• Elinore J Kaufman, Luke J Keele, Christopher J Wirtalla, Claire B Rosen, Sanford E Roberts, Catherine L Mavroudis, Patrick M Reilly, Daniel N Holena, Matthew D McHugh, Dylan Small, and Rachel R Kelz.
• Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA.
• Ann. Surg. 2023 Jul 1; 278 (1): 727872-78.

ObjectiveTo determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.BackgroundMany emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.MethodsWe included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.ResultsFor hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.ConclusionsThe effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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