High-Risk Surgery and the Disruption of Restorative Sleep
Sleep is far more than a passive state of rest; it is a critical physiological process essential for metabolic homeostasis, immune modulation, neurocognitive function, and tissue repair. For the surgical patient, these processes are the very foundation of recovery. However, the perioperative period is notoriously disruptive to sleep, characterized by fragmented rest, environmental noise, and the physiological stress of the procedure itself.
While clinicians have long recognized that patients sleep poorly after surgery, the specific nature of these disruptions—and how they vary according to the complexity of the procedure—has remained poorly understood. A landmark study by Elemosho et al., recently published in JAMA Surgery, leverages wearable device technology to provide a high-resolution look at postoperative sleep dynamics. The findings suggest that the risk level of a surgical procedure dictates the depth and duration of sleep architecture impairment, with significant implications for postoperative complications.
Highlights of the Study
The research provides several critical insights into the relationship between surgical intervention and sleep:
1. Surgical risk is a primary determinant of sleep disruption: High-risk procedures lead to significant and sustained reductions in both REM and deep sleep, lasting at least a week postoperatively.
2. Opioid exposure exacerbates architectural changes: Opioids were found to increase light sleep and wake-stage durations while further suppressing restorative deep sleep.
3. Sleep loss correlates with clinical outcomes: Even minor reductions in total sleep duration were significantly associated with higher odds of postoperative complications (Clavien-Dindo grades I and II).
4. Wearable technology offers a viable pathway for long-term monitoring: The study demonstrates the utility of using consumer wearables to track recovery trajectories in the real world.
The Clinical Burden of Sleep Fragmentation
The physiological toll of surgery triggers a systemic inflammatory response, increases sympathetic nervous system activity, and alters the hypothalamic-pituitary-adrenal axis. Sleep is the primary mechanism through which the body rebalances these systems. When sleep is fragmented, particularly the deep (slow-wave) and Rapid Eye Movement (REM) stages, the body’s ability to manage pain, fight infection, and heal wounds is compromised.
Historically, studying sleep in surgical patients required polysomnography (PSG), which is cumbersome, expensive, and difficult to implement in an acute care setting. Consequently, most existing data on postoperative sleep were limited to small samples or short-duration observations. The advent of wearable devices allows for the continuous monitoring of sleep metrics across large populations in their natural environments, providing a more comprehensive view of the recovery timeline.
Study Design and Methodology
This retrospective cohort study utilized data from the All of Us Research Program, a large-scale, prospective database in the United States. Researchers identified 512 unique patients who underwent a total of 634 surgical procedures between January 2012 and December 2024.
To ensure data robusticity, participants were required to have at least 90 days of preoperative and 30 days of postoperative wearable sleep data. Procedures were stratified into low, intermediate, or high-risk categories based on established surgical risk scales. The primary outcomes measured included total sleep duration and specific durations of REM, deep, light, and wake-stage sleep across nine postoperative epochs.
The researchers utilized linear mixed-effects models to adjust for confounding variables, including patient age and opioid exposure (dose and duration). Furthermore, multivariate logistic regression was employed to assess the association between sleep metrics and postoperative complications, specifically those categorized under the Clavien-Dindo classification system.
Key Findings: Risk-Stratified Sleep Trajectories
The study revealed a clear dose-response relationship between surgical risk and the severity of sleep disruption.
High-Risk Procedures
High-risk surgeries, such as major abdominal or thoracic procedures, were associated with the most profound changes. Patients in this group experienced significant mean reductions in restorative sleep stages through postoperative day 7. Specifically, deep sleep decreased by an average of 18.7 minutes (P < .001) and REM sleep by 12.4 minutes (P < .001). Total sleep duration saw an acute drop of nearly 20 minutes in the immediate postoperative period. Perhaps most notably, wake-stage duration increased significantly, suggesting high levels of sleep fragmentation.
Intermediate and Low-Risk Procedures
Intermediate-risk procedures showed milder disruptions, with changes primarily localized to the first three days following surgery. By contrast, low-risk procedures (such as minor outpatient surgeries) did not result in statistically significant changes to any sleep metrics at any point during the postoperative epochs studied. This suggests that the physiological stress of the surgery itself, rather than just the hospital environment or the psychological stress of having a procedure, is a primary driver of sleep architecture changes.
The Role of Opioids and Age
Opioid exposure emerged as a significant modifier of sleep quality. The data indicated that opioids increased light sleep and wake-stage durations (approximately +10.2 minutes for wake) while suppressing deep sleep. This creates a clinical paradox: while opioids are necessary for pain management, they may simultaneously impair the very restorative processes needed for long-term recovery. Additionally, increasing age was linked to greater sleep fragmentation and reduced restorative sleep stages, suggesting that older patients may be particularly vulnerable to postoperative sleep deficits.
Sleep as a Predictor of Complications
One of the most clinically relevant findings was the association between sleep duration and surgical outcomes. The researchers found that each 10-minute reduction in the change of total sleep duration was associated with an 11.3% increase in the odds of experiencing Clavien-Dindo grade I or II complications (adjusted OR, 1.13; 95% CI, 1.04-1.24; P = .006). While these grades represent relatively minor complications, they are often precursors to more significant morbidity and can increase the length of hospital stays and healthcare costs.
Expert Commentary and Clinical Implications
This study represents a significant advancement in our understanding of the postoperative period. By using wearable technology, the authors moved beyond the “snapshot” view of recovery and provided a longitudinal map of physiological restoration.
From a mechanistic perspective, the suppression of REM and deep sleep following high-risk surgery is likely tied to the inflammatory cytokine surge (such as IL-6 and TNF-alpha) that accompanies major tissue trauma. These cytokines are known to modulate sleep-wake cycles. The findings regarding opioids reinforce the importance of opioid-sparing anesthetic and analgesic techniques, such as regional anesthesia and multimodal analgesia, which may help preserve sleep architecture.
However, the study is not without limitations. The use of wearable devices, while practical for large-scale data collection, may lack the precision of gold-standard polysomnography for distinguishing specific sleep stages. Furthermore, the cohort was 88% female, which may limit the generalizability of the findings to male populations. There is also a potential for selection bias, as individuals who consistently use wearable devices may have different health behaviors or socioeconomic statuses than the general surgical population.
Conclusion
The study by Elemosho and colleagues underscores that sleep is a vital sign of surgical recovery. The profound disruption of REM and deep sleep following high-risk surgery—and its direct association with complications—suggests that clinicians must prioritize sleep hygiene as part of postoperative care. Monitoring sleep via wearable technology could eventually serve as an early warning system, identifying patients who are failing to recover at an appropriate physiological pace. Future research should focus on whether interventions to improve sleep, such as melatonin administration or environmental modifications, can directly reduce complication rates and improve patient-reported outcomes.
References
Elemosho A, Chatzipanagiotou OP, Angez M, Baldo A, Mevawalla A, Ekenze SO, Alizai Q, Pawlik TM. Postoperative Sleep Dynamics Across Surgical Risk Using Wearable Device Technology. JAMA Surg. 2026 Feb 4. doi: 10.1001/jamasurg.2025.6386. Epub ahead of print. PMID: 41637091.
