Fit for Surgery?

Abstract

In this issue of Anesthesia & Analgesia, Banz et al. “… provide a survey of fields of opportunities for improving outcome after major surgery.”1 In particular, they review the pathophysiologic considerations. They start by reminding us that despite patients having worse clinical and pathologic characteristics, outcomes are improving. Elective surgical patients are not sick and there is no need for them to get sick. Postoperative complications can be and should be completely avoided. An elective surgical procedure is not an illness but rather a marathon or a big hill. Patients are physiologically and emotionally challenged by trauma, inflammation, immunomodulation, pain, and any iatrogenic harm. A major determinant of outcome is their ability to rise to the challenge that they are presented with. We now have increasingly sophisticated strategies to minimize the challenges (i.e., shorten the marathon or reduce the size and slope of the hill). Modern perioperative care pathways have 3 broad strategic aims: (a) to modulate inflammation, (b) to minimize pain, and (c) to avoid iatrogenic harm. Over the last few decades, we have amassed an increasing understanding of the importance of balancing pro- and antiinflammatory responses to pathologic insults such as trauma or infection. We understand that excessive inflammation causes harm, but some inflammation is absolutely necessary to enable effective healing. As detailed in the article by Banz et al., modulating and immunomodulating strategies are now routinely used, such as the increasing use of minimally invasive surgery and optimizing oxygen delivery and tissue perfusion by using a goal-directed approach.2 A grayer area is the use of antiinflammatory drugs such as steroids. As our understanding of biology grows, options for therapeutic intervention and particularly drug intervention will increase. We can anticipate accelerated developments in this area, because a link has now clearly been demonstrated between systemic inflammation and postoperative cognitive dysfunction.3 Other potential areas for immune-modulation include the possibility of preemptive active or passive immunization of patients who have weakened or impaired natural immunity.4,5 Minimization of pain has always been at the heart of perioperative care, but the choice of therapeutic drugs has in reality changed little over the last 40 years. What has changed is the way in which we use the drugs. The increasing use of a multimodal approach and regional techniques that use ultrasound-guided catheter placements have improved the provision of postoperative pain relief. However, the biggest change has been the use of effective pain minimization to facilitate immediate postoperative mobilization. There is no doubt that achieving effective pain relief is much easier with minimally invasive surgical techniques such as laparoscopic and/or robotic surgery. Probably the biggest change in perioperative care in the last decade has been the increased awareness of, and avoidance of, iatrogenic harm. We now recognize that many of the traditions of perioperative care were not evidence based and caused more harm than good, approaches such as dehydration and starvation, the use of bowel preparation, the use of premedicating drugs and long-acting anesthetic drugs, enforced bed rest and nil-by-mouth postoperatively, routine placement of nasogastric tubes and percutaneous drains, salt and water overload, and the use of long-acting opiate drugs to relieve pain. We can add to this list the use of long midline incisions when smaller lateral incisions or laparoscopic techniques can be used to achieve the same goals. As concluded by Banz et al., bundles of care and pathways are undoubtedly the way forward. Much progress has been seen in this area, and the exemplar is the so-called “Enhanced Recovery” or “fast-track” approach to major surgery.6 Pioneered by Prof. Henrik Kehlet and now increasingly widely adopted throughout the world, Enhanced Reco