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The search was restricted to titles and abstracts, and the results were limited to studies that used human participants and were written in English. The search strategies are presented in online supplementary material 1. Database searching was complemented by reviewing the reference lists of eligible articles.

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Studies were included in the review if they met the following criteria:. Studies that measured surgical complications and psychosocial outcomes but not their association were not included as a primary analysis of reported data was beyond the scope of this review. Psychosocial outcomes were measured with validated self-report tools or psychological assessment.

Studies that reported surgical complications after cardiac, thoracic, gastrointestinal or vascular surgery, where complications are more likely to occur. Conference proceedings, non-empirical data and articles that were published before the year or with the majority of their participants recruited before the year were excluded. This current approach in the selection of literature was expected to reduce bias resulting from studies of out-dated surgical practices. The remaining half of the retrieved abstracts were reviewed by the primary researcher AP based on the consensus that was achieved for the first half.

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After excluding ineligible articles at abstract and title level, the remaining articles were assessed in full text. The eligibility criteria were applied again on each article.

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Reasons for exclusion were coded. Articles for which there was uncertainty were discussed between the primary researcher AP , a researcher with background in psychology RD and a researcher with background in surgery AA. Any disagreements were resolved by consensus. The primary researcher AP and a researcher with a background in surgery AA independently extracted data from 20 articles, which they reviewed for any disagreements. Disagreements were resolved by consensus or referral to a third senior researcher OF. Data were extracted from the remaining articles by the primary researcher and were later checked by the second reviewer AA.

A total of 10 authors were contacted by email to provide information that was not included in the manuscripts. Three articles were excluded from the analysis because their authors did not respond to our requests for further information. The latter included any reported findings on the association of surgical complications with the psychosocial outcomes, including both overall scale and subscale scores where available. The included studies were first synthesised narratively ie, using words and text. In order to quantify the degree of the impact of surgical complications on psychosocial outcomes, quantitative procedures were also used.

A meta-analysis was conducted on each extracted psychosocial outcome using Review Manager V. Nine hundred and ninety-four articles remained to be assessed in full text. A total of 51 articles 50 studies were eligible for inclusion in the final stage of the review see figure 1. There were 29 studies in gastrointestinal, 16—44 17 in cardiothoracic 45—62 and 4 in vascular surgery.

The most common indications for surgery were heart conditions, followed by different types of cancer. The majority of the studies were cohort studies. There were four case—control and 20 cross-sectional studies.

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The majority of the studies were prospective, including baseline measures of psychosocial outcomes. Cardiac: arrhythmia requiring treatment with antiarrhythmic medication or electrical cardioversion reversion; radiological evidence of pulmonary oedema; or myocardial infarction, defined by new Q waves on ECG or creatine kinase-MB isoenzyme concentration greater than twice normal. Renal: acute renal failure, defined by serum creatinine concentration greater than M. Sepsis: wound infection requiring excision of tissue or antibiotic therapy, or positive microbial culture other than pneumonia.

CLI, critical limb ischaemia; GRE, graft-related event; NA, not available; QoL, quality of life; VascuQol, a validated instrument assessing pain, symptoms, activities, social life and emotional state in patients with vascular disease. QoL was the main reported psychosocial outcome. Three studies measured anxiety, 30 40 62 four studies measured depression 31 41 49 62 and one study measured mood states. The vast majority of the studies used a priori definitions of complications. For example, Bloemen et al 19 recorded only severe complications based on a grading system of surgical complications.

Others used predefined categories of complications such as infections, respiratory complications, chronic postoperative pain or perioperative myocardial infarctions. A total of 14 studies did not define or describe the complications that were recorded. The majority of the studies recorded a range of postoperative complications. Eighteen studies focused on a single category of complications eg, anastomotic leaks, perioperative myocardial infarctions, wound complications, atrial fibrillation. Complications were mostly recorded through medical records review, clinical examinations and review of administrative databases.

Study quality varied. The scores of the included studies ranged from 2 to 8, with a mean score of 5. Points were deducted for the following reasons: lack of information on how complications were defined or on the methods for their recording, 16—18 21—23 25 29 35 37 40—42 46 51 55—57 61 63 lack of information on response rates, 16 21 22 25—27 29 37 40 50 52 54 55 57 60 61 baseline psychosocial outcomes were either not measured or controlled for, 17 19 20 25 27 30—36 38—40 43—45 47 49 53 63 and demographic or clinical factors were not controlled for.

Complications that were found to be significantly associated with worse psychosocial outcomes included both major events such as perioperative myocardial infarctions after CABG, 50 severe incontinence after internal sphincterectomy 31 or graft-related events after vascular surgery, 65 and minor complications such as wound infections after hepatic resection, 20 or new cardiac arrhythmias after CABG.

For example, four studies had very small samples.

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A series of supplementary meta-analyses were attempted on each extracted psychosocial outcome ie, QoL, anxiety, depression. For a meta-analysis on QoL, a synthesis of data from widely disparate assessment tools with very different composite scores eg, social, emotional and physical was not considered valid. For that reason, only studies that used the SF scales 67 were considered as they were the most commonly used QoL measures. Only three studies had sufficient data on the SF physical and mental QoL component scores.

Two studies provided sufficient data for a meta-analysis on anxiety. A meta-analysis on depression was not possible as there was only one study with available data. For a more detailed report of the meta-analyses, see online supplementary materials 2—4. The vast majority of those studies were of high quality. For instance, more than half of the studies with significant findings found that complications were an independent predictor of postoperative psychosocial outcomes after controlling for pre-existing differences on psychosocial outcomes, clinical and demographic variables.

Significant associations were reported in individual studies between surgical complications and lower scores on physical, emotional and social dimensions of the various QoL measures. A meta-analysis of three studies with sufficient QoL data collected with the SF scales suggests significant adverse effects of complications both on the physical and the mental health components.

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These findings are in agreement with earlier preliminary findings on the psychological burden that surgical adverse events often impose on patients. Despite the fact that QoL is a useful screening outcome offering a general picture of a person's physical health and psychological state, 68 future studies on the psychosocial impact of surgical complications should also consider outcomes such as anxiety and depression as they offer a more accurate picture of a person's psychological well-being.

Other relevant psychological outcomes such as post-traumatic stress, which was not measured in any of the included studies, would also be of relevance for future research in this area. It is also worth noting that strong conclusions cannot be drawn on the basis of the meta-analyses results due to the small number of studies included in them.

The exact relationships between surgical complications, psychological distress and speed of recovery warrant further investigation. Even in studies showing a significant impact, there will be many patients who largely maintain their psychological health and QoL in the aftermath of complications. Overall, the quality of the included studies was good as indicated by their relatively high-quality assessment scores and the small number of studies that scored exceptionally low. The fact that the included studies used validated self-report measures for the measurement of psychosocial outcomes and the use of a very comprehensive search strategy also increase the validity of the findings.

A few caveats should be borne in mind when interpreting the above findings. First, one-third of the studies did not define complications or did not describe the methods they used to record complications. Moreover, almost one-third of the studies did not provide information on response rates, which does not allow inferences about the representativeness of their samples. Regarding the methodology of the systematic review, studies that were published before the year or with the majority of patients recruited before the year were excluded, albeit limiting this review to literature that was published in the last decade is expected to be more reflective of current surgical practice.

It should also be noted that studies that were published past the final run of the search strategy ie, May have not been considered. Another limitation was the very small number of studies with sufficient data for quantitative synthesis and the difficulty of synthesising data from different QoL measures, which resulted in restricting the meta-analyses on data collected only with the SF scales.

Lastly, there is always the potential for publication bias where studies with significant results and big effect sizes are more easily published. Screening patients who suffer postoperative complications for symptoms of psychological distress could help identify those patients who need psychological support. Primary care practitioners and carers need to be aware of the psychological burden that surgical complications impose on patients in order to recognise their distress in time and to provide the support that patients need.

Patients who experience surgical complications report worse levels of different aspects of QoL than patients with uncomplicated recovery, often more than a year after their operation. Future research is needed on the contribution of the above factors on the impact of surgical complications on psychological outcomes such as anxiety, depression and post-traumatic stress, as well as on how to support patients who experience a complicated postoperative recovery. AP also screened all the articles retrieved by the literature searches, extracted and synthesised the data of the eligible for inclusion articles, appraised the study quality of the included articles and wrote the initial draft of this manuscript.

RD screened a sample of the retrieved articles at title, abstract and full text, and AA extracted data from and scored the quality of a sample of the included articles. Disclaimer: The views expressed are those of the author s and not necessarily those of the funders. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Data sharing statement: No additional data are available.

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BMJ Open. Published online Feb Author information Article notes Copyright and License information Disclaimer. Correspondence to Dr Anna Pinto; ku. This article has been cited by other articles in PMC. Abstract Objective Surgical complications may affect patients psychologically due to challenges such as prolonged recovery or long-lasting disability. Results 50 studies were included in the narrative synthesis. Conclusions Surgical complications appear to be a significant and often long-term predictor of patient postoperative psychosocial outcomes. Strengths and limitations of this study.

Introduction Surgical complications pose significant challenges for surgical patients. The three facets of the search strategy were: Adult surgical patients Terms such as patients, inpatients, outpatients, men and women were used for this facet. Patient psychosocial outcomes A broad definition of psychosocial outcomes was considered for the purposes of this systemic review including search terms for anxiety, depression, QoL and post-traumatic stress. Surgical complications Surgical complications were defined as any adverse event in relation to the surgical procedure including search terms for complications eg, adverse events, untoward incidents and terms about the surgical setting eg, surgical, postoperative.

Data extraction and quality assessment The primary researcher AP and a researcher with a background in surgery AA independently extracted data from 20 articles, which they reviewed for any disagreements. Data synthesis The included studies were first synthesised narratively ie, using words and text. Open in a separate window. Slippage with a peak incidence during the second postoperative year. Band erosion with penetration into the stomach. Patients who underwent colorectal resection for benign and malignant diseases. Symptoms specific to oesophageal cancer.

Meta-analyses A series of supplementary meta-analyses were attempted on each extracted psychosocial outcome ie, QoL, anxiety, depression. Limitations A few caveats should be borne in mind when interpreting the above findings. References 1. Classification of surgical complications: a new proposal with evaluation in a cohort of patients and results of a survey. Ann Surg ; — Postoperative complications and implications on patient-centered outcomes.

J Surg Res ; — Qual Health Care ; 2 — Patient experiences following cardiothoracic surgery: an interview study. Eur J Cardiovasc Nur ; 4 — Psychological stress and wound healing in humans: a systematic review and meta-analysis. J Psychosom Res ; 67 — Perceived stress and cortisol levels predict speed of wound healing in healthy male adults.

Psychoneuroendocrinology ; 29 — Herbert TB, Cohen S. Stress and immunity in humans: a meta-analytic review. Psychosom Med ; 55 — Psychoneuroimmunology: psychological influences on immune function and health. J Consult Clin Psych ; 70 — Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol ; 53 — Yehuda R. Post-traumatic stress disorder.

N Engl J Med ; — The incidence and nature of surgical adverse events in Colorado and Utah in Surgery ; — The Cochrane Collaboration. Review Manager RevMan.

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Version 5. Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Field AP, Gillett R. How to do a meta-analysis. Br J Math Stat Psychol ; 63 — Surgical complications exert a lasting effect on disease-specific health-related quality of life for patients with colorectal cancer. Satisfaction with care: an independent outcome measure in surgical oncology. Ann Surg Oncol ; 13 — Assessing patient-reported outcomes of cholecystectomy in short-stay surgery. Surg Endosc ; 22 — Long-term quality of life in patients with rectal cancer: association with severe postoperative complications and presence of a stoma.

Dis Colon Rectum ; 52 —8. Quality of life after curative liver resection: a single center analysis. World J Gastroenterol ; 16 — Quality of life after laparoscopic gastric banding: prospective study cases with a follow-up of 2 years. Surg Laparosc Endosc Percutan ; 16 —6. Prospective study of health-related quality of life after Roux-en-Y bypass surgery for morbid obesity. Br J Surg ; 97 —6. RCS commissioning guides - grouped by topic - are available for download below. We aim to continually improve our commissioning guides to meet the needs of commissioners and providers.

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