Peri-operative care and collaboration between surgeons and anaesthetists - it's about time.

Abstract

In hospital care, arguably nothing comes closer than the working relationship between surgeon and anaesthetist. Their joint endeavour to keep patients alive and well, while they undergo surgery, creates a bond that is strong and rewarding. Initially, this working relationship focused on the surgical procedure itself, but as time has passed, it has become obvious that optimal care requires careful pre-operative patient assessment and good postoperative care, in addition. The roles of surgeon and anaesthetist have expanded to cover this peri-operative interval in many and varied ways. This initiative, a single special issue on peri-operative care spread across two journals, BJS and Anaesthesia, showcases collaborative work between surgeons and anaesthetists. It not only celebrates their achievements in improving peri-operative care but also highlights current and ongoing research to optimise the care of patients undergoing surgery. The editors have invited experts in the field to contribute state-of-the-art leaders and reviews, and also included a number of articles submitted following specific calls in the journals and on social media. Both journals have produced special issues that are entirely free to download and enjoy. In the modern era, anaesthetists are becoming more and more involved in peri-operative care, expanding their role to assessing and optimising patients before surgery and also looking after them during recovery from surgery. These aspects of care may be somewhat controversial, but there is little doubt that collaborating together over the peri-operative period will improve outcomes. The last 20 years has seen an explosion of interest in improving outcomes after surgery, and enhanced recovery after surgery (ERAS) has become almost the norm during elective surgery, with surgeons and anaesthetists embracing the package of care into their practice. The Godfather of ERAS, a surgeon from Copenhagen, Professor Kehlet, presents an update and discussion on the future of ERAS in this supplement. He argues that future research in ERAS should focus on the inflammatory and neurohormonal surgical stress response, fluid management, mechanisms of orthostatic intolerance, postoperative cognitive dysfunction and mechanisms and prevention of postoperative ileus 1. Foss and Kehlet go further and discuss research and implementation of ERAS into emergency laparotomy 2. Access and admission to the intensive care unit after emergency surgery is reviewed by Onwochei et al. 3. Safety is and should be a major focus of surgical and peri-operative care, and Marshall and Touzell review the importance of human factors and teamwork in the operating theatre 4. A team that communicates well, defines the roles of its members and is aware their limitations will provide safe patient care 3. Charlesworth and Pandit argue that an efficient operating theatre is a safe one, and describe metrics that can be used to drive improvement 5. There is no doubt that the mode of anaesthesia can affect surgical outcomes, and Morley and colleagues describe the emerging evidence 6. Likewise, effective postoperative pain relief improves both outcomes and patient experience. There are several examples in the current special issue, including a network meta-analysis on analgesia after colorectal surgery 7. Reduction in postoperative complications, such as delirium, so common in the elderly, can also drive outcome improvement. Dexmedetomidine is a promising agent in this regard 8. Finally, variations in use of the surgical safety checklist and other aspects of safe peri-operative care differ around the world, which is a challenge of critical importance to all healthcare workers 9, 10. We hope you enjoy this special issue, which is a unique collaboration between two leading journals in surgery and anaesthesia. We have been unable to find other examples of collaboration between surgical and anaesthetic journals, and many will agree that it is about time that this happened. This is true because, in practice, surgeons and anaesthetists work together, not only in the operating theatre but also in research. Surgeons and anaesthetists need each other to do good research and must not forget the role of the anaesthetic or the surgery in each other's studies. Patient-centred outcomes should be the focus of clinical research, and this necessitates involving surgeons and anaesthetists in planning and performing clinical research in peri-operative and surgical care, as well as the patients themselves. Surgeons and anaesthetists need to talk, and perhaps also read each other's journals. Positive evidence that specialisms can work together to the benefit of patients will attract attention and co-operation from the wider multidisciplinary team.