Contentious Issues in Surgical Gastroenterology - ECABEditor-in-Chief:
- Samiran Nundy
All surgeons are convinced that they provide the best possible care to their patients and fortunately most patients are happy with their surgeons. Where safety and quality were once considered to be self-evident, these issues need to be made more explicit in modern surgery. Doctors and the general public alike are nowadays more aware of the variations in quality that exist among surgeons and institutions and of the unwarranted harmful effects surgery can have. Super- or sub-specialization seems one way to improve both its quality and safety. Surgical Gastroenterology or Gastrointestinal Surgery is one of these new superspecialties. The path towards this specialization is not easy and turf battles between General Surgery and Surgical Gastroenterology are still being fought. Professor Kaushik recounts the history and development of this superspecialty in India. He recounts that although the history of Surgical Gastroenterology in this country is short, its future is bright but, as has happened in other countries, its further division into organ-based superspecialties can be expected. âPractice makes one perfectâ is the motto that is probably true for the high-risk surgery which is still being performed in small institutions or by surgeons with only little expertise. The inverse correlation between volume and outcome expressed as mortality and morbidity has been shown all over the world. Wouters et al systematically analyze the literature covering this topic. They also show that concentration and regionalization do not automatically lead to an improved quality of surgery, since other issues for quality assurance are of equal importance, such as adherence to evidence-based guidelines, feedback, and monitoring. Despite all the inputs in training and instruction by experts, a uniformly high quality of surgery is hard to achieve in day-to-day gastrointestinal surgery. Sudhir Joseph and his colleagues show that a dedicated checklist can save lives and reduce postoperative morbidity in many countries with different systems and levels of healthcare. A similar beneficial effect was found in The Netherlands using a more comprehensive checklist that covers the whole period of the hospital stay. The new type of surgeon is aware of the principles of evidence-based medicine and he/she will challenge the dogmas of the âoldâ surgery. Over the years our surgical masters have told us about the importance of good pre-operative and postoperative care for our patients. The bowel should be put at rest before operation and oral feeding restored only slowly after surgery starting with nothing by mouth to sips of clear water. Bed rest was essential for recovery. He introduced the ERAS (Enhanced Recovery after Surgery) strategy also named Fast Track Surgery. Mitchell et al provide ample evidence that all surgeons should adopt the ERAS strategy. Implementation of this will lead to better and more cost-effective operations.
One of the dogmas in surgery is that prophylactic abdominal drains are useful after gastrointestinal surgery. Surgeons were taught for many years to drain the abdominal cavity to prevent infected collections and to diagnose leaks and hemorrhage early. Roulin and Demartines show that in almost all types of gastrointestinal surgery there is no good evidence to advise prophylactic abdominal drainage. Drainage can be even harmful in some cases and can lead to leaks from colonic anastomoses. It can also affect respiration in the postoperative phase leading to lung problems. There are some âmodernâ dogmas that might be criticized as well. One of these is that in gastrointestinal surgery the laparoscopic approach will replace all open surgery with great benefit to patients. Despite reducing the length of hospital stay, decreasing the number of complications and improving cosmesis, the introduction of laparoscopic surgery, especially for more advanced procedures such as gastrointestinal cancer surgery still lags behind its open predecessor. This is because the procedures are technically demanding and specialized, and expensive instruments are needed. Further, evidence for the superiority of laparoscopic surgery over the open approach is still limited as has been shown by Demartines in a critical overview. Many more prospective studies are needed to justify broader implementation of this promising technique. Secondary peritonitis is frequent and can vary from being caused by acute appendicitis to severe generalized fecal peritonitis from ruptured colonic diverticulitis. Postoperative peritonitis as a result of intra-abdominal leakage is a known calamity that is not infrequently encountered in centers of general and gastrointestinal surgery alike, despite all our efforts to lower postoperative complications. The diagnosis and treatment of peritonitis is an essential part of General Surgery and transportation to a center of Surgical Gastroenterology is not always possible or even indicated. Diagnosis and treatment, especially the timing of treatment of peritonitis are challenges where surgeons work together with many other disciplines. After initial control of the source of peritonitis the surgical strategy of a planned relaparotomy (in contrast with relaparotomy on demand) was previously followed in many centers. Kiewiet and Boermeester have shown in a randomized controlled study that this promising strategy was inferior to relaparotomy on demand and should therefore be abandoned. Using modern diagnostic techniques these authors offer us help in the decision making and timing of the relaparotomy procedure. I hope that this issue on Contentious Issues in Surgical Gastroenterology will fuel the debate on the various strategies and techniques that seem to have become an integral part of surgery. I hope too that these chapters written by experienced Surgical Gastroenterologists will help modern surgeons to move from authority-based surgery to evidence-based surgery so that its safety and quality is enhanced and patient care improved.
Published: June 2012
Surgical Gastroenterology in India
Procedural Volume and Quality Assurance in Surgery for Gastrointestinal Cancers
Checklists in Surgery
Enhancing Recovery after Gastrointestinal Surgery
Prophylactic Drainage in Gastrointestinal Surgery
Gastrointestinal Laparoscopic Surgery
Surgical Approaches to Peritonitis