Come out of the operating room and see the light!
Surgeons often like to think that any improvement in patient outcomes comes from what is done in the operating room. Less pain and morbidity? That is because minimally invasive surgery has been done. Better respiratory function? That is all due to lung-preserving segmentectomy or sleeve resections.
However, this kind of thinking may be somewhat narrow-minded. Although there is no denying the potential benefits of modern advances in the operating room, the impact they have on patients is probably less than surgeons would like to believe (1,2). Shortening of chest drain durations may be a matter of mere hours. Reduction in pain may be a matter of a point or less on a 10-point analog scale.
The fact is that there have been so many good advances in the field of intraoperative management that we are reaching the point of Diminishing Returns. The current standard of intraoperative care is so high that if we want to see improvement in patient outcomes after surgery, it will take a huge amount of effort, time and investment before a small increment in benefit is realized. Great breakthroughs in technique and technology will be required before the next great leap forward in intraoperative care can emerge—and these are unlikely in the next few years.
Looking to the near future, if patient outcome improvements are the goal, perhaps the focus should be placed elsewhere. Instead of only going back to the operating room, perhaps we should be looking at making a difference in the Perioperative Care. Emerging evidence from different surgical specialties has already shown that simple modifications of the perioperative algorithm can already deliver remarkable benefits (3,4). Instead of mere hours, recovery and discharge may be expedited in terms of days. Instead of minor lessening of pain, substantial pain reduction associated with reduction in harmful analgesic usage may be seen.
The most amazing thing about focusing on Perioperative Care is that it is so simple, safe and cheap. There is no need to buy fancy equipment, invest in sophisticated technologies, or engage in lengthy training. Instead, all it takes is usually simple modification of how we manage patients after surgery, and better-structured scheduling of that management. In Thoracic Surgery, the changes are in such mundane and easily overlooked items as chest drain management, analgesic use, physiotherapy and mobilization schedules, and so on. These can be assembled into a Clinical Pathway for the objective, protocol-based care of the patient, and backed up by an update of the hospital’s IT system.
Improving Perioperative Care is undeniably effective. The only problem is that it is not really ‘sexy’. Surgeons get excited by videos of an ultra-complex minimally invasive surgical procedure, or the introduction of the latest technological breakthrough for intraoperative use. So talking about chest drains, analgesic dosages, and Clinical Pathways tends to get ignored in the surgical literature, or shuffled into the background.
That is why this Special Issue is so important. For the first time, we are dedicating an entire Special Issue to advances in Perioperative Care in Thoracic Surgery. Perioperative management is being given its own deserved spotlight, away from the distraction of glitzy articles on operative technique and expensive new technologies.
This Special Issue begins with a large section on how success has been achieved with Clinical Pathways and Fast Track programs for Thoracic Surgery in different parts of the world. Readers can see what has worked in their own region, as well as learn from experiences in other regions. It then explores some of the key specific improvements that can promote better patient outcomes, including advanced anesthetic and analgesic strategies, and modern postoperative chest drain and air leak management. The third section looks at more holistic approaches, away from conventional physician-led ‘medicine’. The role of nurses, physiotherapists and rehabilitative therapy is explained. The articles in this Special Issue have been written by experts in Perioperative Care who have achieved outstanding results with patients undergoing Thoracic Surgery. Readers have much to gain from their sharing of their wealth of experience.
This Special Issue warmly invites readers to step out of the operating room, and see the great potential for doing good after the operation is over and the skin closed!
References
- McElnay PJ, Molyneux M, Krishnadas R, et al. Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: an observation study. Eur J Cardiothorac Surg 2015;47:912-5. [PubMed]
- Chung JH, Choi YS, Cho JH, et al. Uniportal video-assisted thoracoscopic lobectomy: an alternative to conventional thoracoscopic lobectomy in lung cancer surgery? Interact Cardiovasc Thorac Surg 2015;20:813-9. [PubMed]
- Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189-98. [PubMed]
- Spanjersberg WR, Reurings J, Keus F, et al. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011.CD007635. [PubMed]
