More Than Surgery

Illustration by Anne Kramer

Illustration by Anne Kramer

A little over six decades ago, kidney transplantation was not an option for those afflicted with chronic kidney disease. Almost five decades ago, the first human heart transplantation surgery lasted nine hours while the patient survived for less than three weeks afterwards. A little over three decades ago, the first robot-assisted surgical procedure was performed in neurosurgery. Undoubtedly, medical technology has been developing rapidly and continues to deliver the medical miracles we see today. Evermore cutting-edge research and technology seem to promise us a brighter medical future; however, amidst the excitement that surrounds medical breakthroughs like a halo, one question must not be forgotten: where is the patient? Buried underneath their CT or MRI scans, bloodwork, angiographies, biopsies, medical bills, or the publicity of newer surgical techniques, patients can easily miss having a say in their own treatments and recoveries.

“Historically, we’ve often measured things that we as physicians care about, and not necessarily things that the patients care about. And what people care about is, obviously, what’s going to affect their lives,” said Dr. Michael S. Avidan, MBBCh, an anaesthesiologist and intensive care physician at Barnes-Jewish Hospital, the Dr. Seymour and Rose T. Brown Professor of Anaesthesiology, and professor of surgery at Washington University in St. Louis School of Medicine (WUSM).

As an anaesthesiologist, Dr. Avidan’s plays a key role in overseeing the array of factors— preoperative, perioperative, and postoperative—that affect patients’ surgical outcomes. Anaesthesiology is a specialty that spans many different areas.

One particular area that Dr. Avidan’s research focuses on is in falls, especially preoperative falls, and their implications on patients’ health and outcomes. Research in this area is currently lacking.

“Because something like a fall can be associated with a whole number of different problems— like poor baseline health, diabetes, or heart diseases—researchers often might not think about falls specifically,” said Dr. Avidan, “But from the patient’s perspectives, especially with older adults, a fall can change your life.”

Falls, especially among the elderly, may lead to serious injuries that heavily compromise the independent living. In an aging society, the significance of falls and their prevention has been increasingly recognized by organizations like the Centres for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Patient-Centred Outcomes Research Institute (PCORI).

Recently, in August of this year, a study led by Dr. Avidan was published in EBioMedicine. The study examined 7982 unselected patients undergoing elective surgery for a correlation between preoperative falls and postoperative falls; other outcomes considered were functional dependence, quality of life, postoperative complications, and readmission. The study concluded that preoperative falls alone may indicate lower baseline health and predict worse overall surgical outcomes. Interestingly, the effect was not limited to elderly patients and was observed across all age groups. Much of the study has also been conducted by Vanessa L. Kronzer, a fourth year medical student at WUSM.

“We found that patients who had fallen [in the six months prior to surgery] also had worse functionalities and worse qualities of life after their surgeries than those who hadn’t fallen,” said Dr. Avidan.

Through a study called SATISFY-SOS (“Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys”), more than 15000 patients undergoing elective surgeries were enrolled and their health tracked from before surgery to one month, and later one year, after surgery.

The implication of this study is that just by incorporating a simple question into routine clinical practice, physicians can gain much information about patients’ qualities of life and baseline health conditions, thereby prevent or prepare for potential postoperative complications and/or risks to maximize patients’ outcomes.

The less obvious concern for patients undergoing elective surgeries is their postoperative cognitive recovery. Postoperative delirium is characterized by acute disturbances in consciousness, confusion, personality changes, and cognitive impairment; in contrast, postoperative cognitive dysfunction (POCD) is much harder to characterize and analyse in clinical settings. Generally, POCD occurs more frequently in elderly patients and is associated with a gradual decline in memory, concentration, and cognitive abilities.

“Delirium after surgery is incredibly common, especially among older adults and after big operations, and that can be very distressing for patients and their families,” said Dr. Avidan, “Cognitive decline after surgery is more complicated.”

Fortunately, both postoperative delirium and POCD are usually temporary. Patients tend to recover, as long as the surgery was successful and there are no other major postoperative complications.

Of course, the less glamorous cousin of intensive care is preventative care, which can only be effective and efficient if providers are able to first identify high-risk patients through simple indicators like preoperative falls. Many simple interventions may help decrease the risk of postoperative falls; for example, specific strengthening or balancing exercises, fewer medications (especially opioid analgesics and other sedatives), and safer home environments.

So what does all this mean for the patient? It means that the patient’s outcome should not be judged solely on the success of the surgery. A hip replacement or a total knee arthroplasty is no good unless it actually brings improvement to the patient’s life.

As Dr. Avidan mentioned, “People don’t just want their leg to be fixed or their heart to be fixed—they want their overall health to be improved, including cognitive health.”

Providers and patients alike need to be aware that medical care does not end with a surgery and that all surgical procedures, in spite of their benefits, induce trauma and stress responses. Ultimately, patients’ qualities of life and overall outcomes are not to be dictated by providers through a one-size-fits-all model.

“One of the key problems in medicine is that we have often made decisions for other people based on what we think is reasonable in terms of quality of life, and that’s not for us to determine. It’s for people to determine for themselves and to guide us to make joint decisions,” said Dr. Avidan.

Dr. Avidan further noted, “If you have a very good outcome to surgery – if pain decreases and inflammation decreases—you can actually have cognitive recovery and perhaps even cognitive improvement.”

He further explains that once the pain and inflammation after surgery improve, patients will be able to move around and exercise more, and with that comes improved quality of life and cognition.

Certain patient-related and management-related factors may affect cognitive recovery time. For example, the use of general over local anaesthesia, certain types of anaesthesia, longer and more invasive surgeries, revision surgeries, ages over sixty-five years, postoperative complications, pre-existing dementia etc.

Current research that aims to identify specific, sensitive, practical, age-independent, and sex-independent biomarkers for postoperative delirium or POCD has largely been inconclusive. There is a need for the scientific community to grant more emphasis and funding towards replication studies in the field of cognitive decline associated with surgeries. Cognitive recovery should be recognized as a goal of successful surgery.

“Anaesthesiologists are very involved in preoperative assessments and planning for every patient,” said Dr. Avidan, “[At Barnes-Jewish Hospital] we have an entire anaesthesiology team comprised of CRNAs [certified registered nurse anaesthetists], physicians, anaesthesiologists, and trainees to keep patients safe during the surgery.”

The task is easier said than done. Given the sheer range of medical and social factors that affect patients’ surgical outcomes, concentrating on any one or two factors is unlikely to have significant impact.

“If you manage everything well, then, taken together, there will probably be a relatively big impact [on patients’ recoveries],” said Dr. Avidan, “All you need to do is to do everything really, really well.”

It is time to acknowledge that patient outcomes depend on a multitude of factors interacting in various complex ways. A crucial step to pushing forward patient-centred care is to adopt more multidisciplinary approaches that will improve patients’ qualities of life not only under acute circumstances, but also in long-term outcomes of patients following discharge.


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