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surgery

Indications: - disease, trauma or deformity requiring physical manipulation (surgical procedure) Contraindications: - pregnancy not a contraindication - *general surgery as safe for pregnant women as it is for nonpregnant women [14] Epidemiology: - 1/3 of all surgeries performed in patients > 65 years of age Laboratory: - see preoperative laboratory testing Complications: 1) postoperative mortality - perioperative mortality correlates with functional status, independent of age - frailty is associated with excess risk for postoperative mortality after elective surgery [19] - one year mortality in community-living older adults (>= 65 years) in the U.S. is 7.4% for elective surgeries & 22.3% for non-elective surgeries - overall 1-year mortality is 13.4% - 1-year mortality is 6% for non frail elderly & 28% for frail elderly [29] - patients with dementia undergoing major surgery have high rates of complications & mortality & low probability of being discharged home [29] 2) surgical mortality tends to be lower at hospitals that perform more operations [2] 3) perioperative complications similar in hospitals that differ in perioperative mortality, suggesting 'failure to rescue' as a determinant of in-hospital mortality [4] 4) intraoperative hypotension is associated with excess 30 day mortality [17] - intraoperative hypertension is not associated with excess30 day mortality - lesser blood pressure variability is associated with excess 30 day mortality [17] 5) postsurgical sepsis: 2.3% - postsurgical septic shock 1.6% [5] 6) postsurgical pulmonary embolism: 0.3% 7) postsurgical myocardial infarction: 0.2% [5] - 18% of patients meet diagnostic criteria for myocardial injury after noncardiac surgery [21] - of these, 93% do not have ischemic symptoms [21] - levels of cardiac troponin T in serum after non-cardiac surgery predict 30-day mortality [21] 8) perioperative covert stroke & cognitive decline common in elderly [24] - elective surgery does not increase the rate of incident dementia over a 5 year period vs nonsurgical controls [30] 9) alcohol abuse before surgery increases risk of postoperative complications [6] 10) smoking cessation before surgery might lower risk for postoperative complications; benefit probably grows with longer duration of smoking cessation [7] 11) night surgery associated with increased risk of postoperative morbidity & mortality, due to potentially preventable factors, including: - higher blood transfusion rates, more frequent provider handovers [27] 12) previous night surgery not associated with increased rates of perioperative complications [28] 13) overall complication rates 2-4% [15] - ~11% of surgeons are responsible for ~25% of complications 14) also see intraoperative complication & postoperative complication Management: - also see preoperative evaluation & management, perioperative management, postoperative management & enhanced recovery after surgery - patients should shower or bath before surgery [20] - preoperative skin antisepsis with an alcohol-containing antiseptic agent. - surgical site should not be shaved [20] - if hair remove necessary, clip [23] - no evidence supports delay of showering > 48 hours after surgery reduces risk of surgical-site infection - triclosan-coated sutures for all surgery [20] - delay non-cardiac surgery if possible for at least 4-6 weeks after myocardial infarction [12,13] - lung protective ventilation may be of benefit [16] - many surgeons feel that withdrawing life support during the first postoperative week is unacceptable [9] - no role for perioperative aspirin or clonidine for non-cardiac surgery [10] - surgical safety checklists do not reduce perioperative complications or mortality [11] Notes: - older surgeons may have a small advantage in operative mortality rates over younger colleagues [22] - female surgeons 50-59 years of age with lowest operative mortality rates [22] - no other differences in gender with operative mortality - internist involvement helps only as part of a multidisciplinary team [26]

Related

enhanced recovery after surgery (ERAS); modified ERAS (mERAS) intraoperative complication perioperative management perioperative risk assessment post-operative management postoperative complication predictors of noncardiac surgery mortality preoperative evaluation & management preoperative laboratory testing prophylaxis for perioperative infection

Specific

abdominal surgery ablation; extirpation abscess/cyst drainage adnexectomy anorectal surgery antrostomy antrotomy avulsion breast conservation therapy cancer surgery capsulotomy cardiothoracic surgery cardiovascular surgery cautery complex wound repair, eyelid/nose/ear/lip complex wound repair, forehead/cheeks/chin//mouth/neck/axillae/genitalia/hand/foot complex wound repair, scalp/arm/leg computer-assisted surgical navigational procedure cryosurgery (cryoablation) curettage dermatologic surgery dissection elective surgery endocrine surgery ENT surgery; otorhinolaryngologic surgery; ear, nose & throat surgery exploratory surgery eye surgery; opthalmologic surgery; ocular surgery fistulization foot surgery gastrointestinal surgery (GI surgery) general surgery genitourinary surgery (urogenital surgery) gynecologic surgery hand surgery head & neck surgery hematologic/lymphatic surgery intermediate wound repair, face/ear/eyelid/nose/lip/mucous membrane intermediate wound repair, neck/hand/foot/genitalia intermediate wound repair, scalp/neck/axilla/genitalia/trunk/extremity intraoperative neurophysiology monitoring laparoscopic surgery laser surgery (radiosurgery) maxillofacial surgery microscope-enabled surgery minimally invasive surgery morcellation neck/thoracic surgery neurosurgery obstetric surgery oral surgery orthognathic surgery orthopedic surgery ostomy parabiosis pelvic surgery plastic surgery plication proctectomy puncture removal of implant replantation separation of conjoined twins sham procedure simple wound repair, face/ear/eyelid/nose/lip/mucous membrane simple wound repair, scalp/neck/axilla/genitalia/trunk/extremity sling procedure stent/stenting surgery in HIV patients surgery in the elderly; geriatric surgery surgical anastomosis surgical clip surgical debulking; cytoreductive surgery surgical evacuation surgical hemostasis surgical hyperthermia surgical infiltration surgical ligation surgical removal surgical repair/revision/reconstruction surgical replacement surgical tissue replacement surgical transection surgical transposition surgical tunneling tissue decompression tissue graft transgender surgery transplantation urgent surgery; emergency surgery wrong-site surgery

General

clinical procedure medical specialty

References

  1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999.
  2. Journal Watch 24(1):11, 2004 Birkmeyer JD et al, N Engl J Med 349:2117, 2003 PMID: 14645640
  3. Surgical site infection National Institute for Cost Effectiveness (NICE) http://www.nice.org.uk/Guidance/CG74
  4. Ghaferi AA et al Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009 Oct 1; 361:1368 PMID: 19797283 http://content.nejm.org/cgi/content/full/361/14/1368?ijkey=294abe840512f21af94da7bf1cf5a5bccb489006&keytype2=tf_ipsecsha - Jacobs DO. Variation in hospital mortality associated with inpatient surgery - An S.O.S. N Engl J Med 2009 Oct 1; 361:1398. PMID: 19797288 http://content.nejm.org/cgi/content/full/361/14/1398?ijkey=4912dc43fd0dfc3fec779ce907adeb6d01438c1c&keytype2=tf_ipsecsha
  5. Moore LJ et al Sepsis in General Surgery The 2005-2007 National Surgical Quality Improvement Program Perspective Arch Surg. 2010;145(7):695-700. PMID: 20644134 http://archsurg.ama-assn.org/cgi/content/abstract/145/7/695
  6. Bradley KA et al. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med 2011 Feb; 26:162. PMID: 20878363 - Harris AHS et al. Preoperative alcohol screening scores: Association with complications in men undergoing total joint arthroplasty. J Bone Joint Surg Am 2011 Feb; 93:321 PMID: 21325583
  7. Mills E et al. Smoking cessation reduces postoperative complications: A systematic review and meta-analysis. Am J Med 2011 Feb; 124:144. PMID: 21295194
  8. O'Leary JG, Yachimski PS, Friedman LS. Surgery in the patient with liver disease. Clin Liver Dis. 2009 May;13(2):211-31. PMID: 19442915
  9. Paul Olson TJ et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg 2013 Jan; 148:29 PMID: 23324837 - Schwarze ML et al. Surgeons expect patients to buy-in to postoperative life support preoperatively: Results of a national survey. Crit Care Med 2013 Jan; 41:1. PMID: 23222269
  10. Devereaux PJ et al for the POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014 Mar 31 PMID: 24679062 http://www.nejm.org/doi/full/10.1056/NEJMoa1401105 - Devereaux PJ et al for the POISE-2 Investigators. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014 Mar 31 PMID: 24679061 http://www.nejm.org/doi/full/10.1056/NEJMoa1401106
  11. Urbach DR et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014 Mar 13; 370:1029. PMID: 24620866 http://www.nejm.org/doi/full/10.1056/NEJMsa1308261 - Leape LL. The checklist conundrum. N Engl J Med 2014 Mar 13; 370:1063. PMID: 24748068 http://www.nejm.org/doi/full/10.1056/NEJMe1315851
  12. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  13. Livhits M, Ko CY, Leonardi MJ et al Risk of surgery following recent myocardial infarction. Ann Surg. 2011 May;253(5):857-64. PMID: 21372685
  14. Moore HB et al Effect of Pregnancy on Adverse Outcomes After General Surgery. JAMA Surg. Published online May 13, 2015 PMID: 25969946 http://archsurg.jamanetwork.com/article.aspx?articleid=2289162
  15. ProPublica. July 13, 2015 Making the Cut. Why choosing the right surgeon matters even more than you know. https://www.propublica.org/article/surgery-risks-patient-safety-surgeon-matters - ProPublica. Surgeon Scorecard https://projects.propublica.org/surgeons/
  16. Ladha K et al. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: Hospital based registry study. BMJ 2015; 351:h3646 PMID: 26174419
  17. Monk TG et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology 2015 Aug; 123:307. PMID: 26083768 - Mascha EJ et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology 2015 Apr 30; 123:79. PMID: 25929547
  18. Merrill AL et al Clinical Effect of Surgical Volume. N Engl J Med 2016; 374:1380-1382. April 7, 2016 PMID: 27050211 http://www.nejm.org/doi/full/10.1056/NEJMclde1513948
  19. McIsaac DI, Bryson GL, van Walraven C. Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery: A Population- Based Cohort Study. JAMA Surg. 2016 Jun 1;151(6):538-45. PMID: 26791334 - Mosquera C, Spaniolas K, Fitzgerald TL. Impact of frailty on surgical outcomes: The right patient for the right procedure. Surgery. 2016 Aug;160(2):272-80. PMID: 27267548
  20. World Health Organization (WHO) WHO recommends 29 ways to stop surgical infections and avoid superbugs. WHO News Release, Nov 3, 2016 http://www.who.int/mediacentre/news/releases/2016/recommendations-surgical-infections/en/ - Allegranzi B, Zayed B, Bischoff P et al New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence- based global perspective. Lancet Infectious Diseases. Nov 2, 2016 PMID: 27816414 http://thelancet.com/journals/laninf/article/PIIS1473-3099(16)30402-9/fulltext - Allegranzi B, Bischoff P, de Jonge S et al New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infectious Diseases. Nov 2, 2016 PMID: 27816413 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30398-X/fulltext
  21. Writing Committee for the VISION Study Investigators Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017;317(16):1642-1651 PMID: 28444280 http://jamanetwork.com/journals/jama/article-abstract/2620089
  22. Tsugawa Y, Jena AB, Newhouse RL et al Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ 2018;361:k1343 PMID: 29695473 Free PMC Article https://www.bmj.com/content/361/bmj.k1343 - Coburn N, Wallis CJD, Baxter N. Links between age and sex of surgeons and patients' outcomes. BMJ 2018;361:k1691 PMID: 29695477 https://www.bmj.com/content/361/bmj.k1691
  23. American Academy of Nursing Twenty-Five Things Nurses and Patients Should Question Choosing Wisely. An initiative of the ABIM Foundation Released April 19, 2018 (21-25) http://www.choosingwisely.org/societies/american-academy-of-nursing/
  24. The NeuroVISION Investigators Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study Lancet. Aug 15, 2019 PMID: 31422895 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31795-7/fulltext - Vlisides PE, Avidan MS, Mashour GA Uncovering covert stroke in surgical patients Lancet. Aug 15, 2019 PMID: 31422896 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31770-2/fulltext - Szczeklik W, Dmytriw AA, Agid R et al Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study. BMJ Open. 2018 Jul 6;8(7):e021521. PMID: 29982215 Free PMC Article - Mrkobrada M, Hill MD, Chan MT, Sigamani A et al Covert stroke after non-cardiac surgery: a prospective cohort study. Br J Anaesth. 2016 Aug;117(2):191-7. PMID: 27440630 Free Article
  25. NEJM Knowledge+ Question of the Week, June 30, 2020 https://knowledgeplus.nejm.org/question-of-week/635/ - Bratzler DW et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013 Feb 1; 70:195 PMID: 23327981
  26. Shaw M et al. Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes: A systematic review and meta-analysis. JAMA Netw Open 2020 May 1; 3:e204088 PMID: 32369179 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2765514
  27. Althoff FC, Wachtendorf LJ, Rostin P et al Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study BMJ Qual Saf. 2020;Epub Oct 9. PMID: 33028658 https://psnet.ahrq.gov/issue/effects-night-surgery-postoperative-mortality-and-morbidity-multicentre-cohort-study
  28. Sun EC et al. Assessment of perioperative outcomes among surgeons who operated the night before. JAMA Intern Med 2022 May 23; [e-pub] PMID: 35604661 PMCID: PMC9127708 Free PMC article https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2792088
  29. Shah SK et al. Patients living with dementia have worse outcomes when undergoing high-risk procedures. J Am Geriatr Soc 2022 Oct; 70:2838. PMID: 35637607 PMCID: PMC9588582 (available on 2023-10-01) https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17893 - Gill TM, Vander Wyk B, Leo-Summers L et al Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults. JAMA Surg. Published online October 19, 2022. PMID: 36260323 https://jamanetwork.com/journals/jamasurgery/fullarticle/2797666
  30. Reich KM, Gill SS, Eckenhoff R et al Association between surgery and rate of incident dementia in older adults: A population-based retrospective cohort study. J Am Geriatr Soc 2025. 72(5):1348-1359 PMID: 38165146 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18736