Emergency reoperation is considered to be a quality indicator in surgery. We analyzed the risk factors for emergency reoperations.
Patients who underwent emergency operations from January 1, 2017, to December 31, 2017, at our hospital were reviewed in this retrospective study. Multivariate logistic regression was performed for the perioperative risk factors for emergency reoperation.
A total of 1,481 patients underwent emergency operations during the study period. Among them, 79 patients received emergency reoperations. The variables related to emergency reoperation included surgeries involving intracranial and intraoral lesions, highest mean arterial pressure ≥ 110 mmHg, highest heart rate ≥ 100 beats/min, anemia, duration of operation >120 min, and arrival from the intensive care unit (ICU).
The type of surgery, hemodynamics, hemoglobin values, the duration of surgery, and arrival from ICU were associated with emergency reoperations.
Complications after surgical procedures are frequently associated with poor outcomes and high costs [
Emergency reoperation is an important index of quality indicators in healthcare institutions [
However, reports of emergency reoperations tend to be infrequent, brief, and fragmented [
After receiving Institutional Review Board approval (no. HIRB-2019-0717-070), we retrospectively analyzed all consecutive patients aged ≥ 16 years who underwent emergency operations from January 1, 2017, to December 31, 2017 (
The cases were divided into Group O (emergency operations without a previous operation) and Group R (emergency reoperations following a previous operation within 60 days). Age was categorized as patients older or younger than 65 years. The medical specialties included general surgery, orthopedic surgery, neurosurgery, and others. The operative lesions were grouped into intracranial, intraoral, cervical, intrathoracic, intra-abdominal, and other categories. Abnormal pre-induction blood pressure and heart rate were categorized as pre-induction systolic blood pressure (SBP) ≥ 180 mmHg, pre-induction mean arterial pressure (MAP) ≥ 110 mmHg, and pre-induction heart rate (HR) < 40 or ≥ 100 beats/min. Based on abnormality in the highest SBP, MAP, and HR during the operation, the patients were categorized as follows: SBP ≥ 180 mmHg, MAP ≥ 110 mmHg, and HR ≥ 100 beats/min. Based on abnormality in the lowest SBP, MAP, and HR values during surgery, the following categories were created: SBP ≤ 80 mmHg, MAP ≤ 60 mmHg, and HR ≤ 40 beats/min. Anemia was defined by Hgb levels < 13 g/dl and < 40% in males and < 12 g/dl and < 36%, respectively, in females according to our laboratory guidelines. The duration of anesthesia was categorized as ≤ 120 min or longer. Based on the time surgery commenced, the surgeries were categorized as regular working time (from 8:00 am to 5:00 pm) on weekdays or non-holidays and outside of working time. Postoperative mortality was defined as death within 30 days postoperatively [
The data are expressed as frequencies (%) and median (range), as appropriate for comparison between the groups. The chi-squared test or Fisher’s exact test was used for categorical variables and the Wilcoxon rank-sum test was applied for continuous variables. Univariate and multivariate logistic regression analysis was used to identify the independent predictors of emergency reoperation. A multivariate logistic regression model was constructed using stepwise selection with entry criteria of P < 0.1 and significant criteria of P < 0.05. We applied Firth’s penalized maximum likelihood estimation to reduce bias in the parameter estimates in the multivariate analyses with few events, leading to non-estimable coefficients or 95% confidence intervals. A P value of < 0.05 was statistically considered significant. All statistical analyses were performed using SAS software ver. 9.4 (SAS Institute Inc., USA).
During the study period, 1,481 emergency operations were performed with anesthesiologist involvement (
The diagnoses in Group O were appendicitis (249 [17.8%]), followed by cholecystitis (219 [15.6%]), fracture (212 [15.1%]), and pregnancy (119 [8.5%]) (
The most common cause of emergency reoperation was hemorrhage in 42 (53.2%) cases, followed by infection or sepsis in 11 (13.9%) cases, wound dehiscence in seven (8.8%), and increased intracranial pressure in four (5.1%) patients. Sixty-four (4.3%) of the 1,481 patients died within 30 days postoperatively. Mortality was observed in 16.5% (13/79) in Group R. Death occurred in 11 patients after neurosurgery and in two patients after general surgery in Group R. The fatality rate associated with each cause of reoperation ranged from 0% to 36.4% (
Multivariate analysis revealed that intracranial (odds ratio [OR] = 6.32, P < 0.001) and intraoral (OR = 28.37, P < 0.001) lesions were significantly associated with emergency reoperation. The highest MAP ≥ 110 mmHg was significantly correlated with emergency reoperation compared to MAP < 110 mmHg (OR = 1.76, P = 0.040). The highest HR ≥ 100 beats/min was significantly correlated with emergency reoperation compared to HR < 100 beats/min (OR = 2.87, P < 0.001). Hemoglobin levels < 13 g/dl in males and < 12 g/dl in females were significantly correlated with reoperation (OR = 2.47, P = 0.001). Duration of surgery over two hours was significantly related to reoperation (OR = 1.94, P = 0.025). The number of patients treated in the intensive care unit (ICU) (OR = 2.89, P = 0.007) remained statistically significant (
Emergency reoperation has been reported to have distinguishing features and risks. Therefore, we investigated the clinical features, as well as anesthetic considerations, of emergency reoperation compared to ordinary emergency operations. In the present study, the factors related to emergency reoperation were intracranial and intraoral lesions, MAP ≥ 110 mmHg and HR ≥ 100 beats/min before surgery, anemia, duration of operation > 2 h, and ICU stay before the operation.
Emergency reoperation was defined as surgery performed due to a primary surgical condition [
Published data related to the incidence of reoperation vary between different populations, with reported rates ranging from 2% to 21% according to the definition used, institutional bias, the departments, pathology and operation type, and the presence of coexisting problems [
One of the most important factors affecting mortality rates in emergency reoperations is the cause, lesion, and organ involved in the reoperation [
Causes of urgent abdominal re-explorations were known to involve leakage from the intestinal repair site, hemorrhage, intestinal perforation, intra-abdominal infection or sepsis, mechanical obstruction, intestinal necrosis, enteral anastomosis failure, stomal complications, surgical wound dehiscence, fistulas, and ileus [
In our study, the highest MAP ≥ 110 mmHg and the highest HR ≥ 100 beats/min were related to emergency reoperations, which indirectly reflected high hemodynamic instability. Hypertension may be due to Cushing reflex in intracranial problems, the use of inotropics, and psychological stress. Shock and hemorrhage requiring blood transfusion increase patients’ susceptibility to postoperative mortality in emergency surgeries [
The possibility of effectively lowering the mortality rate depends on the success of the first operation [
This study had several limitations. First, our research was limited by the size of the study groups. This study was based on data obtained from a single institution and surgeries of short duration (70.0% were less than two hours) and involved minor-to-moderate types of surgery (83.9%). Therefore, the results may differ from those involving larger populations and multiple institutions, such as regional emergency trauma centers. Our institution is a university-affiliated community hospital. Institutional factors may limit generalizability. Second, the variables in our investigation may be too diverse to perform a comprehensive analysis and exclude the role of unmeasured variables. The variety of diseases and operations included did not allow a clear distinction between the effects of reoperation on patient outcomes. The results should be based on analyses according to individual departments and procedures in the future. The selection of abnormal variables, including vital signs, was defined arbitrarily and these aspects may have affected our results. Third, we could not analyze the anesthetic implications for postoperative mortality as an endpoint due to the small number of mortalities. Lastly, variations in surgical procedures due to the surgeon’s experience, operative devices, and methods could not be analyzed in a meaningful way and were beyond the scope of the study.
In summary, our results described the clinical features of emergency reoperations. The factors associated with a higher proportion of emergency reoperations were intracranial and intraoral lesions, highest MAP ≥ 110 mmHg and HR ≥ 100 beats/min, anemia, and arrival from the ICU. Emergency anesthesia is an important segment of clinical anesthesiology and advances in anesthetic care affect mortality. Particular attention must be paid to emergency reoperation and more time and resources are required to redefine the clinical features of emergency reoperation.
No potential conflict of interest relevant to this article was reported.
Conceptualization: Jun Rho Yoon. Data acquisition: Jun Rho Yoon, Yeon-Ju Hong, Kyoung Rim Kim, Taehee Kim. Formal analysis: Tae Kwan Kim. Funding: Ui Jin Park. Supervision: Jun Rho Yoon. Writing—original draft: Jun Rho Yoon. Writing—review & editing: Yu Na Choi, Tae Kwan Kim.
Flow diagram of patient selection process for this study. Any patient who has received multiple operations is counted as one patient and his or her last operation is selected.
Patient Characteristics
Variable | Overall (n = 1,481) | Group O (n = 1,402) | Group R (n = 79) | P value |
---|---|---|---|---|
Sex | 0.582 | |||
Male | 668 (45.1) | 630 (44.9) | 38 (48.1) | |
Female | 813 (54.9) | 772 (55.1) | 41 (51.9) | |
Age (yr) | 51.0 ± 19.2 | 51.0 ± 19.0 | 57.0 ± 19.0 | 0.004 |
< 65 | 1,069 (72.2) | 1,026 (73.2) | 43 (54.4) | < 0.001 |
≥ 65 | 412 (27.8) | 376 (26.8) | 36 (45.6) | |
ASA | < 0.001 | |||
1–2 | 1,100 (74.3) | 1,068 (76.2) | 32 (40.5) | |
3–6 | 381 (25.7) | 334 (23.8) | 47 (59.5) | |
Operator | < 0.001 | |||
General surgery | 612 (41.3) | 599 (42.7) | 13 (16.5) | |
Orthopedic surgery | 283 (19.1) | 276 (19.7) | 7 (8.9) | |
Neurosurgery | 224 (15.1) | 188 (13.4) | 36 (45.6) | |
Others | 362 (24.4) | 339 (24.2) | 23 (29.1) | |
Lesion | < 0.001 | |||
Intracranial | 221(14.9) | 186 (13.3) | 35 (44.3) | |
Intraoral | 10 (0.7) | 4 (0.3) | 6 (7.6) | |
Cervical | 22 (1.5) | 15 (1.1) | 7 (8.9) | |
Intrathoracic | 31 (2.1) | 31 (2.2) | 0 (0.0) | |
Intra-abdominal | 793 (53.5) | 779 (55.6) | 14 (17.7) | |
Other regions | 404 (27.3) | 387 (27.6) | 17 (21.5) | |
Surgical complexity |
< 0.001 | |||
Minor | 253 (17.1) | 216 (15.4) | 37 (46.8) | |
Moderate | 989 (66.8) | 962 (68.6) | 27 (34.2) | |
Major | 231 (15.6) | 216 (15.4) | 15 (19.0) | |
Major + | 8 (0.5) | 8 (0.6) | 0 (0.0) | |
Type of anesthesia | 0.123 | |||
General anesthesia | 1,429 (96.5) | 1,352 (96.4) | 77 (97.5) | |
Regional anesthesia | 37 (2.5) | 35 (2.5) | 2 (2.5) | |
MAC | 15 (1.0) | 15 (1.1) | 0 (0.0) | |
Main anesthetic agent in general anesthesia | < 0.001 | |||
Desflurane | 780 (52.7) | 758 (54.1) | 22 (27.8) | |
Sevoflurane | 598 (40.4) | 547 (39.0) | 51 (64.6) | |
Propofol | 51 (3.4) | 47 (3.4) | 4 (5.1) | |
Duration (min) | 116.0 ± 96.0 | 114.0 ± 95.0 | 148.0 ± 95.0 | < 0.001 |
≤ 120 | 1,042 (70.4) | 1,001 (71.4) | 41 (51.9) | < 0.001 |
> 120 | 439 (29.6) | 401 (28.6) | 38 (48.1) | |
Net fluid balance (ml/min) | 6.0 ± 55.8 | 6.1 ± 57.3 | 4.3 ± 5.0 | 0.712 |
Transfusion | < 0.001 | |||
No | 1,370 (92.5) | 1,309 (93.4) | 61 (77.2) | |
Yes | 111 (7.5) | 93 (6.6) | 18 (22.8) | |
Inotropics | < 0.001 | |||
No | 1,176 (79.4) | 1,134 (80.9) | 42 (53.2) | |
Yes | 305 (20.6) | 268 (19.1) | 37 (46.8) | |
PCA | 0.005 | |||
No | 863 (58.3) | 805 (57.4) | 58 (73.4) | |
Yes | 618 (41.7) | 597 (42.6) | 21 (26.6) | |
Commencement of operation | 0.751 | |||
Working time | 818 (55.2) | 773 (55.1) | 45 (57.0) | |
Other | 663 (44.8) | 629 (44.9) | 34 (43.0) | |
Origin | < 0.001 | |||
ER | 603 (40.7) | 588 (41.9) | 15 (19.0) | |
ICU | 117 (7.9) | 85 (6.1) | 32 (40.5) | |
Ward | 761 (51.4) | 729 (52.0) | 32 (40.5) | |
Destination | < 0.001 | |||
ICU | 383 (25.9) | 335 (23.9) | 48 (60.8) | |
Ward | 1,098 (74.1) | 1,067 (76.1) | 31 (39.2) |
Values are presented as number (%) or mean ± SD. Group O: patients who underwent emergency operations without a previous operation, Group R: patients who underwent emergency reoperations following a previous operation within 60 days. ASA: American Society of Anesthesiologists, MAC: monitoring anesthesia care, PCA: patient-controlled analgesia, ER: emergency room, ICU: intensive care unit.
Surgical complexity: minor, moderate, major, and major. + blood loss ≤ 100, 101–500, 501–999, and 1,000 ml.
P values for differences were determined by using the chi-squares, Fisher's exact test,
Top 10 Primary Diagnoses in Emergency Operations and Reoperations
No. | Group O |
Group R |
||
---|---|---|---|---|
Diagnosis | Number (%) | Diagnosis | Number (%) | |
1 | Appendicitis | 249 (17.8) | SAH | 10 (12.7) |
2 | Cholecystitis | 219 (15.6) | ICH | 9 (11.4) |
3 | Fracture | 212 (15.1) | SDH | 7 (8.9) |
4 | Pregnancy | 119 (8.5) | EDH | 5 (6.3) |
5 | SDH | 79 (5.6) | Tonsillitis | 5 (6.3) |
6 | Ovary cyst torsion | 42 (3.0) | Deep neck infection | 3 (3.8) |
7 | ICH | 41 (2.9) | Pyogenic arthritis | 3 (3.8) |
8 | SAH | 29 (2.1) | Uterine cancer | 3 (3.8) |
9 | Cerebral infarct | 28 (2.0) | Thyroid cancer | 2 (2.5) |
10 | Pneumothorax | 24 (1.7) | Ectopic pregnancy | 2 (2.5) |
SDH: subdural hematoma, ICH: intracerebral hemorrhage, SAH: subarachnoidal hemorrhage, EDH: epidural hematoma.
Patients who underwent emergency operations without a previous operation.
Patients who underwent emergency reoperations following a previous operation within 60 days.
Surgical Procedures in Group O and Previous Operations in Group R
No. | Group O |
Group R |
||
---|---|---|---|---|
Surgery | Number (%) | Surgery | Number (%) | |
1 | Appendectomy | 251 (17.9) | EVD | 14 (17.7) |
2 | Cholecystectomy | 222 (15.8) | Craniectomy | 11 (13.9) |
3 | OR&IF | 130 (9.3) | Tonsillectomy | 6 (7.6) |
4 | Cesarean section | 119 (8.5) | Craniotomy | 4 (5.1) |
5 | CR&IF | 59 (4.2) | Debridement | 4 (5.1) |
6 | Ovary cystectomy | 45 (3.2) | OR&IF | 2 (2.5) |
7 | Burr hole trephination | 42 (3.0) | Burr hole trephination | 2 (2.5) |
8 | EVD | 41 (2.9) | Navigation guided removal of intracranial hematoma | 2 (2.5) |
9 | Craniectomy | 40 (2.9) | Oophorectomy | 2 (2.5) |
10 | Tenorrhaphy | 32 (2.3) | Salpingectomy | 2(2.5) |
OR&IF: open reduction and internal fixation, CR&IF: closed reduction and internal fixation, EVD: extraventricular drainage.
Patients who underwent emergency operations without a previous operation.
Patients who underwent emergency reoperations following a previous operation within 60 days.
Causes of Emergency Reoperation and Mortality Rates
Causes | Emergency reoperation (n = 79) | Mortality rate |
---|---|---|
Hemorrhage | 42 (53.2) | 6 (14.3) |
Infection or Sepsis | 11 (13.9) | 1 (9.1) |
Wound dehiscence | 7 (8.8) | 1 (14.3) |
Increased intracranial pressure | 4 (5.1) | 1 (25.0) |
Thrombotic artery occlusion | 2 (2.5) | 0 (0) |
Ileus | 2 (2.5) | 0 (0) |
Others |
11 (14.0) | 4 (36.4) |
Values are presented as number (%) of categorical variables.
The parentheses include the mortality percentage calculated from each cause of emergency reoperation.
Others include airway obstruction, cerebellar infarction, cerebrospinal fluid leakage, hardware loosening, hygroma, intestinal anastomosis leakage, nerve injury, nonunion, pharyngocutaneous fistula, tracheostoma, and ureteral injury.
Among the other causes, airway obstruction, cerebellar infarction, cerebrospinal fluid leakage, and intestinal anastomosis leakage resulted in death.
Multivariate Logistic Regression Analyses of Factors Associated with Reoperations (n = 1,481)
Variable | Crude odds ratios (95% CI) | P value | Adjusted odds ratios (95% CI) | P value |
---|---|---|---|---|
Lesion | ||||
Intracranial | 4.22 (2.31–7.68) | < 0.001 | 6.32 (2.41–16.58) | < 0.001 |
Intraoral | 31.98 (8.30–123.20) | < 0.001 | 28.37(6.26–128.62) | < 0.001 |
Cervical | 10.71 (3.89–29.48) | < 0.001 | 2.07 (0.62–6.93) | 0.238 |
Intrathoracic | 0.35 (0.02–6.25) | 0.477 | 1.06 (0.05–22.83) | 0.920 |
Intra-abdominal | 0.41 (0.20–0.84) | 0.014 | 1.50 (0.64–3.56) | 0.354 |
Others | Reference | Reference | ||
Surgical complexity | ||||
Minor | 2.95 (0.14–61.87) | 0.487 | 17.23 (0.72–413.69) | 0.079 |
Moderate | 0.49 (0.02–10.24) | 0.643 | 2.71 (0.12–61.46) | 0.531 |
Major | 1.22 (0.06–26.19) | 0.900 | 1.57 (0.07–36.91) | 0.779 |
Major + | Reference | Reference | ||
Highest MAP | ||||
< 110 | Reference | Reference | ||
≥ 110 | 3.19 (2.01–5.04) | < 0.001 | 1.76 (1.03–3.03) | 0.040 |
Highest HR | ||||
< 100 | Reference | Reference | ||
≥ 100 | 6.21 (3.91–9.87) | < 0.001 | 2.87 (1.64–5.02) | < 0.001 |
Hgb (g/dl) | ||||
Male < 13, female < 12 | 3.18 (1.99–5.07) | < 0.001 | Reference | |
Male ≥ 13, female ≥ 12 | Reference | 2.47 (1.44–4.27) | 0.001 | |
Duration (min) | ||||
≤ 120 | Reference | Reference | ||
> 120 | 2.31 (1.47–3.64) | < 0.001 | 1.94 (1.09–3.46) | 0.025 |
Origin | ||||
ER | 0.59 (0.32–1.09) | 0.094 | 0.48 (0.23–1.01) | 0.052 |
ICU | 8.53 (4.99–14.59) | < 0.001 | 2.89 (1.34–6.23) | 0.007 |
Ward | Reference | Reference |
A multivariate logistic regression model was constructed using stepwise selection (with entry criteria of P < 0.1 and significant criteria of P < 0.05). CI: confidence interval, MAP: mean arterial pressure, HR: heart rate, Hgb: hemoglobin, ER: emergency room, ICU: intensive care unit.