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doi: 10.1097/ALN.0000000000000214

Predicting Postoperative Morbidity: In What Procedures and What Patients?

Kehlet, Henrik M.D., Ph.D.; Jørgensen, Christoffer C. M.D.

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To the Editor:

In an extensive effort, Moonesinghe et al.1 summarize risk-stratification tools for predicting morbidity and mortality after major surgery and conclude that studies have limitations and further international studies are required regarding clinical decision making and patient outcome. Although this review is a laudable effort, unfortunately the review predominantly is based on studies published before 2010 and may otherwise not provide a critical reassessment to the question raised in 2013 for several reasons:
1. First of all, the review fails to discuss that surgical techniques have changed over the last decade regarding the use of different minimal invasive techniques which may decrease postoperative morbidity, and thereby hindering translation of previous prediction studies from open procedures to minimal invasive surgery.
2. There is a need for procedure-specific studies and not a combination of prediction studies from different surgeries, because different procedures have different outcome problems and different pathogenic mechanisms.
3. There is no mentioning in the review by Moonesinghe et al.1 of the implications of the fast-track methodology (or Enhanced Recovery Programs) for the value of predictive scores. This may be important, because these optimized perioperative care programs have been demonstrated to decrease postoperative morbidity,2–4 but neither included nor mentioned in the reported studies. Therefore, valid future predictive tools must be based on well-defined, procedure-specific, evidence-based care programs including details on choice of anesthetic and analgesic techniques, which may also modify outcomes. Such assessments may preferably be based on studies based on the question “Why is the surgical high-risk patient at risk?,”3 or in other words whether new predictive tools will show whether the previous risk indices may or may not be exported to fast-track surgery.3,4
In conclusion, there is an urgent need for new and better tools to predict postoperative morbidity after major surgery compared with previous data. Such efforts should consider developments in surgical techniques, surgical care and anesthetic and opioid-sparing multimodal analgesic techniques, and then on a procedure-specific basis. Otherwise, we will continue to look at data which reflect the past surgical and perioperative care programs which may not be able to provide relevant information where modern care principles have been introduced.
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Competing Interests

The authors declare no competing interests.
Henrik Kehlet, M.D., Ph.D., Christoffer C. Jørgensen, M.D.
Rigshospitalet, Copenhagen, Denmark (H.K.).
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1. Moonesinghe SR, Mythen MG, Das P, Rowan KM, Grocott MP. Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: Qualitative systematic review. ANESTHESIOLOGY. 2013;119:959–81

2. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr. 2010;29:434–40

3. Kehlet H, Mythen M. Why is the surgical high-risk patient still at risk? Br J Anaesth. 2011;106:289–91

4. Kehlet H. Fast-track hip and knee arthroplasty. Lancet. 2013;381:1600–2

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