3 in 49.9% versus 41.2%, P < 0.001), and harbored higher risk for inadvertent enterotomies (3.0% versus 0.9%, P < 0.001). In multivariable analyses, CAs independently predicted higher morbidity (adjusted odds ratio [OR], 1.35; 95% confidence interval, 1.13-1.61, P = 0.001). Specifically, CAs independently correlated with superficial and deep or organ-space surgical site infections (OR = 1.42 (1.02-1.86), P = 0.036; OR = 1.47 (1.09-1.99), P = 0.013, respectively), and prolonged postoperative hospital stay (≥7 d, OR = 1.34 [1.11-1.61], P = 0.002). No difference in 30-d mortality was detected.
  
  
  CONCLUSIONS
  CAs significantly increase morbidity in abdominal surgery. Risk adjusting for the presence of adhesions is crucial in any efforts aimed at quality assessment and/or benchmarking of abdominal surgery.
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts; Department of Surgery, MedStar Washington Hospital Center, Washington, District of Columbia.
authors.forename: Michael N
authors.initials: MN
authors.lastname: Mavros
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
authors.forename: Andreas
authors.initials: A
authors.lastname: Larentzakis
authors.affiliation: Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts. Electronic address: hkaafarani@mgh.harvard.edu.
authors.forename: Haytham M A
authors.initials: HM
authors.lastname: Kaafarani
mesh_terms: D000005:Abdomen / Q000473:pathology / Q000601:surgery*; D000368:Aged; D019985:Benchmarking; D015897:Comorbidity; D013505:Digestive System Surgical Procedures / Q000009:adverse effects* / Q000592:standards; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000592:standards; D006498:Hepatectomy / Q000009:adverse effects / Q000592:standards; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D015999:Multivariate Analysis; D010180:Pancreatectomy / Q000009:adverse effects / Q000592:standards; D010537:Peritoneum / Q000473:pathology / Q000601:surgery; D058996:Quality Improvement; D020379:Risk Adjustment; D012307:Risk Factors; D000267:Tissue Adhesions / Q000453:epidemiology* / Q000473:pathology
keywords: Adhesiolysis; Adhesions; General surgery; Postoperative complications