Overlapping Surgeries Safe for Most Patients

A recent retrospective study published in JAMA found that most patients who undergo certain overlapping surgeries may not have greater odds for complications or death. For high-risk patients or those undergoing coronary artery bypass graft (CABG) surgery, though, the outcomes may be different.

“Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes,” the study authors wrote.

To determine whether a link exists between overlapping surgery and harmful outcomes, the researchers retrospectively reviewed a total of 66,430 operations at eight different centers in patients aged between 18 and 90 years. They analyzed total knee arthroplasty, total hip arthroplasty, spine surgery, CABG surgery, and craniotomy. Operations took place between Jan. 1, 2010, and May 31, 2018, and patients were followed until discharge. The researchers specified overlapping surgery, the primary exposure, to be “≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed.” Surgery duration and in-hospital mortality or major/minor complications were the primary outcomes; major complications were thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction, and minor complications were urinary tract or surgical site infection.

Overlapping Surgeries: Largely Safe, But Length of Surgery May Increase

Among the 66,430 operations included in the final analysis, the mean patient age was 59 years old, and just under half (n = 31,915, 48%) of patients were women; 12% of the total surgeries were overlapping. When adjusting for confounding factors, there was no significant difference between overlapping and nonoverlapping surgeries in terms of in-hospital mortality (1.9% overlapping vs. 1.6% nonoverlapping; difference, 0.3% [95% CI, −0.2% to 0.7%]; P = 0.21) or risk of complications (12.8% overlapping vs. 11.8% nonoverlapping; difference, 0.9% [95% CI, −0.1% to 1.9%]; P = 0.08). Overlapping surgery patients had longer operative times than nonoverlapping surgery patients (204 vs. 173 minutes; difference, 30 minutes [95% CI, 24 to 37 minutes]; P < 0.001).

Patient characteristics changed these odds in overlapping procedures, the researchers observed: “Overlapping surgery was significantly associated with increased mortality and increased complications among patients having a high preoperative predicted risk for mortality and complications, compared with low-risk patients (mortality: 5.8% vs 4.7%; difference, 1.2% [95% CI, 0.1% to 2.2%]; P = .03; complications: 29.2% vs 27.0%; difference, 2.3% [95% CI, 0.3% to 4.3%]; P = .03).”

Notably, when looking specifically at CABG patients, overlapping surgery was associated with a slightly increased risk for in-hospital mortality (4.0% vs. 2.2%, P = 0.009) and more complications (34.5% vs. 30.2%, P = 0.007).

In an accompanying editorial, Edward H. Livingston, MD, wrote of the study’s results, “This work appealed to me because it answered an important, unresolved question: Is surgery safe as practiced in academic environments that balance the needs of safe patient care with those required to train the next generation of surgeons? The answer appears to be yes.”

What this study does not touch on, though, is the risk associated with concurrent surgery when a doctor is not in the room during a critical part of the operation.

“Major complications attributable to concurrent surgery have been highlighted by the news media, yet whether this practice is safe or acceptable remains unresolved and is not addressed in the current study,” according to Livingston.

Addressing concurrent surgery risks “requires a precise definition of the critical part of the operation that requires the presence of the attending surgeon,” Livingston wrote. “That definition should be determined by an independent body of clinicians familiar with the operating room environment and monitoring to ensure that the attending surgeon is in the operating room during that time.”