A large study has found that 4 of every 100 surgical patients die in the 2 months after their surgery. That is at least twice as high as what was previously thought. The study included more than 46,000 surgery patients in 28 European countries. All types of surgery except heart-related surgery were included. In the 60 days after surgery, 4% died. Deaths were from all causes, not just surgical complications. But most people who died were never admitted to intensive care. Rates varied by country as well.

By Mary E. Pickett, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

This week, I found my husband looking stunned after a phone call about a childhood friend. "I know he was young," the brother of his friend had told him, "but he died two weeks after routine gallbladder surgery. They think it was a clot." My husband showed me a picture of his friend -- a father with young children -- that his friend had texted to him after a recent fishing trip.

No one expects complications when they have surgery. But complications occur. This week, researchers showed us that death rates after surgery may be more than twice as high as previous estimates. A study tracked 46,000 adult patients from 500 hospitals in Europe. All of them had surgery. None of the surgeries involved the heart. The death rate in the first 60 days after surgery was 4%: a number that nobody expected. Certainly, not all of these deaths were caused by surgery. All of these people had medical problems that led to surgeries in the first place. But it is worth considering surgical risk.

Why does surgery put people at risk? We used to speak about the "risks of anesthesia." In truth, close monitoring and skilled medical care has made this risk very low. Many of my own patients also think about surgery as a "stress." But most people who die after surgery don't die from anesthesia or from stress. They die from blood clots. Heart attack, stroke, pulmonary embolism, sudden death -- these big events all come from blood clots.

When you are well and are not having surgery, your blood makes sure that clots do not form too easily. Small "starter clots" form and are broken down quickly. But after an injury -- or after surgery -- blood vessels that have been cut or damaged send a chemical message into your bloodstream. This chemical message results in blood that clots more easily. Your body needs to stop bleeding from places where you have been cut. It is an ingenious thing that your body can start the healing process after injury. But this shift in priorities -- clot, so you will not bleed -- makes the weeks of healing from surgery a time of real risk.

How risky is surgery if you are in good health when you enter it? One example that has been studied closely is prostate surgery. Prostatectomy leads to about 1 death for every 200 patients who have the operation (a mortality rate of 0.5%). In addition, 3 in 100 (3%) of patients will have a severe artery clot event, such as a heart attack or stroke, and 2 in 100 (2%) will have a clot in a vein (deep venous thrombosis, or DVT).

What Changes Can I Make Now?

Most people who have surgery will get through the operation and the recovery with no major problems. Still, if you are considering surgery, be informed about the risks. Do what you can to stay safe.

• Pass up surgeries that are not essential. Ask about other options for treatment. No surgery is free of risk.
• Put your health in order first. Your risk will be lowest after surgery if chronic illnesses are in good control. Your risk can be increased by high blood pressure, poor diabetes control and thyroid disease that hasn't been recently monitored.
• Get back on your feet. Staying in bed after surgery may seem to make sense, but it is not good for you. If you can get up and walk, do it. Walk with a nurse or physical therapist when you are first recovering. Then stay active once you are home.
• Be a non-smoker. Smoking increases clot risk. Avoid smoking in the week that leads up to surgery and in the month that follows. Surgery is a great opportunity to quit smoking.
• Restart aspirin. Aspirin is commonly stopped a week before surgeries. It does not always need to be stopped. Most people who have a strong need for aspirin should continue it before surgery. This can include people with a history of heart attack or a stent in an artery. Surgeries for which aspirin must be stopped are surgeries in the brain, the spine, the middle ear, some bladder operations and some deep eye operations (but not cataract surgery). The American College of Chest Physicians recommends that patients restart their usual aspirin the morning after surgery, as long as there are no signs of bleeding.

What Can I Expect Looking to the Future?

Today, more surgeries can be done with minimally invasive techniques. Procedures such as robotic surgeries or camera-guided (endoscopic) surgeries allow some people to avoid having large surgical wounds.

It is not yet clear whether endoscopic surgeries offer a real safety advantage. These surgeries may take a bit longer in the operating room. When a surgery becomes complex, these techniques may not allow enough maneuvering. But when less invasive surgeries go well, they allow for faster healing.

Future study will be able to tell us whether the risks for catastrophic complications are lower for these surgeries, compared with open operations. It is likely that less invasive surgeries do carry lower risks, so it is likely we will see more of them in the future.