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Improving surgical outcomes

Review of evidence
Review of pilot studies
Doing it
Comment

Bandolier occasionally likes to look at something different. A remarkably different paper from 2002 might be hailed as a new departure in the use of evidence [1]. This paper applies the best evidence we have to thinking about surgical interventions, and not just what to do, but how to do it. It pulls together evidence about perioperative medicine, performs a systematic review of pilot studies, and suggests mechanisms of implementation.

Review of evidence

The paper has 144 references, many of them systematic reviews and meta-analyses in the area of perioperative medicine. While in some circles surgery is thought to be an “evidence-free zone”, there is actually a remarkably strong body of evidence, and particularly in the area of perioperative medicine. The review of evidence (Figure 1) breaks this down into:


Figure 1: Factors in recovery from surgery
































Review of pilot studies

The authors provide us with a summary of results from fast-track surgical programs, most of which are small, and not randomised, and in many different settings. As such, they would be inadequate compared with a review based only on randomised trials.

On the other hand, fast track programs reduced postoperative hospital stay by 60-70%. For instance, two case series of open and laparoscopic colorectal resections sent patients home in 2-3 days, compared with 4-11 days with traditional surgery, and with reduced morbidity in high risk patients.

Doing it

Accelerated recovery programmes need multidisciplinary collaboration and seamless organisation. A bare outline of the process is in the Box below. The authors set out known principles of good management (the sort that get things done, not medical management, or the sort in large organisations that exist to avoid getting things done).




Organisational steps for fast track surgery

  1. Develop a plan or critical pathway
  2. Outline specifics of preoperative preparation
  3. Develop anaesthesia and analgesia programmes
  4. Minimise stress of operation
  5. Adjust postoperative care according to evidence-based studies
  6. Develop postoperative nursing care programmes
  7. Determine patient follow up
  8. Develop a patient information programme
  9. Document results, tabulate problems and patient satisfaction
  10. Revise and improve programme



Comment

Cookbook medicine this is not. The complete article it is not. But, boy, does it make you think. This particular paper could be expanded into a book, and any sensible publisher would be on the ‘phone to sign the authors up. There is much evidence, and more coming, with a conveyor-belt of systematic reviews appearing in perioperative medicine, particularly from Denmark and Switzerland.

The paper makes you think about research. It isn't just saying that we need randomised trials of A versus B. The trouble is that with complex packages of care, A will rarely be A, and B will rarely be B, because the packages will change with local circumstance. So such trials may lack applicability outside of the particular circumstance in which it was conducted. We may have to think more about applying the principles of industrial quality control to surgical (and other care). Not being randomised may not mean not being best.

Reading this paper is a great way to start the new year, by blowing away lots of cobwebs. No-one who is involved with planning surgical care, or hospital services, or healthcare services in general can afford not to read it. It may give you a glance at a future coming to you soon.

Reference:

  1. H Kehlet, DW Wilmore. Multimodal strategies to improve surgical outcomes. American Journal of Surgery 2002 183: 630-641.

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