Predictors of Postoperative Morbidity Following Major Surgery: A Prospective Cohort Study Comparing Elective and Emergency Procedures

Background: Major emergency surgeries have been reported to carry greater postoperative morbidity compared to elective surgery.However, to what degree the difference exists due to urgency per se, rather than any concomitant physiological and operative risk profile, is not known.This study, therefore, compared major elective and emergency surgeries and independently evaluated predictors of overall postoperative morbidity.Methods: This was an observational cohort study that involved 300 adult patients who had undergone major surgery at a tertiary referral center from August 2024 to February 2026.The main outcome measure was the Comprehensive Complication Index (CCI).Patients were stratified based on whether they underwent elective (n=169) or emergency (n=131) surgery, and comparison between groups was done using nonparametric and categorical tests.Predictors of CCI were evaluated using multivariable linear regression analysis for the whole cohort, as well as independently for elective and emergency surgeries.The overall model considered surgical urgency, age, gender, body mass index (BMI), albumin, hemoglobin, length of surgery, bleeding volume, hemodynamic instability, and wound classification.Heteroscedasticityconsistent HC3 standard errors were applied.Results: Median CCI was 20.9 (interquartile range (IQR) 0-29.6) after elective surgery and 46.4 (IQR 23.4-74.2) after emergency surgery (p < 0.001).Additionally, emergency cases had longer median hospital stays (18 vs. 13 days), higher ICU stays (eight vs. one day), and higher mortality (19.8% vs. 3.0%).In the adjusted overall model (R²=0.481;adjusted R²=0.458), lower preoperative albumin (beta=-9.02per g/dL, 95% CI -13.82 to -4.21; p<0.001), contaminated wounds (beta=11.47,95% CI 4.07-18.86;p=0.002), dirty wounds (beta=20.16,95% CI 8.15-32.18;p=0.001), and intraoperative hemodynamic instability (beta=20.61,95% CI 12.38-28.84;p<0.001) independently predicted higher CCI.Emergency scheduling itself was not independently significant (beta=8.656,95% CI -5.796 to 23.108; p=0.240While for elective surgeries, lower albumin levels and intraoperative hemodynamic instability independently predicted higher CCI, in emergency patients, higher age, lower albumin levels, prolonged operative time, intraoperative hemodynamic instability, and contaminated or dirty wounds independently predicted higher CCI.Conclusions: The emergency cases showed increased morbidity rates over time, greater resource utilisation, and a higher death rate when compared to the planned elective procedures.However, emergency scheduling was not independently associated with CCI after adjusting for covariates in the multivariable model.In the entire sample, nutritional status, intra-operative hemodynamic instability, and wound contamination were found to be the important predictors of cumulative morbidity.The pattern of the important predictors was different when the patients were grouped according to the urgency of the surgery.Overall, the findings support the development of plans based on the urgency of surgery.In both elective and emergency settings, attention needs to be paid to better nutritional status and physiologic optimization, though it is impossible in the case of emergencies.Attention must also be paid to blood loss and hemodynamic instability during surgery.For surgical emergencies, additional attention is required for minimizing the operation time and wound contamination Categories: General Surgery