Surgeons have been gradually adopting methods to optimize patients before surgery and better help them recover, but there is still room for improvement, experts said at the Society of American Gastrointestinal and Endoscopic Surgeons 2020 annual meeting, held virtually this year.
One question that remains today is how to improve quality in surgery, said Dana Telem, MD, MPH, the division chief of minimally invasive and bariatric surgery, and vice chair for quality and patient safety, at the University of Michigan, in Ann Arbor.
“Oftentimes we talk about improving technique in perioperative care, but we don’t spend enough time talking about our patients and thinking about how to get them to and through surgery as safely as possible,” Dr. Telem said. “If you think of surgery as a marathon, we need to spend time training our patients to get through this insult to their bodies and help them recover better.”
Preoperative optimization, or “prehabilitation,” is a process to mitigate patient risks before surgery. Studies have shown that delaying surgery when possible to manage modifiable risk factors, such as diabetes, obesity, smoking and substance abuse, preoperatively can reduce surgical complication rates up to 40% (Surgery 2016;160[5]:1189-1201), she said. In a review of elective hernia repairs in the state of Michigan (JAMA Netw Open 2019;2[11]:e1916330), nearly 25% of patients were found to have a modifiable risk factor, which increased rates of complications and added an estimated $60 million to episode-of-care spending. High BMI alone added about $1,300 per case, for a total of nearly $1.2 million.
Dr. Telem interviewed 21 practicing surgeons in the state (JAMA Netw Open 2020; in press), identifying three barriers to more widespread adoption of preoperative optimization. The first is financial: Surgeons don’t get paid if they don’t operate, and some expressed concern about loss of referrals or reputation damage by putting off patients. In addition, some surgery practices lack the infrastructure or knowledge to put such programs in place, while others may have organizational barriers or clinicians who like to do their own thing.
“Preoperative optimization is a great target for change and a great target to improve the quality of patient care,” Dr. Telem said. “Just telling surgeons to do best practice isn’t going to work if we don’t address the multifaceted barriers that impede people from doing the right thing.”
Multipronged strategies are needed to change behavior and fill the gap between evidence-based practice and implementation, she said. She and others in the state are working with their local Blue Cross Blue Shield partner to release a pay-for-performance measure around patient preoptimization, as soon as 2021. They also are looking to establish provider-led trainings to deploy a statewide preoperative patient optimization program, with help available for on-site facilitations.
On the recovery side, physical therapy may help patients bounce back sooner after hernia repair and potentially other laparoscopic procedures, said Howard Levinson, MD, FACS, an associate professor of plastic and reconstructive surgery at Duke University, in Durham, N.C.
Surgeons should think of the linea alba as the central tendon of the abdomen, Dr. Levinson said. Cutting through or disrupting that tissue can be akin to how orthopedic surgeons handle tendon reconstruction, he said.
“You would never expect to fix an extremity or tendon and not have patients see a physical therapist, yet we all the time operate on the abdominal wall and don’t have people see a physical therapist,” he said. “It’s time for a change.”
His center, so far, has followed about 100 patients after surgery referred to physical therapy for a customized low-, medium- or high-intensity rehabilitation program based on their needs and preoperative functioning levels. The programs combine walking with exercises to strengthen core muscles and provide a point of contact for patients who have questions about exercise and activity. Without guidance, patients may do either no activity or too much, he said. Physical therapy programs also can play an early and important role in pain management, he noted.
Investigators are analyzing data now and looking to expand to collaborative centers.
Enhanced recovery after surgery (ERAS) pathways also can do more, said Michelle Fillion, MD, FACS, a surgical oncologist with New Hanover Regional Medical Center, in Wilmington, N.C. The pathways, started in colorectal surgery to decrease perioperative stress, pain, and GI dysfunction and accelerate recovery after surgery, have been gradually expanding to other areas. The ERAS Society now has specific pathways recommended for some 14 procedures, she said, most recently including neonatal intestinal surgery.
Implementing these programs successfully into other areas and health systems requires several factors, Dr. Fillion said. These include buy-in from hospital or health-system leadership; dedicated ERAS coordinators, nurses and staff; a protocolized approach for patient optimization, such as referring patients with angina to cardiology; expanding preoperative optimization to include nutrition, fragility and cognitive function assessments; and the involvement of dedicated hospitalists and anesthesiologists to help with risk assessment.
Beyond implementation, ERAS program leaders need to do a better job with compliance, reporting that compliance, and auditing programs to assess where improvements can be made, Dr. Fillion said. A 2015 meta-analysis (Br J Surg 2015;102[13]:1594-1602) of 50 publications about enhanced recovery protocols found that less than 50% reported compliance data.
“If we can learn and track our own data, and how well we’re applying these ERAS pathways, they can continue to be modified and tailored overall to improve the care of the surgical patient,” she said.
Dr. Telem reported research funding from Medtronic. She is an editorial board member of GSN. The other speakers reported no relevant financial conflicts of interest.
This article is from the December 2020 print issue.
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