Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in the Operating Room.
We sought to assess the impact of intraoperative adverse events (iAEs) on 30-day postoperative mortality, 30-day postoperative morbidity, and postoperative length of stay (LOS) among patients undergoing abdominal surgery. We hypothesized that iAEs would be associated with significant increases in each outcome.



The relationship between iAEs and postoperative clinical outcomes remains largely unknown.



The 2007 to 2012 institutional ACS-NSQIP and administrative databases for abdominal surgeries were matched then screened for iAEs using the Agency for Healthcare Research and Quality's 15 Patient Safety Indicator, "Accidental Puncture/Laceration". Each chart flagged during the initial screen was then manually reviewed to confirm whether an iAE occurred. Univariate then multivariable logistic regression models were constructed to assess the independent impact of iAEs on 30-day mortality, 30-day morbidity, and prolonged (≥7 days) postoperative LOS, controlling for preoperative/intraoperative variables (eg, age, comorbidities, ASA, wound classification), procedure type (eg, laparoscopic vs open, intestinal, foregut, hepatopancreaticobiliary vs abdominal wall procedure), and complexity (eg, adhesions; relative value units). Propensity score analyses were conducted with each iAE patient matched with 5 non-iAE patients. Sensitivity analyses were performed.



A total of 9288 cases were included; 183 had iAEs. Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intraoperatively (92%). In multivariable analyses, iAEs were independently associated with increased 30-day mortality [OR = 3.19, 95% confidence interval (CI) 1.52-6.71, P = 0.002], 30-day morbidity (OR = 2.68, 95% CI 1.89-3.81, P < 0.001), and prolonged postoperative LOS (OR = 1.85, 95% CI 1.27-2.70, P = 0.001). Postoperative complications associated with iAEs included deep/organ-space surgical site infection (OR = 1.94, 95% CI 1.20-3.14), P = 0.007), sepsis (OR = 2.14, 95% CI 1.32-3.47, P = 0.002), pneumonia (OR = 2.18, 95% CI 1.11-4.26, P = 0.023), and failure to wean ventilator (OR = 3.88, 95% CI 2.17-6.95, P < 0.001). Propensity score matching confirmed these findings, as did multiple sensitivity analyses.



iAEs are independently associated with substantial increases in postoperative mortality, morbidity, and prolonged LOS. Quality improvement efforts should focus on iAE prevention, mitigation of harm after iAEs occur, and risk/severity-adjusted iAE tracking and benchmarking.
*Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA †Department of Surgery, MedStar Washington Hospital Center, Washington, DC ‡Department of Surgery, Oregon Health & Science University, Portland, OR §Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA.
Jordan D
JD
Bohnen
Michael N
MN
Mavros
Elie P
EP
Ramly
Yuchiao
Y
Chang
D Dante
DD
Yeh
Jarone
J
Lee
Marc
M
de Moya
David R
DR
King
Peter J
PJ
Fagenholz
Kathryn
K
Butler
George C
GC
Velmahos
Haytham M A
HMA
Kaafarani
D000005:Abdomen / Q000601:surgery*; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D019985:Benchmarking; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007430:Intraoperative Care / Q000592:standards; D007431:Intraoperative Complications / Q000145:classification / Q000517:prevention & control; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009873:Operating Rooms; D011183:Postoperative Complications / Q000453:epidemiology*; D057216:Propensity Score; D012189:Retrospective Studies