Authors: Hyder O, Pawlik T M
Anesthesiology, March 12, 2026, 10.1097/ALN.0000000000005948
This national analysis examined the relationship between surgical urgency and perioperative mortality using a procedure-specific framework. Previous research had suggested that surgical urgency—elective versus nonelective—was the primary determinant of perioperative mortality, with reported mortality rates of approximately 0.3% for elective surgery and about 2.3% for nonelective surgery. However, those earlier analyses evaluated mortality at an aggregate level without accounting for differences among specific procedures. The authors sought to determine whether mortality risk varies substantially across procedure types within each urgency category.
The investigators conducted a retrospective cohort study using the 2022 Healthcare Cost and Utilization Project National Inpatient Sample, which represents approximately 20% of U.S. hospital discharges and covers roughly 97% of the national population. Adult patients undergoing major surgical procedures were included. Elective status was defined as elective admission with surgery performed on the day of admission and without emergency department codes.
Two classification systems were used to analyze procedures. First, the Procedure Classes Refined system was used to validate earlier findings. Second, the Centers for Disease Control and Prevention National Healthcare Safety Network operative procedure classification system was applied to categorize operations into 39 specific procedure types. This approach allowed the authors to compare identical surgical procedures performed under elective versus nonelective conditions.
Across the national dataset, the findings confirmed earlier work. Overall mortality was approximately 0.3% for elective procedures and about 2.4% for nonelective procedures, representing roughly an eightfold difference. However, when examined by individual procedure type, mortality risk varied dramatically.
Some procedures showed very large differences in mortality between elective and nonelective cases. Abdominal aortic aneurysm repair had one of the largest differences, with mortality of about 3.4% when performed electively versus 18.7% when performed urgently. Splenic surgery showed mortality of approximately 1.6% electively versus 12.7% nonelectively. Neurosurgical procedures demonstrated mortality of about 0.5% electively versus 11.4% nonelectively. In contrast, certain common procedures such as cesarean delivery had extremely low mortality regardless of urgency.
The analysis also examined how much each procedure contributed to overall surgical mortality. Some procedures accounted for a disproportionately large share of deaths relative to their frequency. For example, coronary artery bypass grafting and cardiac valve surgery accounted for only about 5.5% of elective procedures but represented over 31% of elective deaths. Similarly, neurosurgical procedures represented about 5.5% of nonelective cases but accounted for more than 26% of nonelective deaths.
Additional procedures disproportionately associated with nonelective mortality included colorectal surgery, small bowel surgery, exploratory laparotomy, and urgent cardiac operations.
The authors performed enrichment analysis to identify diagnoses that were commonly associated with high-risk nonelective procedures. Nonelective neurosurgical procedures were frequently associated with traumatic brain injury, subdural hemorrhage, and ischemic stroke requiring thrombectomy or hematoma evacuation. Nonelective colorectal procedures were commonly associated with peritonitis, septic shock, or abscess drainage. Small bowel procedures were often linked to bowel obstruction, perforation, or sepsis. Nonelective cardiac procedures were frequently associated with acute myocardial infarction and mechanical circulatory support interventions.
Overall, the analysis demonstrated that although surgical urgency is an important determinant of perioperative mortality, risk is not evenly distributed across procedures. Instead, mortality is concentrated in a relatively small number of high-risk operations and clinical scenarios.
The authors conclude that quality improvement efforts should not rely solely on urgency-based approaches. Instead, targeted strategies focusing on high-risk procedures and specific disease processes are likely to be more effective in reducing perioperative mortality.
What You Should Know
Nonelective surgery carries significantly higher mortality than elective surgery, but this risk varies widely depending on the procedure.
Certain operations—particularly cardiac surgery, neurosurgery, and major abdominal procedures—account for a disproportionate share of surgical deaths.
Many common emergency procedures such as appendectomy or cholecystectomy have relatively low mortality despite being nonelective.
Identifying procedure-specific risk patterns may allow more focused perioperative quality improvement efforts.
High-risk nonelective cases are often associated with severe underlying conditions such as trauma, organ ischemia, or sepsis.
Key Points
National analysis of more than five million surgical hospitalizations using the 2022 National Inpatient Sample.
Overall mortality was about 0.3% for elective surgery and about 2.4% for nonelective surgery.
Mortality differences varied widely across procedure types.
Procedures such as abdominal aortic aneurysm repair, splenic surgery, and neurosurgery showed large mortality differences between elective and nonelective cases.
Cardiac surgery and neurosurgical procedures accounted for a disproportionately large share of perioperative deaths.
Targeted procedure-specific strategies may be more effective than broad urgency-based interventions for reducing perioperative mortality.
Thank you to Anesthesiology for allowing us to summarize this article.