A renaissance in surgery

Abstract

A new and welcome vigour is evident in surgery, spurred by the enthusiasm of young surgeons and the collaboration of established researchers from other disciplines. In today's issue of The Lancet, the sixth annual surgery-themed issue published to coincide with the American College of Surgeons Clinical Congress (in San Francisco, CA, on Oct 26–30, 2014), we present recent developments in surgical research and consider how they might influence the conference theme: the surgeon of the future.The Royal College of Surgeons of England has also examined the changing role and responsibilities of surgeons in Good Surgical Practice, published on Aug 29. A similar document, Good Medical Practice, was updated by the UK General Medical Council in 2013 to show the behaviour expected of any doctor registered with the Council. Whereas the General Medical Council took a philosophical approach to practice, Good Surgical Practice adopts a more practical attitude. Both documents can be commended for the promotion of compassionate, collaborative, and effective care. However, the emphasis on minimal standards, care pathways, and guidelines in Good Surgical Practice results in a document that might have been written by the government, rather than a Royal College promoting ambitions for the profession. Absent are the higher aspirations of providing a truly excellent service that might inspire the next generation, and the transition from experience-based surgery to evidence-based practice that could empower both surgeons and patients to achieve better outcomes more consistently.In particular, the section on research misses the opportunity to promote a truly evaluative culture, as it could do by making recruitment to and support of research an integral part of clinical service. Exactly why research and evaluation are important to all surgeons is shown well by two Articles in today's issue on knee arthroplasty for osteoarthritis by Linda Hunt, Alexander Liddle, and their respective colleagues. These are examples of how careful and consistent recording of data from operations for total knee replacement and unicompartmental knee replacement can create a valuable dataset to inform care. As Comment author Justin Cobb concludes “these two papers should provoke a review of knee arthroplasty by policy makers worldwide”.The data for the aforementioned studies came from the National Joint Registry of England, Wales, and Northern Ireland—the largest such registry in the world with more than 1 million records. Many other registries for different devices exist in several countries. The potential to detect early signals of device performance from registry data is enormous, and was discussed at the annual meeting of the Medical Device Epidemiology Network initiative (MDEpiNet) during the past week in Washington, DC. Nurtured by the US Food and Drug Administration, MDEpiNet is evolving into a public–private partnership between regulators, universities, and other stakeholders to develop and apply new analytical techniques to assess devices throughout their life cycle.Other aspects of surgical care also benefit from a cross-disciplinary approach, as in the surgical trauma Series, where common pathways in physiology and immunology contribute to understanding the derangements that follow acute trauma and how they can best be corrected. The opportunity equally exists for surgeons within the controlled trauma environment of an operation to contribute new insights into the underlying molecular biology of tissue damage and repair.Research in Surgery crosses borders and cultures. The Comment on global child health competencies by Bhanu Williams and colleagues might well be expanded to discuss surgery within child survival initiatives. Indeed, surgery is a critical component not only for child survival, but for global health in general, as will be elaborated in The Lancet Commission on Global Surgery to be published in 2015.The surgeon of the future needs to be prepared for a world that in some aspects would be familiar to the profession's pioneers, while in others will stretch contemporary imagination and capabilities. The Article by Paul Myles and colleagues on nitrous oxide anaesthesia illustrates this point by seeking new answers for an old question so that surgical care can be safer. Patients need to remain at the centre of care, while at the same time acknowledging that the diversity and complexity of care—and the ways in which that care is delivered—will evolve. Above all, it is the commitment to surgical research and research training in the present that will both drive advances in care and shape the surgeon of the future. A new and welcome vigour is evident in surgery, spurred by the enthusiasm of young surgeons and the collaboration of established researchers from other disciplines. In today's issue of The Lancet, the sixth annual surgery-themed issue published to coincide with the American College of Surgeons Clinical Congress (in San Francisco, CA, on Oct 26–30, 2014), we present recent developments in surgical research and consider how they might influence the conference theme: the surgeon of the future. The Royal College of Surgeons of England has also examined the changing role and responsibilities of surgeons in Good Surgical Practice, published on Aug 29. A similar document, Good Medical Practice, was updated by the UK General Medical Council in 2013 to show the behaviour expected of any doctor registered with the Council. Whereas the General Medical Council took a philosophical approach to practice, Good Surgical Practice adopts a more practical attitude. Both documents can be commended for the promotion of compassionate, collaborative, and effective care. However, the emphasis on minimal standards, care pathways, and guidelines in Good Surgical Practice results in a document that might have been written by the government, rather than a Royal College promoting ambitions for the profession. Absent are the higher aspirations of providing a truly excellent service that might inspire the next generation, and the transition from experience-based surgery to evidence-based practice that could empower both surgeons and patients to achieve better outcomes more consistently. In particular, the section on research misses the opportunity to promote a truly evaluative culture, as it could do by making recruitment to and support of research an integral part of clinical service. Exactly why research and evaluation are important to all surgeons is shown well by two Articles in today's issue on knee arthroplasty for osteoarthritis by Linda Hunt, Alexander Liddle, and their respective colleagues. These are examples of how careful and consistent recording of data from operations for total knee replacement and unicompartmental knee replacement can create a valuable dataset to inform care. As Comment author Justin Cobb concludes “these two papers should provoke a review of knee arthroplasty by policy makers worldwide”. The data for the aforementioned studies came from the National Joint Registry of England, Wales, and Northern Ireland—the largest such registry in the world with more than 1 million records. Many other registries for different devices exist in several countries. The potential to detect early signals of device performance from registry data is enormous, and was discussed at the annual meeting of the Medical Device Epidemiology Network initiative (MDEpiNet) during the past week in Washington, DC. Nurtured by the US Food and Drug Administration, MDEpiNet is evolving into a public–private partnership between regulators, universities, and other stakeholders to develop and apply new analytical techniques to assess devices throughout their life cycle. Other aspects of surgical care also benefit from a cross-disciplinary approach, as in the surgical trauma Series, where common pathways in physiology and immunology contribute to understanding the derangements that follow acute trauma and how they can best be corrected. The opportunity equally exists for surgeons within the controlled trauma environment of an operation to contribute new insights into the underlying molecular biology of tissue damage and repair. Research in Surgery crosses borders and cultures. The Comment on global child health competencies by Bhanu Williams and colleagues might well be expanded to discuss surgery within child survival initiatives. Indeed, surgery is a critical component not only for child survival, but for global health in general, as will be elaborated in The Lancet Commission on Global Surgery to be published in 2015. The surgeon of the future needs to be prepared for a world that in some aspects would be familiar to the profession's pioneers, while in others will stretch contemporary imagination and capabilities. The Article by Paul Myles and colleagues on nitrous oxide anaesthesia illustrates this point by seeking new answers for an old question so that surgical care can be safer. Patients need to remain at the centre of care, while at the same time acknowledging that the diversity and complexity of care—and the ways in which that care is delivered—will evolve. Above all, it is the commitment to surgical research and research training in the present that will both drive advances in care and shape the surgeon of the future. Patient safety after partial and total knee replacementMore than 90 000 people in the UK had knee replacements in 2012, according to the National Joint Registry of England and Wales (NJR).1 The human cost of this expensive surgery is addressed in two articles in The Lancet2,3 that question conclusions from the NJR, with major consequences for patient safety and the knee replacement industry. Full-Text PDF Open AccessDo we need to know whether nitrous oxide harms patients?In The Lancet, Paul Myles and colleagues1 investigate the association between nitrous oxide exposure and cardiovascular complications such as non-fatal myocardial infarction, stroke, pulmonary embolism, cardiac arrest, and death, within 30 days of surgery, in patients with known or suspected coronary artery disease having major non-cardiac surgery under general anaesthesia. The rationale for this large, multicentre study, which involved more than 7000 patients from 45 centres, was the observation that short-term exposure to nitrous oxide led to significant increases in plasma homocysteine. Full-Text PDF Robotic surgery: where are we now?Robotic surgery has fascinated surgeons since its inception almost 30 years ago. US Food and Drug Administration (FDA) approval of the Da Vinci surgical system in 2000 led to the expansion of robotic-assisted laparoscopic surgery—most rapidly in urology but also in gynaecology, cardiothoracics, head and neck, and general surgery. But has this innovation in surgery translated to benefits for patients? Full-Text PDF Clare Marx: new President of the Royal College of SurgeonsAn amiable and unstuffy woman, Clare Marx welcomes me into an office about an eighth the size of the room next door used by most of her male predecessors. Not to begin by asking how she feels about being the first woman President in the 214-year history of the Royal College of Surgeons of England seems absurd. But isn't she bored with people referring to it? Apparently not. “I'm actually quite amused”, she says. “I've always thought of myself as a doctor and a surgeon. I just happen to be female.” The issue, she insists, is more on other peoples' minds than hers. Full-Text PDF Surgery and conflictMaxillofacial surgeon Ashraf Bustanji's day starts normally enough in Amman, Jordan. Shortly after the morning call to prayer, he drops his son off at school, and drives to work. But once at a reconstructive surgery project run by Médecins Sans Frontières (MSF), he is confronted with the impact of war on individual lives. Bustanji operates on a man whose legs have been shattered by shrapnel, another whose limbs were mangled by a rocket blast, and an 8-year-old girl with third-degree burns. Surgical patients in conflict zones are unlike any other, he says. Full-Text PDF The secret scalpel: plastic surgery for wartime disguiseIn 1945, with the fighting in Europe over, a curious story appeared in the pages of British newspapers. It concerned the war record of James Hutchison, an army colonel standing for Parliament in that July's general election. A year earlier, so Hutchison had revealed to the press, he had parachuted into Nazi-occupied France to work with the French Resistance. What had really caught journalists' attention, however, was his claim to have disguised his wartime identity by undergoing surgery to his face. Full-Text PDF 45-day mortality after 467 779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational studyPostoperative mortality after knee replacement has fallen substantially between 2003 and 2011. Efforts to further reduce mortality should concentrate more on older patients, those who are male and those with specific comorbidities, such as myocardial infarction, cerebrovascular disease, liver disease, and renal disease. Full-Text PDF Adverse outcomes after total and unicompartmental knee replacement in 101 330 matched patients: a study of data from the National Joint Registry for England and WalesIn decisions about which procedure to offer, the higher revision/reoperation rate of UKR than of TKR should be balanced against a lower occurrence of complications, readmission, and mortality, together with known benefits for UKR in terms of postoperative function. If 100 patients receiving TKR received UKR instead, the result would be around one fewer death and three more reoperations in the first 4 years after surgery. Full-Text PDF Open AccessThe safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trialOur findings support the safety profile of nitrous oxide use in major non-cardiac surgery. Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection, the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis, and a desired effect of reduced volatile agent use was shown. Full-Text PDF The systemic immune response to trauma: an overview of pathophysiology and treatmentImprovements in the control of haemorrhage after trauma have resulted in the survival of many people who would otherwise have died from the initial loss of blood. However, the danger is not over once bleeding has been arrested and blood pressure restored. Two-thirds of patients who die following major trauma now do so as a result of causes other than exsanguination. Trauma evokes a systemic reaction that includes an acute, non-specific, immune response associated, paradoxically, with reduced resistance to infection. Full-Text PDF Postinjury abdominal compartment syndrome: from recognition to preventionPostinjury abdominal compartment syndrome (ACS) is an example of a deadly clinical occurrence that was eliminated by strategic research and focused preventions. In the 1990s, the syndrome emerged with the widespread use of damage control surgery and aggressive crystalloid-based resuscitation. Patients who previously exsanguinated on the operating table made it to intensive care units, but then developed highly lethal hyperacute respiratory, renal, and cardiac failure due to increased abdominal pressure. Full-Text PDF