What defines success after major surgery?

About 190 million adults undergo major surgery in high-income countries every year.¹ Older adults with concomitant frailty and comorbid disease constitute a substantial, and increasing, proportion of this population.² Despite these demographic shifts, evolutions in perioperative care and surgical technique have meant that short-term postoperative survival has continued to improve, especially in the setting of elective (or scheduled) surgery. For example, the risk of 30-day postoperative mortality was 1.1% in a multinational cohort of more than 20,000 adults (aged ≥ 45 yr) who underwent elective inpatient noncardiac surgery.³ If 99% of patients remain alive at 30 days following major noncardiac surgery, how should clinicians, researchers, and health system administrators then determine whether surgery and perioperative care were “successful”? In part to address this relatively low risk of postoperative mortality, there has been an increased focus on biomarker-based outcomes, such as acute elevations in troponin (i.e., acute myocardial injury) or creatinine (i.e., acute kidney injury). Even small elevations in such biomarkers are prognostically important, but often not associated with overt clinical symptoms.³ Thus, how patients view the importance of an asymptomatic elevation in a postoperative biomarker concentration is open to question. …