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Overlapping surgeries are generally safe

But extra caution is needed with cardiac procedures and other high-risk patients

Ingrid Torjesen

Wednesday, 27 February 2019

A surgeon sometimes moves from one surgical procedure on a patient to begin surgery on another, leaving less experienced surgeons to finish some parts of the procedure and close up, and research* published in JAMA has concluded that this practice does not greatly increase risk for patients except for cardiac surgery and other high-risk patients.

Researchers at Harvard Medical School and Stanford University analysed outcomes among 66,430 patients, ages 18 to 90, undergoing eight common procedures at eight medical centres across the United States between 2010 and 2018. The procedures included knee and hip repairs, spinal surgeries, brain surgeries and coronary artery bypass grafting, a type of cardiac surgery to restore blood flow to the heart.

While they found that overall overlapping surgeries do not increase the risk for post-surgical complications and patient death in the immediate aftermath of the procedure, there were two important exceptions: patients deemed high risk (relatively high predicted probability of complications from surgery, due to age and pre-existing medical condition) and patients undergoing coronary artery bypass. Overlapping procedures ran about a half hour longer on average than non-overlapping procedures, the study found.

"For most surgeries, and most patients, our findings should be reassuring," said Anupam Jena, the Ruth L. Newhouse associate professor of health care policy in the Blavatnik Institute at Harvard Medical School and an internal medicine physician at Massachusetts General Hospital. "But for certain types of procedures and certain patients, the evidence suggests that we need to be thoughtful about whether a particular individual is a good candidate for overlapping surgery."

The mortality rate was 1.6% for patients undergoing non-overlapping surgeries, compared with 1.9% among patients undergoing overlapping procedures. Postoperative complications occurred in 11.8% of patients undergoing non-overlapping procedures, compared with 12.8% among those undergoing overlapping surgeries. Overlapping surgeries ran for 204 minutes, which was longer than the 173 minutes for non-overlapping procedures.

For high-risk patients, the mortality rate was 5.8% for patients undergoing overlapping surgeries, compared with 4.7% among patients undergoing non-overlapping procedures. The complication rate was 29.2% for patients undergoing overlapping surgeries, compared with 27% among patients undergoing non-overlapping procedures.

For patients undergoing coronary artery bypass graft surgery, the mortality rate was 4% in surgeries with overlap versus 2.2% in surgeries without overlap. Complication rates were also higher in coronary artery bypass graft surgeries that involved overlap.

It is important to remember that overlapping surgeries have clear advantages, the researchers said, including maximizing the use of top surgeons and busy operating rooms, increasing patient access to necessary care and providing crucial training experience for junior surgeons. However, the researchers cautioned that these benefits must be weighed carefully against any potential risk to patients.


*Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA. 2019;321(8):762–772. doi:10.1001/jama.2019.0711

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