Impact of Surgery Duration on Postoperative Mortality in Patients With Cirrhosis

While preoperative risk assessment tools exist to estimate mortality, less is known about intraoperative factors, such as surgery duration, which may impact surgical outcomes in this patient population. Understanding these factors could help optimize postoperative care for a population in which surgery often cannot be deferred. This study aimed to evaluate the independent association between surgery duration and 90-day postoperative mortality in patients with cirrhosis.

We conducted a retrospective cohort study of 11,088 patients with cirrhosis undergoing diverse surgeries under general anesthesia, using merged data from the Veterans Outcomes and Costs Associated with Liver Disease dataset with the Veterans Affairs Surgical Quality Improvement Program. Multivariable logistic regression assessed the association between surgery duration and 90-day postoperative mortality, which was transformed using restricted cubic splines due to nonlinearity. Interactions with American Society of Anesthesiologists (ASA) class, surgery type, model for end-stage liver disease with sodium, and laparoscopic surgery were explored.

Overall, 324 (2.9%) patients died within 90 days. In adjusted analyses, surgery duration was significantly associated with 90-day postoperative mortality, demonstrating a bimodal pattern where shorter and longer duration surgeries conferred higher mortality risk. A significant interaction between ASA class and surgery duration (P = .002) was found, suggesting ASA 3 patients may experience disproportionately increased mortality. Sensitivity analyses accounting for center-level variation and exclusion of surgeries less than 30 minutes confirmed the robustness of findings.

Surgery duration is independently and nonlinearly associated with 90-day postoperative mortality in patients with cirrhosis, with important interaction by ASA class. Surgery duration may enhance postoperative risk stratification by triaging high-risk patients who may need more intensive postoperative management.