Michael N Mavros1, George C Velmahos2, Jarone Lee2, Andreas Larentzakis2, Haytham M A Kaafarani3. 1. 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. 2. Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts. 3. 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.
Abstract
BACKGROUND: We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery. MATERIALS AND 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.
BACKGROUND: We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery. MATERIALS AND 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.