The new medical specialty aiding post-surgery recovery

by Ruth Nichol / 12 January, 2018

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Perioperative medicine aids in post-operative recovery and is of particular benefit to the frail.

Not all elderly people are frail, but the prevalence of frailty increases with age – and that’s bad news for the increasing number of New Zealanders having surgery later in life.

According to Christchurch anaesthetist Dick Ongley, being both old and frail means you’re more likely to experience complications in the first few weeks after surgery, including confusion, chest infections, falls and – in some cases – death.

“Medical professionals have started to recognise that there is this geriatric syndrome that signifies a person is having a change in their physical health and that they might not do as well from surgery as hoped.”

Although most of us assume the worst is over when an older relative emerges from the operating theatre, the danger period is really just beginning. “When you have surgery, it sets up a big inflammatory response in the body, which we call the surgical insult – some people equate it to trauma. The longer you spend on the operating table, the bigger the insult.”

There’s growing evidence that the effects of surgical insult can last as long as a year. For over 65s, who are more likely to have both elective and emergency surgery, that can mean a longer recovery time. Even if they do technically recover, they might not be able to return to the activities they enjoyed before their operation, or they might need a higher level of care than previously.

The good news is that a relatively new medical specialty, perioperative medicine, can improve the recovery of high-risk surgical patients. Ongley is helping to develop it in New Zealand and Australia. Perioperative medicine covers the care of patients from the time they first contemplate surgery through to their full recovery at home. The goal is to make surgery more efficient and effective.

Dick Ongley. Photo/Canterbury District Health Board

Ongley, who is a member of the perioperative special interest group run by the Australian and New Zealand College of Anaesthetists, says perioperative teams include not just anaesthetists but also GPs, surgeons, geriatricians, physiotherapists and occupational therapists.

“It’s a collaborative game and it’s about communication. It’s about us having frank conversations with patients, and it’s also about having conversations with each other to produce better outcomes for patients.”

Anaesthetists have become involved in perioperative medicine because, unlike most medical specialists, they have to understand how all the organs in the body work and interact. Their job in the perioperative team is to assess the risks presented by surgery and to recommend ways to minimise them to get the best possible outcome.

That can include the patient preparing for surgery by stopping smoking, eating better and exercising more. For people with medical conditions such as high blood pressure, diabetes or heart disease, their GP needs to make sure the drugs they’re on are doing what they’re supposed to.

“There’s no point in finding out at the 11th hour that we failed to control Mrs W’s blood pressure when we had months to do it.”

In some cases, an anaesthetist may recommend a different operation, or an alternative to surgery, such as prescribing more-effective painkillers for an elderly person rather than doing a hip replacement.

Age and frailty are known risk factors for post-surgical complications. Signs of frailty can include weakness, weight loss, exhaustion and a slow walking speed. Ongley is involved in a study at Auckland City Hospital to identify which symptoms of frailty present the most risk.

But younger patients with conditions such as diabetes or those who smoke, eat badly or do little exercise are also more likely to experience complications following surgery.

Some overseas doctors use the term “futile surgery” to describe operations carried out on high-risk patients. Ongley prefers to talk about “low-benefit surgery”. He says that although an operation may ultimately be unsuccessful, few surgeons would perform surgery if they thought it had no chance of succeeding.

The goal of perioperative medicine is not to stop high-risk patients from having surgery but to make sure they get as much benefit from it as possible.

“It’s not a cost-cutting exercise. Reducing the complications will have benefits to the coffers of the hospital, but it’s also going to benefit the patient, their family and their medical team.”

This article was first published in the November 11, 2017 issue of the New Zealand Listener.

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