Overlapping surgery not associated with adverse patient outcomes

1. In this retrospective cohort study, overlapping surgery was not associated with increased in-hospital mortality or post-operative complication rates but was associated with increased surgery length.

2. In patients with high preoperative risk for mortality and complications, overlapping surgery was significantly associated with increased mortality and complications when compared to low-risk patients.

Evidence Rating Level: 2 (Good)           

Study Rundown: Overlapping surgery, when two procedures are performed during the same operation, is commonly practiced at high-volume medical centers. And while most single-center studies have found no association between overlapping surgery and patient outcomes, this has not been studied over many centers. In this multicenter retrospective cohort review, overlapping surgery was not associated with differences in in-hospital mortality or post-operative complication rates but was associated with increased surgery length. In patients with high preoperative risk for mortality and complications, overlapping surgery was significantly associated with increased mortality and complications when compared with low-risk patients.

Overall, this study corroborates other single-center studies suggesting that overlapping surgery is not associated with increased complications. The findings are limited in its generalizability and may not extend to low-volume centers and pediatric patients. Further, post-discharge complications were not measured. There is a possibility of selection bias in the type of patients that are selected by the surgeons to undergo overlapping surgery. Finally, the data source does not provide information on the level of experience of the personnel performing the procedures, which may also affect the outcomes of the procedure.

Click to read the study, published today in JAMA

Relevant Reading: The evolving story of overlapping surgery

In-Depth [retrospective cohort]: Data was obtained from the Multicenter Perioperative Outcomes Group (MPOG), which is an electronic health record registry of all surgical and diagnostic procedures requiring anesthesia care from more than 50 hospitals across 18 states and the Netherlands. Included patients were between 18 and 90 years old who underwent procedures between January 1, 2010 and May 31, 2018. Procedures that were commonly performed during overlapping surgery included: total knee or hip arthroplasty, spine surgery, coronary artery bypass graft (CABG) surgery, and craniotomy. Patients could be included more than once if they underwent multiple procedures during this period. Data was restricted to 8 US institutions that consistently reported discharge diagnosis codes. Overlapping cases were defined as those where the surgery start and end time overlapped with at least 1 other operation (of any type) performed by the same surgeon for at least 60 minutes. Primary outcomes included in-hospital mortality, in-hospital postoperative surgical complications (major: thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction; minor: urinary tract or surgical site infection), and duration of the surgery. Based on the study results, overlapping surgery was not significantly associated with differences in in-hospital mortality (1.9% overlapping vs 1.6% non-overlapping; p = 0.21) or post-operative complication rates (12.8% overlapping vs 11.8% non-overlapping; p = 0.08). Overlapping surgery was associated with increased surgery length (204 vs 173 minutes; p = 0.001). In patients with high preoperative risk for mortality and complications, overlapping surgery was significantly associated with increased mortality and complications when compared with low-risk patients (mortality: 5.8% vs 4.7%; p = 0.03; complications: 29.2% vs 27.0%; p = 0.03).

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