“It’s okay, you don’t have to be there, it’s only a small surgery.” These words were spoken by a close family member of mine before undergoing a pacemaker placement. Her insistence on not inconveniencing us for her minor surgery did cause us to avoid taking off work and traveling to be by her side before and after her procedure. As the true outcome of the surgery was revealed to us piece by piece, we vowed never to underestimate surgery again: she suffered from complications both during and after the surgery. Before knowing about her complications, she called us worried from her hospital bed feeling like she couldn’t breathe. As my husband and I are both in the medical field, we were able to guess from her symptoms that she had a pneumothorax, or air in the compartment surrounding her lungs, preventing her from taking a full breath. When we finally reached the surgeon, he revealed that she had had a cardiac arrest, her heart stopped beating, while on the table, leading to emergent placement of the pacemaker and inadvertent piercing of the lining around the lung which caused the pneumothorax.
This phenomenon of a seemingly routine surgery leading to a complication is surprisingly common. Within my extended family and network of close friends, I have seen multiple complications from minor surgeries, such as nerve injury from wisdom tooth extraction, chronic pain after a pelvic surgery, another cardiac arrest during pacemaker placement, and a pulmonary embolism leading to death following debridement of a diabetic foot ulcer. After a major surgery, I have seen a dire infection following gastrectomy for stomach cancer that led to bacteria pouring from the surgical site into the lungs, resulting in a three-month intensive care unit stay and additional surgery.
While these surgeries ranged from elective to emergent and varied in invasiveness, I am often surprised at the cavalier attitude towards surgery in our current age, and the willingness of individuals to seek out surgery without much preparation to prevent complications. Surgery is indisputably an incredibly important and life-saving event in many situations, such as in the case of cancer, trauma, or even appendicitis, and the effectiveness of anesthesia in allowing pain-free surgery has been a major revolution. However, the commonplace occurrence of surgery for both emergent and elective indications has emphasized the importance of surgical complications. Throughout history, a surgery may have been performed without anesthesia to amputate a gangrenous leg that had festered after a trauma. The expectations of those around this patient were that she would die without the surgery and would also likely die from infection after the surgery; however, there was a small hope she would live, making it all worth it. Today, if a patient decides to undergo a gastric bypass surgery for weight loss and dies from a postoperative infection, the difference between expectation and outcome is too stark to accept.
In my own practice, I perform mostly minor surgery in the oral cavity. Each patient’s approach to their upcoming surgery is different, and their willingness to take their surgery seriously and to optimize their chance at healing ranges. As my practice is hospital-based, I rarely see patients without significant medical comorbidities, from severe cardiac disease, to cancer, to organ failure, before or after transplant. I can count on certain conditions or therapies affecting my patients’ ability to heal from surgery in the mouth. My patients who have undergone radiation for head and neck cancer have poor blood flow and cellularity in their jaw bones leading to tissue death rather than healing following surgery. Those who are taking medicine to block bone loss from osteoporosis or bone cancer are not able to recruit the cells necessary to remodel and heal their bone after surgery, also leading to bone necrosis and infection. Patients on chemotherapy often have poor immune function at certain phases in the treatment cycle making healing a challenge and infection a reality. Often lifelong immunosuppression following organ transplant to prevent graft rejection also devastates wound healing after surgery. However, as I see these conditions frequently in my practice and am aware of their challenges to healing, I can care for these patients with evidence to guide my decisions and therefore prevent postoperative complications.
More worrisome are the seemingly healthy patients with poor reserve, due to undiagnosed disease or undetected immunological, metabolic, or neuro-endocrine dysfunctions that may predispose them to surgical complications. Although routine clinical evaluation and screening may be “within normal limits”, such patients may not have the capacity to efficiently mobilize key immune responses necessary for wound healing, fending off infection and recovery of function.
In an ideal world, every patient should receive accurate and personalized information about their risk of complication after a surgery based on an objective assessment of their biological reserve to sustain surgery. In this regard, emerging precision medicine tools that functionally monitor a patient’s immune system before surgery are extremely promising. In the meantime, all patients are entitled to the highest level of evidence-based information with respect to the risk of every surgery (no matter how “minor”). Known risk factors for poor outcomes, such as smoking, should be taken seriously and known lifestyle factors that can improve a patients’ metabolic and immunological reserve, such as proper nutrition, exercise, and stress-reduction should be optimized. “Don’t worry, it’s just a minor surgery”, should signal a need for more information, more education, and more preparation…not less.
Dyani Jones
https://www.linkedin.com/in/dyani-gaudilliere
