Postoperative complications and mortality after major gastrointestinal surgery

Background and objective: The incidence of postoperative complications and death is low in the general population, but a subgroup of high-risk patients can be identified amongst whom adverse postoperative outcomes occur more frequently. The present study was undertaken to describe the incidence of postoperative complications, length of stay, and mortality after major abdominal surgery for gastrointestinal, hepatobiliary and pancreatic malignancies and to identify the risk factors for impaired outcome.

Material and methods: Data of patients, operated on for gastro-intestinal malignancies during 2009-2010 were retrieved from the clinical database of Tartu University Hospital. Major outcome data included incidence of postoperative complications, hospital-, 30-day, 90-day and 1-year mortality, and length of ICU and hospital stay. High-risk patients were defined as patients with American Society of Anesthesiologists (ASA) physical status ≥3 and revised cardiac risk index (RCRI) ≥3. Multivariate analysis was used to determine the risk factors for postoperative mortality and morbidity.

Results: A total of 507 (259 men and 248 women, mean age 68.3±11.3 years) were operated on for gastrointestinal, hepatobiliary, or pancreatic malignancies during 2009 and 2010 in Tartu University Hospital, Department of Surgical Oncology. 25% of the patients were classified as high risk patients. The lengths of intensive care and hospital stay were 4.4±7 and 14.5±10 days, respectively. The rate of postoperative complications was 33.5% in the total cohort, and 44% in high-risk patients. The most common complication was delirium, which occurred in 12.8% of patients. For patients without high risk (ASA<III; RCRI<3) in-hospital, 30-, 90-day and 1-year mortality were 2%, 5%, 12.7% and 26.0%. Patients with ASA≥III and RCRI≥3 had 2.3% in-hospital mortality, and at 30-, 90 days and 1 year the mortality was 8.5%, 17.8%, and 42.2%, respectively (P=0.001, P<0.0001 and P<0.0001 compared to the lower risk patients). On multivariate analysis, age above 70 years, ASA≥III, RCRI≥3, duration of surgery >130min, and positive fluid balance >1300mL after the 1st postoperative day, were identified as independent risk factors for the development of complications.

Conclusion: The complication rate after major gastro-intestinal surgery is high. ASA physical status and revised cardiac risk index adequately reflect increased risk for postoperative complications and worse short and long-term outcome.