Major surgery may trigger a deterioration in long-term illness and delay patient recovery. We must use the time between the decision to perform surgery, and the procedure itself to assess the needs of individual patients, and to optimise treatment of long-term disease. There are many examples that show how we modify perioperative care to the benefit of both the patient and the healthcare system.
The needs of each patient
Most patients make a quick recovery after surgery, but not all. Medical complications such as pneumonia and myocardial infarction are an important cause of poor outcomes after surgery. As a cause of acute illness, surgery has one major advantage over sepsis, trauma and other conditions – we know when and where it is going to happen. This provides an opportunity to assess the needs of each individual patient, to determine the risks of the proposed surgery, and to optimise treatment of any long-term disease.
Taking this opportunity will allow both patient and doctor to make fully informed decisions about whether to proceed with surgery, and to plan the necessary care. Many patients who present for surgery have undiagnosed long-term illnesses such as lung disease or diabetes.
The decision to perform surgery
It is essential to make the most of the time between the decision to perform surgery, and the procedure itself. Delivering high-quality care in this limited time frame may be challenging, but there are many examples of it in the NHS today, which show how we can modify perioperative care to the benefit of both the patient and the healthcare system. We need to build on these models of care to embed planning before surgery into a pathway of care that continues until all the consequences of surgery have been addressed.
Assessing patient risk before surgery
Assessing the risk of complications following major surgery is a key part of perioperative care. All NHS hospitals provide nurse-led preoperative assessment, and four out of five also provide consultant anaesthetist led clinics to assess complex patients before surgery. This ensures all relevant medical problems are identified and treated in advance, so there are no surprises for the team on the day of surgery.
The approach to risk assessment is becoming increasingly sophisticated. Many hospitals offer Cardiopulmonary Exercise Testing (CPET) to assess physical fitness. This accurately quantifies exercise capacity, which has been used for many years as a guide to perioperative risk. Other forms of risk assessment include simple blood tests used elsewhere to assess heart failure, kidney disease and other acute and chronic conditions.
In one hospital in the south-west of the UK, risk-assessment data are used to generate survival curves using a statistical model. Surgeons and anaesthetists use this to help in deciding which patients require postoperative critical care, as well as other support. Early evidence suggests that patients who are assessed in clinics like these, have a higher rate of survival, although this may also be affected by other aspects of care.
The obvious benefit of preoperative assessment is the opportunity to optimise treatment of existing disease, and plan for care during and after surgery. However, these assessments also inform the discussions between doctor and patient, on whether surgery is the best option if the risks outweigh the benefits.
Multi-disciplinary teamwork in cancer surgery
Despite steady improvements in outcomes, patients undergoing major gastrointestinal surgery are still exposed to a significant risk of complications. Oesophageal and pancreatic surgery have some of the highest mortality rates for elective surgery. These procedures therefore need careful planning.
In many hospitals, anaesthetists now attend multi-disciplinary meetings with surgeons, oncologists, radiologists and specialist cancer nurses. The presence of a diverse group of experts allows the risks and benefits of different treatments to be carefully discussed. In some patients with serious co-morbidity, the risks of surgery may outweigh the benefits, and other less invasive treatments are considered.
Referrals for more detailed assessment and optimisation before surgery are made on the basis of these discussions and shared with patients. With the increasing use of neo-adjuvant chemotherapy before surgery, the need to tackle the problem of patient frailty is growing. In some centres, this multi-disciplinary approach is extended further to include a Care of the Elderly physician for all patients older than 65 or 70 years.
The inclusion of perioperative care within the cancer multi-disciplinary team is an excellent example of how we can broaden the view of the surgical team to focus not just on the index disease for which the patient is having surgery, but also on the harm associated with surgery itself.