Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue

Qi Yan, Jeongsoo Kim, Daniel E. Hall, Myrick C. Shinall, Katherine Moll Reitz, Karyn B. Stitzenberg, Lillian S. Kao, Chen Pin Wang, Zhu Wang, Susanne Schmidt, Bradley B. Brimhall, Laura S. Manuel, Michael A. Jacobs, Paula K. Shireman

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Introduction: Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. Methods: The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. Results: Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. Conclusions: Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.

Original languageEnglish (US)
Pages (from-to)34-46
Number of pages13
JournalJournal of Surgical Research
StatePublished - Feb 2023


  • Clavien-Dindo level IV
  • Health disparities
  • Present at the time of surgery
  • Sex-related mortality

ASJC Scopus subject areas

  • Surgery


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