Evaluating surgical risk: The importance of technical factors in determining outcome

Abstract

A total of 113 patients having elective resection of the alimentary tract were studied prospectively to examine the relationship of pre-operative clinical and nutritional assessment to the development of major postoperative complications. In addition, the operating surgeon made a risk assessment on a linear analogue scale before and immediately after operation. Major complications developed in 28 patients (25 per cent). Age, weight loss and relative weight did not select high risk patients, but patients with a serum albumin of 29 g/l developed significantly more complications than those with higher levels (60 versus 22 per cent, P less than 0.05). Clinical assessment also selected some high risk patients but patients selected by the surgeon's pre-operative assessment did not develop significantly more complications than those not selected (38 versus 21 per cent). However, the surgeon's postoperative assessment did select patients at significantly increased risk, especially when compared with his pre-operative assessment. Of 38 patients who were selected pre-operatively as high risk or who increased their risk ranking postoperatively, 20 (53 per cent) developed complications, as opposed to only 6 of 65 patients (9 per cent) who were low risk or decreased their risk ranking (P less than 0.001). The surgeons changed their ranking postoperatively in 44 patients and in 36 (82 per cent) the reason given was the technical ease or difficulty of the procedure. Using receiver-operating characteristic curves, immediate postoperative assessment was superior to any pre-operative method of selecting high risk patients. Of 15 patients with normal serum albumin levels whose risk ranking increased postoperatively 6 (40 per cent) developed complications while none of the 7 patients with low serum albumin (high risk) who decreased their risk ranking developed complications. It is concluded that operative performance is the main factor in the development of postoperative complications and should be assessed in future studies of outcome.

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

“…The results of our study clearly identify the lack of a reliable intra-operative predictive test for anastomotic leakage by the operating surgeon, whereas several studies identify a large number of risk factors for anastomotic leakage. In general, the global, clinical judgement seems to localize a subset of patients at risk for developing complications in general, whereas many patients with no risk factors at all may develop anastomotic leakage [12]. The risk factors for anastomotic leakage identified by univariate and multivariate analysis in our study corroborate with those found in other studies [1][2][3][4][5][6][7][8].…”

“…Based on this striking finding, they concluded that surgical performance during the operation is an important predictor of post-operative complications. Considering this latter study [12], it might be assumed that the surgeon is able to reliably predict the risk of anastomotic leakage, but as mentioned by Markus et al [14], they found the surgeons' risk estimation after completion of the operation not to be a good predictor of post-operative complications, particularly in colorectal surgery. This finding is emphasized by our study.…”

“…In a population of 218 patients undergoing major gastrointestinal surgery, they reported that global risk assessment by the operating surgeon is less accurate (sensitivity 32%, specificity 83%) than careful assessment of in particular cardiorespiratory disease and nutritional status of the patient. In a third study using a similar design [12] but evaluating the surgeons' judgement before and after surgery as well, they concluded the surgeons' post-operative judgement to be superior to the surgeons' preoperative judgement or assessment of either preoperative patient factors or systematic clinical factors. Based on this striking finding, they concluded that surgical performance during the operation is an important predictor of post-operative complications.…”

“…Three studies have shown that the surgeons' global assessment is a predictor of complications in general [12,13] and is even more accurate than risk assessment by Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scores [14]. Until now, no studies have been published evaluating the surgeons' clinical judgement on the risk of anastomotic leakage.…”

Infections intraabdominales postopératoires

“…Néanmoins, ce sont surtout les conditions locales (zone irradiée ou cancéreuse), et la diffi culté du geste chirurgical qui favorisent la survenue d'un sepsis postopératoire. Dans une série de patients opérés de résection colique [11], 53 % des patients jugés à risque du fait de la diffi culté du geste chirurgical ont développé une complication chirurgicale postopératoire, et seulement 15 % des patients jugés à faible risque. Enfi n, l'expérience de l'opérateur est également un élément important à prendre en compte.…”