Risk Of Emergency Surgery Research Articles

A population-based case–control study on statin exposure and risk of acute diverticular disease

Objective: A reduced risk of perforated diverticular disease among individuals with current statin exposure has been reported. The aim of the present study was to investigate whether statins reduce the risk of acute diverticular disease. Material and methods: A nation-wide population-based case–control study was performed, including 13,127 cases hospitalised during 2006–2010 with a first-time diagnosis of colonic diverticular disease, and 128,442 control subjects (matched for sex, age, county of residence and calendar year). Emergency surgery, assumed to be a proxy for complicated diverticulitis, was performed on 906 of the cases during the index admission, with 8818 matched controls. Statin exposure was classified as “current” or “former” if a statin prescription was last dispensed ≤125 days or >125 days before index date, respectively. The association between statin exposure and acute diverticular disease was investigated by conditional logistic regression, including models adjusting for country of birth, educational level, marital status, comorbidities, nonsteroidal anti-inflammatory drug/steroid exposure and healthcare utilisation. Results: A total of 1959 cases (14.9%) and 16,456 controls (12.8%) were current statin users (crude OR 1.23 [95% CI 1.17–1.30]; fully adjusted OR 1.00 [0.94–1.06]). One hundred and thirty-two of the cases subjected to surgery (14.6%), and 1441 of the corresponding controls (16.3%) were current statin users (crude OR 0.89 [95% CI 0.73–1.08]; fully adjusted OR 0.70 [0.55–0.89]). Conclusions: The results do not indicate that statins affect the development of symptomatic diverticular disease in general. However, current statin use was associated with a reduced risk of emergency surgery for diverticular disease.

Wound Healing Following Open Groin Hernia Surgery: The Impact of Comorbidity.

The aim of this study was to explore the impact of chronic concomitant disease on the risk for postoperative complications following open groin hernia surgery. During the study period (2002-2011), 133,074 open repairs were registered in the Swedish Hernia Register. History of peripheral vascular disorders, connective tissue disease, chronic renal failure, obesity, and liver cirrhosis as well as data on hemorrhage or hematoma, wound dehiscence, postoperative infection, and reoperation for superficial infection or bleeding within 30 days after surgery were obtained by matching with the Swedish Patient Register. In the multivariate logistic regression analysis, a significantly increased risk for hemorrhage or hematoma within 30 days after surgery was seen for older patients, males, liver cirrhosis, peripheral vascular disease, and connective tissue disease (p < 0.05). High age (>80 years), previous history of peripheral vascular disease, connective tissue disease, and male gender were risk factors for wound dehiscence (p < 0.05). Liver cirrhosis, chronic kidney disease, BMI > 25, and male gender were associated with increased risk for postoperative wound infection (p < 0.05). A significantly increased risk for reoperation for superficial infection or bleeding was seen in patients with peripheral vascular disease and elderly patients (p < 0.05). Risk for postoperative complications in open groin hernia surgery is increased in elderly patients, patients with liver cirrhosis, and those with peripheral vascular disease. The indications for surgery should be weighed against the risk for wound-healing complications in these patient groups. Watchful waiting may be an alternative, although this carries the risk of emergency surgery.

Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.

To characterize the clinical course of patients with diverticulitis after nonoperative management and determine factors associated with readmission and subsequent emergency surgery. Clinical course of this disease remains poorly understood; indications for elective colectomy are unclear. This was a retrospective cohort study of patients managed nonoperatively after a first episode of diverticulitis in Ontario, Canada (2002-2012). Time-to-event analysis and Fine and Gray multivariable regression were used to characterize the risks of readmission and emergency surgery for diverticulitis, accounting for death and elective colectomy as competing events. A total of 14,124 patients were followed for a median of 3.9 years (maximum 10, interquartile range: 1.7-6.4). Five-year cumulative incidence was 9.0% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality. Patients younger than 50 years had higher incidence of readmission than patients aged 50 years and older (10.5% vs 8.4%; P < 0.001) but not emergency surgery (1.8% vs 2.0%; P = 0.52). Patients with complicated disease (abscess, perforation) were at increased risk of readmission than those with uncomplicated disease (12.0% vs 8.2%; P < 0.001), as well as increased risk of emergency surgery (4.3% vs 1.4%, P < 0.001). In multivariable regression, complicated disease and number of prior admissions were associated with increased risk of emergency surgery, yet age less than 50 years was not. Risks associated with complicated disease were nonproportional over time, being highest immediately after discharge and decreasing thereafter. Absolute risks of readmission and emergency surgery are low after nonoperative management of diverticulitis, providing evidence for the practice of deferring colectomy for patients without persistent symptoms or multiple recurrences.

Racial/ethnic and socioeconomic disparities in the use of helmets in children involved in bicycle accidents

PurposeWhile bicycle helmet use reduces bicycle-related head injury, few children wear them regularly. We aimed to describe racial/ethnic and socioeconomic differences in pediatric helmet use in Los Angeles County (LAC) to help target groups for injury prevention programs. MethodsA retrospective review of all pediatric patients involved in bicycle-related accidents in LAC between 2006 and 2011 was performed. Our primary analysis examined the association between helmet use and age, gender, insurance status, and race/ethnicity. We also evaluated the association between helmet use and the need for emergency surgery, mortality, and length of hospital stay (LOH), after adjusting for injury severity score (ISS), age, insurance status, and race/ethnicity. ResultsOf 1248 patients, 11.3% wore helmets, with decreased use among children 12years and older, minorities, and those without private insurance. Overall, 5.9% required an emergency operation, 34.1% returned to their pre-injury capacity, and mortality was 0.7%. On multivariable analysis, higher ISS increased LOH, the risk for emergency surgery, and mortality. ConclusionNearly 90% of children involved in bicycle-related accidents were not wearing helmets. Helmet use was lower among older children, minorities, and those from a low socioeconomic status. Injury prevention programs targeting low-income middle and high schools and minority communities may help increase helmet use in children in LAC.

The development and validation of the Calculation of post-Operative Risk in Emergency Surgery (CORES) model

This study was undertaken to establish a model to predict the post-operative mortality for emergency surgeries. A regression model was constructed to predict in-hospital mortality using data from a cohort of 479 cases of emergency surgery performed in a Japanese referral hospital. The discrimination power of the current model termed the Calculation of post-Operative Risk in Emergency Surgery (CORES), and Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were validated using the area under the receiver operating characteristic curve (AUC) in another cohort of 494 cases in the same hospital (validation subset). We further evaluated the accuracy of the CORES in a cohort of 1,471 cases in six hospitals (multicenter subset). CORES requires only five preoperative variables, while the P-POSSUM requires 20 variables. In the validation subset, the CORES model had a similar discrimination power as the P-POSSUM for detecting in-hospital mortality (AUC, 95% CI for CORES: 0.86, 0.80-0.93; for P-POSSUM: 0.88, 0.82-0.93). The predicted mortality rates of the CORES model significantly correlated with the severity of the post-operative complications. The subsequent multicenter study also demonstrated that the CORES model exhibited a high AUC value (0.85: 0.81-0.89) and a significant correlation with the post-operative morbidity. This model for emergency surgery, the CORES, demonstrated a similar discriminatory power to the P-POSSUM in predicting post-operative mortality. However, the CORES model has a substantial advantage over the P-POSSUM in that it utilizes far fewer variables.

Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion‐based audit

To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. A quality assurance analysis based on a retrospective criterion-based audit. Two rural hospitals in Tanzania. From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. Prevalence of suboptimal care. Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.

Are there racial disparities in the use of restraints and outcomes in children after motor vehicle crashes?

BackgroundThis study determines whether racial/ethnic disparities exist with respect to restraint use and outcomes in pediatric motor vehicle crash passengers. MethodsA review of passengers (<16 years old) involved in motor vehicle crashes from the National Trauma Database from 2002 to 2006 was performed. Outcome measures were emergency surgery, morbidity, mortality, and length of stay (LOS). ResultsA total of 37,375 patients were identified (mean age, 9.3 years; 95% confidence interval, 9.2-9.4 years; 59% male). Of the patients, 45.7% were restrained with the lowest use among African Americans, Hispanics, and Native Americans; 12.6% required emergency surgery; morbidity was 6.7%, and mortality, 5.8%. On multivariable analysis, race/ethnicity did not affect mortality or LOS. Higher Injury Severity Score (ISS) was associated with increased need for emergency operation, higher morbidity and mortality, and longer LOS. The use of restraints was associated with a lower ISS and a decreased risk for emergency surgery. The interaction between restraint use and ISS increased the need for emergency surgery, morbidity, and LOS. ConclusionsLess than half of pediatric passengers in this study were restrained. The use of restraints was associated with a lower ISS, whereas a higher ISS was associated with increased need for emergency surgery, morbidity, mortality, and LOS. These data emphasize the need for increased education in preventive measures to minimize the risk of death and injury.

Article review: Left-sided acute diverticulitis

Background. The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. Methods. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. Results. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32.6%) underwent emergency surgery at accrual. After a mean follow-up of 10.7 years, rates of recurrence (17.2% vs. 5.8%; P < 0.001) and emergency surgery (6.9% vs. 1.3%; P = 0.021) were higher in medically treated patients than in those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1% and diseaserelated mortality was zero in this group. The disease-related mortality rate was 0.6% among patients who had surgical treatment. Conclusion. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Emergency Surgery in the Elderly: A Retrospective Observational Study

We conducted a retrospective observational study in a regional hospital on patients aged 80 years or over undergoing emergency procedures. We included 202 emergency procedures performed on 178 patients over 185 separate admissions. The aim was to obtain a 'snapshot' of the risks of emergency surgery in the elderly and to analyse functional status both as a risk factor and as an outcome in this patient group. The most common complications were infective (21% of patients), cardiovascular (18%) and neurological (18%). Overall mortality was 9%. Increasing age, higher American Society of Anesthesiologists physical status score and poorer pre-admission functional status appeared to be associated with increased complications and mortality. Although two-thirds of both functionally independent and partially dependent patients were discharged at their original level of function, 28% of partially dependent patients required discharge to a high-level care nursing home, whereas only 5% of the initially independent patients had this poor outcome. Improvement in our ability to stratify risk in this enlarging patient group should help improve our clinical decision-making, which may have benefits both for patients and resource allocation.

Multicentre observational study of the natural history of left-sided acute diverticulitis

The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Update on the Indications and Use of Colonic Stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Management of Acute Sigmoid Volvulus: An Institution’s Experience Over 9 Years

Management of sigmoid volvulus is often challenging because of its prevalence in high-risk patients and the associated perioperative morbidity and mortality rates. This study was designed to review the management and outcome of all patients admitted with sigmoid volvulus. A retrospective review of all patients who were admitted for sigmoid volvulus from October 2001 to June 2009 was performed. Diagnosis was confirmed on clinical evaluation, radiological studies, and/or intraoperative findings. Seventy-one patients, median age 73 (range, 17-96) years, were admitted a total of 134 times for acute sigmoid volvulus during the study period. The majority (n = 51, 71.8%) were older than aged 60 years, and 41 (57.7%) had at least one premorbid condition. Seven (9.9%) patients underwent emergency surgery on presentation. The remaining 64 (90.1%) patients were initially managed conservatively using a flatus tube and/or sigmoidoscopic decompression. One patient had an endoscopic-related perforation and required emergency surgery. Another ten patients failed conservative management for which nine underwent operative intervention. The last patient refused surgery and died subsequently. Fifty-three (74.6%) patients had successful conservative management; seven of them underwent elective surgery subsequently. Of the remaining 46 patients, 28 (60.9%) were admitted for recurrent sigmoid volvulus. Of these 28 patients, 12 eventually had elective surgery after successful decompression, whereas the remaining 16 were not operated. In our series, three patients died after emergency surgery and there was no mortality after elective surgery. Another six patients died from medical conditions that were unrelated to sigmoid volvulus. Acute sigmoid volvulus is a surgical emergency, although the majority (75%) can be successfully decompressed nonoperatively. Emergency surgery in these patients is associated with a mortality of 17.6% in our series. Elective definitive surgery is suggested in view of the high recurrence rate (>60%) and the considerable risks of emergency surgery.

Repeat Mitral Valve Replacement: 30-Years’ Experience

Prosthetic heart valve dysfunction is an acquired condition that carries a significant risk of emergency surgery. However, the long-term natural history of the condition is not well understood. Between 1974 and 2006, 1535 isolated mitral valve replacements were performed at our hospital (in-hospital mortality 5%). In total, 369 patients needed a second operation (in-hospital mortality 8.1%), while 80 (age 59.8+/-11.4 years) needed a third. The reasons for the third intervention were structural deterioration (67.5%), paravalvular leak (20%) and endocarditis (6.3%). Some 15 patients died in hospital (18.8%). After a mean follow-up period of 17.8 years, 21 patients needed another intervention (i.e., a fourth intervention). The actuarial reoperation-free rate at 20 years was 40.1+/-13.8%. The late mortality rate was 58.5% (18-year survival rate 15.4+/-5.4%). Indications for repeat mitral valve replacement must be judged on an individual basis given the high risk associated with surgery.

Dual Therapy Versus Monotherapy in the Endoscopic Treatment of High-Risk Bleeding Ulcers: A Meta-Analysis of Controlled Trials

There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy. A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis. Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death). Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.

Paraesophageal hernias: operation or observation?

To examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. The management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. A Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted life-years (QALYs). Analysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. If ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.

Effective Dose at Pneumatic Reduction of Paediatric Intussusception

AIM: The purpose of this study was to assess screening times and resulting dose implication at pneumatic reduction of intussusception in the paediatric age group and to examine the relationship with the outcome of the procedure.MATERIALS AND METHODS: We retrospectively reviewed the case notes and departmental records of 143 children who had undergone a total of 153 pneumatic reductions in our department over a 4-year period. Success rates, screening times and available dose-area products (DAP) were recorded. The DAPs were converted to effective dose (ED) for 77 procedures.RESULTS: A 76.5% (117/153) success rate was achieved with a recurrence rate of 6.5% and only one complication: a perforation. Screening times were recorded in 137 reductions and ranged from 15s to 22.6min. Although the longest screening time was associated with an unsuccessful outcome, the second longest time of 21min was successful. This gave a DAP of 1278cGycm2and an ED of 12.73mSv, which is equivalent to approximately 400 abdominal films for a 1-year-old. A lifetime risk of fatal cancer of one in 1000 was achieved, assuming the worst case, after a screening time of 30min on our conventional fluoroscopy unit.CONCLUSION: Our success rate compares well with other centres. Our institution is a tertiary referral centre and the occasional long screening time may reflect the delay and complex nature of the patients referred. Persistence at air reduction may be successful and the success rate increases with delayed attempts but the risks of the increasing radiation burden must be weighed against the risks of emergency surgery and anaesthesia.Heenan, S. D. (2000). Clinical Radiology55, 811–816.

The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited.

The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited.

The risks of emergency surgery for acute cholecystitis.

At the University Hospitals of Cleveland we have felt that a diagnosis of acute cholecystitis demands immediate hospitalization of the patient, but that definitive treatment should be on the ward rather than in the operating room. These patients are admitted to the surgical service in spite of this non-surgical attitude, for experience with this disease has convinced us that its course is not predictable and that a significant percentage of these patients will fail to improve even on intensive medical therapy. Once failure has become apparent, we have not hesitated to operate at any time of day or night on an emergency, off-schedule basis. It was hoped that most patients could be carried through an acute attack of cholecystitis without nonelective surgery; however, on reviewing our recent cases, we have found that approximately one-third of them have gone to the operating room as an emergency after medical treatment failed. This

Causes of operative mortality in chronically ill geriatric patients: II. With an analysis of eighty additional consecutive autopsy records

Eighty consecutive autopsy records in the various systems are analyzed among patients sixty years and over who died within one month after elective and emergency surgery at the Goldwater Memorial Hospital, the population of which consists chiefly of chronically ill geriatric patients who are extreme substandard surgical risks. These cases occurred between the years 1946 and 1952, when the antibiotics were available and when there was also improvement in various types of supportive therapy. The males predominated in a proportion of about 5:1, and a little less than half of all patients were in the eighth decade. In a previous communication 100 autopsies between the years 1939 and 1945, the chemotherapeutic period, have been analyzed and discussed. The pattern of the principal and contributory causes of death was similar in both groups although the mortality rate among all operated cases dropped 7 per cent in the elective and 21 per cent in the emergency cases in the antibiotic period. The outstanding principal causes of death in the present study were bronchopneumonia and peritonitis, and cardiac failure with accompanying pulmonary edema in a little over half the cases. During this same period there was a diminution in the number of deaths from cardiac failure, sepsis, and peritoneal and kidney infection. It is difficult to explain the rise in deaths from bronchopneumonia unless it can be attributed to a longer life after operation and therefore increased susceptibility to the factors which predispose to bronchopneumonia. Other important causes of death were thrombosis and embolism, and pyelonephritis. Among the impressive contributory causes of death were pyelonephritis and cystitis, metastatic carcinoma, intestinal obstruction, intraabdominal abscess, infarcts in abdominal viscera, cirrhosis of the liver, hepatitis, decubitus ulcers and pleural effusion. Most of the deaths after gastrointestinal operations were caused by bronchopneumonia, peritonitis and cardiac failure; after biliary tract operations by bronchopneumonia, cardiac failure and peritonitis; after genitourinary operations by bronchopneumonia, cardiac failure and pulmonary edema, pyelonephritis and peritonitis; and after extremity operations by thrombosis, bronchopneumonia and cardiac failure. Some of the factors which precipitated the deaths were analyzed. Among the more important was the increased risk in emergency surgery, with mortality about twice that of elective surgery, especially when patients came to operation too late. They had rapid deterioration and often irreversible changes or shock which supportive therapy could not combat. Other factors were accompanying multiple degenerative diseases, errors in diagnosis and technics and contraindicated technics. Surgical errors in chronically ill geriatric patients are costly. Their diminished homeostasis and reserve are not comparable with the better repair and vital processes and recuperative powers in younger, healthier people. Mortalities tend to increase with advancing years. Suggestions are made for possible reduction of operative mortality. These include the proper and intensive antibiotic and supportive therapy and indicated operative management. In emergency surgery, especially if the patient is in poor condition, it is safer, if possible, to do just enough to give the patient relief and tide him over until such time as his improved condition warrants additional surgical therapy.