If you read only one chapter in this guide, make it this one. It is my belief that the majority of surgical complications could be eliminated if a few simple rules were followed preoperatively. This chapter spells out these rules. If you follow this advice, I am certain you will enter the operating room in the best possible condition for your surgery. That is not to say these rules will assure a good outcome; there are too many variables out of a patient’s control for anyone to make that guarantee. Think of it this way, you expect your surgeon and your anesthesiologist to do everything possible to ensure a good result from your operation, should you expect anything less from yourself ?
Take the 30 minutes required to complete the PreOp-Worksheet accurately and completely. I know that the last thing you want to do is run around looking up drug dosages and searching through the telephone book for the phone numbers and office addresses of all of your medical practitioners; but if the information you find is needed in an emergency, you’ll be glad you spent the time now instead of having your surgeon doing it under pressure. Furthermore, an accurate medical history is the most important data your surgeon needs to plan your operation.
When I tell you to quit tobacco use, I am specifically referring to smoking cigarettes; however, the advice to give up tobacco pertains to those who indulge in pipe, cigar, or smokeless tobacco products as well. I can tell you for a fact that the use of tobacco has no beneficial effects on your health. Its use has been associated with an increased risk of lung cancer, emphysema, head and neck cancer, esophageal cancer, stomach cancer, heart attack, stroke, high blood pressure, and hardening of the arteries. There is no disputing these facts, and I will not waste your time or mine pretending that if you don’t inhale, or if you feel better after smoking that you are an exception to the rule. Nicotine, which is a major component of cigarette smoke, is an addictive drug; and breaking the nicotine habit is admittedly very difficult. It is not unusual, nor is it shameful to need medical or psychological assistance in quitting a tobacco habit. Since we are specifically referring to preoperative preparation in this chapter, I will give you some information and advice pertaining to that subject, and hopefully giving up cigarettes before your operation will help you stay off them for good.
Smoking cigarettes causes a change in the makeup of the cell layer that lines your trachea (windpipe) and major airways. This change eliminates the ciliated cells that remove mucus and dust from your lungs. As a consequence, mucus, dust, smoke particles, and bacteria that would otherwise be removed from your lungs remain within your airways. To clear this junk from the lungs, smokers develop a cough. Under anesthesia, this cough is suppressed, and the result is a plugging up of the airways with potentially infectious mucus. This results in a higher incidence of pneumonia and airway collapse (called atalectasis) in smokers. It also results in a violent awakening from anesthesia due to an intense stimulus to cough. It is not an exaggeration to say that I have seen smokers rip all of their stitches out when they wake up from anesthesia due to the massive increase in abdominal and thoracic (chest) pressure generated by postoperative coughing fits. Fortunately, it takes only two smoke free weeks for most of this danger to be eliminated. If you can’t make the major step of quitting cigarettes for your lifetime, take off two weeks before your surgery, and save yourself the terrible postoperative complications of atalectasis and pneumonia. You will find that after refraining from smoking for two weeks and having a major operation, quitting for good is much easier.
Behind smoking, alcohol consumption is the next most important cause of preventable postoperative complications. You need not be an alcoholic for your alcohol consumption to present a problem in the postoperative state; in fact, you need not even be a problem drinker. Ethyl alcohol is another drug that causes a physical dependence, just like the nicotine in cigarettes. Anyone who drinks alcoholic beverages on a daily basis risks developing an alcohol withdrawal syndrome postoperatively. This means that even if you have a single glass of wine with dinner or a glass of brandy before bed each night, you are at risk of developing a potentially life-threatening complication. To prevent this possibility, I advise giving up all forms of alcohol for two full weeks before any operation.
For most social drinkers, this poses no problem and carries virtually no risk. If you are a heavier drinker or have ever experienced the symptoms of anxiety, tremor, rapid heartbeat, or confusion when you stop drinking, then simply stopping cold turkey is not an option for you. First, it needs to be emphasized that people who are dependent on alcohol can die when they stop drinking. The brain can become dependent on ethyl alcohol. If this happens and a person just stops drinking alcohol, he/she will experience alcohol withdrawal, ultimately leading to seizures and death. Therefore, anyone scheduled for elective surgery who drinks alcohol on a daily basis should discuss this with his or her surgeon. Medically supervised alcohol cessation programs are available and should absolutely be utilized before any operation. Alcohol dependence need not be a shameful or embarrassing condition, and it does not imply that a person is bad or sinful. It simply indicates that the brain has adapted to the daily intake of alcohol and that medical supervision is required to discontinue daily alcohol use.
When asked about alcohol use by your surgeon or anesthesiologist, and when filling out the PreOp-Worksheet, be honest about your alcohol consumption. These questions are not being asked to embarrass you or delve into your personal life, they are being asked because it has long been recognized how important alcohol dependence can be. If the possibility exists that you may be alcohol dependent, this issue must be explored and resolved prior to surgery. Unrecognized alcohol withdrawal in the postoperative state carries with it a 50% chance of death, even in the nation’s best intensive care units.
A surgical risk factor that receives little attention these days but continues to contribute to a large number of postoperative complications is obesity. Depending upon the type of surgery scheduled, you may not have the luxury of putting off surgery for several weeks to several months for a weight loss and exercise program to be effective. If you are overweight and not under time constraints for surgery, it would be wise to seek professional help from a dietitian before having your operation. Obesity itself increases the likelihood of pulmonary complications and wound infections. It also makes many types of surgeries more technically difficult and dangerous. If you feel your weight may be a problem, ask your surgeon if losing weight would be in your best interest preoperatively. If he or she agrees that weight loss would improve your chances of a successful and uncomplicated operation, then a supervised weight-loss program is the thing for you. Remember you should not take matters into your own hands and put yourself on a strict diet prior to surgery. Wound healing requires adequate body stores of vitamins, carbohydrates, and protein intake. You could seriously impair your ability to heal the operation site properly if your body is depleted of the materials needed in wound healing. So, if you need to loose weight, do it slowly, safely, and while maintaining the proper balance of vitamins and minerals in your diet.
There are more inconclusive studies on the role of individual vitamins on immune function, wound healing, and postoperative recovery than anyone could read in a lifetime. My opinion here is based more on common sense than on hard scientific evidence, but I still believe it to be true. Wound healing is a complex process requiring a multitude of cell types to produce a wide variety of complex protein products that create a strong, permanent bond between injured tissue. This process will be most efficient when all of the necessary materials are present at the time of the incision. I suggest that you take any of the over-the-counter multivitamins available at your local pharmacy for as long as possible preoperatively, and that you continue taking the multivitamin for at least 6 months after your operation (at which time the wound will be almost completely healed). Personally, I use a generic multivitamin, which saves me quite a few dollars a month.
A quick word about other vitamin combinations and trendy vitamin cocktails. There always seems to be a “vitamin of the month” that is suggested for improved wound healing or better immune function. The combinations are too numerous to mention, although there is pretty good data to support the use of some of them, at least in animal models. If you have heard about one of these combinations, use common sense and follow FDA guidelines regarding maximum drug dosages. Remember that you can overdose on vitamins as well as suffer from vitamin deficiencies. Although the FDA tends to be conservative from an evidence standpoint, its daily recommended allowances for vitamins have been pretty well researched.
I have never heard of anyone being in too good shape for an operation. Surgery is a stressful situation, and your body responds to it just as it would to any other stress. This means you will have a catecholamine response (i.e., the fight-or-flight response), which is associated with increased demand on the heart. If you are involved in a regular exercise program, continue it right up to the time of your surgery. If you have not been as vigilant about keeping in shape, the weeks before your operation would be a good time to resume an exercise program. If you can walk up two flights of stairs without experiencing chest pain or shortness of breath, you should be able to begin a program of distance walking safely. If you can’t make it up two flights of stairs or if you have any history of coronary artery disease, peripheral vascular disease, carotid artery stenosis, diabetes, or a family history of heart disease, ask your primary care physician if it would be safe for you to begin an exercise program.
You don’t need to be Charles Atlas to have surgery, but you should be able to walk a mile at a brisk pace without feeling winded or tired. Current recommendations hold that you should exercise vigorously enough to elevate your heart rate to 60-70% of its maximum rate (which can be calculated by subtracting your age from 200) for 20 minutes a day, 4 or more days a week. So if you are age 60, your maximum heart rate should be 140, and your exercise program should elevate your heart rate to between 84-98 beats per minute for 20 minutes a day, 4 days a week. Achieving this before your operation will improve your heart performance under stress and will also put you in a better position to exercise during your recovery phase. Again, as with all the advice presented in this chapter, check with your physician before initiating any exercise program, especially if you fall into one of the high-risk groups noted above.
Bowel (Colon) Preparation
Those about to have surgery involving the abdomen or any portion of the digestive tract (including the esophagus, stomach, duodenum, liver, pancreas, intestines, rectum, and anus) have probably been given instructions on taking a bowel (colon) preparation. This preparation is undoubtedly one of the least favorite parts of the preoperative experience but also one of the most important. As you can imagine, your bowels are full of a variety of ingested material, and as it makes its way from the stomach toward the anus, the character of this material changes from a watery, green liquid to nearly solid stool. As the digested food makes its way toward the anus, the amount of bacteria in this liquid material increases dramatically. The goal of a bowel preparation is twofold: one is to empty the digestive system of this ingested material, and the other is to decrease the amount of bacteria living within the bowel. This is important for a number of reasons. First, if your operation involves the removal of a segment of bowel, it is technically much easier to reconnect clean and empty intestine than it is to reconnect an intestine that is oozing contaminated material. Second, probably the greatest source of potentially infectious bacteria in the human body is the large bowel. Eliminating these bacteria before they are released from an opening in the bowel greatly decreases the chance of developing an infection postoperatively. This is especially true in operations in which prosthetic (man-made) material is going to be placed permanently in the body (as in large hernia repairs and abdominal aortic aneurysm repairs). Third, if your surgeon is trying to locate a mass present within the bowel, it is much easier to feel it from the outside if no other material exists within the bowel to fool him or her. The bottom line is that a good bowel preparation makes most operations much easier. Conversely, a poorly prepped bowel can make the surgery more difficult and increase the risk for postoperative complications.
The next question is, what constitutes a good bowel preparation. The answer to that question is dependent upon your surgeon. Different physicians have very different ideas on how to best prepare the bowel. For simplicity sake, we will break the preparation down into two components. The first is the mechanical preparation (cleaning out the ingested material). To accomplish this, the basic principle is to administer a drug that stimulates the bowel to contract and expel all of its contents in the form of stool and/or diarrhea. This can be done with large volume preparations such as Golyte, which require you to drink a gallon or more of fluid over the span of several hours, or it can be done with smaller volume preparations such as Fleet Phospha-soda or magnesium citrate. Another option is to cleanse the bowel with laxative tablets, and some surgeons prefer the use of enemas. In practice, many surgeons use a combination of these products, and they let their own personal experiences dictate which methods they prefer. For your information, there is no right or wrong method, and there are scientific studies (usually funded by the makers of these products) which suggest that each of them works best. Keep in mind that no matter which technique you surgeon prescribes, all of these products will dehydrate you. To prevent this, you should consume at least 6 full glasses of water or other clear liquid (apple juice, lemon-aid, caffeine-free iced tea, or a sports drink) the day before and the day of your bowel preparation. Also, if you have kidney disease or a known electrolyte disturbance, let your surgeon know prior to taking the bowel preparation. There are several preparations which can disturb your body’s chemical balance if you have pre-existing conditions. Finally, if you are given a large volume preparation (you will know because you will have a large jug of fluid sitting across the table from you for a good portion of the evening prior to surgery), remember to continue drinking the medication as directed on the label or by your surgeon until you are passing clear fluid from your rectum. Typically this requires that you consume at least half, and usually more like three-quarters of the container.
The second portion of the bowel preparation is the antibiotic portion. Two methods seem to be equally effective. The first requires the oral administration of a non-absorbable antibiotic the evening before surgery. Most surgeons consider this the gold standard and prefer to give an oral antibiotic prep. The problem with this preparation is that it typically produces an upset stomach, and some patients fail to complete the prep due to stomach cramps. The second method involves the administration of intravenous antibiotics in the period immediately before surgery. This avoids the upset stomach problem, but some surgeons still prefer the oral method. Again, many surgeons will use a combination of the two techniques. No one preparation is clearly superior to another, so I suggest you follow your surgeon’s advice on this matter, with this caveat: if you fail to complete the preparation as ordered, let your surgeon know prior to your operation. Then he or she can decide to proceed or if a late adjustment in technique is required.
One final note on your bowel preparation. This step used to be accomplished in the hospital the day before your surgery. Current economic considerations do not allow this to occur today; however, if there is a medically sound reason why you should have your bowel preparation as an inpatient, some insurance companies will allow it. Typically, healthy, vigorous people do not have a problem with outpatient prep. If you suffer from congestive heart failure, renal failure, or have lost a significant amount of weight in the months before your operation, check to see if you are permitted to have your preparation as an inpatient with the support of intravenous hydration and electrolyte monitoring.
If you have used any type of antibiotic in the 6 months prior to your operation, you should let your surgeon know. Even if the antibiotics were prescribed to treat a urinary tract infection, bronchitis, or some other infection not related to your present surgery, antibiotics can alter the composition of the bacteria that reside on and within your body. Chances are this will have no effect on your operation or postoperative care, but if a problem does develop, it is helpful to know which antibiotics were taken in the recent past.
Aspirin and Other Over-the-Counter Pain Killers
In the good old days, only a few over-the-counter drugs were available to control the pain from arthritis, gout, or minor injuries. Today the list is too long to consider each drug individually. These drugs, which are closely related to aspirin in that they control pain by reducing inflammation, are typically referred to as anti-inflammatories. They are used to treat a wide variety of disease processes and all have one common property, the inhibition of platelet function. Platelets are the cells in your circulation that are responsible for clotting your blood. Obviously if you are about to undergo an operation, you want your blood to clot as well as possible; therefore, it is essential that you avoid all anti-inflammatory drugs for a period of 1 to 2 weeks prior to surgery. Failure to stop taking these drugs may lead to excessive blood loss at surgery, which may necessitate the administration of blood or platelet transfusions. Even patients who are taking an aspirin a day to prevent heart attack or stroke should stop in the week prior to surgery.
Your primary care physician should have a list of all of the prescription drugs you are taking, so you should ask if there are any you should stop prior to surgery. If you take over-the-counter medications, drop by your local pharmacy to determine if any of the products you use contain one of these drugs. It is important to know that many medications have more than one active ingredient, so you may not even know that you are taking one of these drugs unless you read all of the fine print on your medication bottles or ask a medical professional. If you are forced to stop taking a product you use to control pain, you may consider switching to Tylenol preoperatively. Of all the over-the-counter medications designed to control pain, the active ingredient in Tylenol is the only one that does not inhibit platelet function. Of course, if you have an allergy to Tylenol or have a known liver disorder, this drug should be avoided as well.
Another common blood thinner in use today is Coumadin (warfarin). This is another drug whose use must be discontinued prior to surgery. If you are taking this drug, your surgeon may simply ask you to stop taking it a week before surgery, or he or she may ask you to enter the hospital several days early to allow the Coumadin to exit your system while you have your blood thinned with an intravenous medication called Heparin. Both Coumadin and heparin act to inhibit blood clot formation independent of the function of your platelets. They work by blocking the proteins in your blood that help hold the platelets in a blood clot together. There are many differences between the two drugs, but the important point is that Coumadin takes a long time to take effect, and once stopped, it takes days to weeks for its effect to be reversed. In contrast, heparin is effective immediately, and its effect is terminated within hours of its discontinuation. Therefore, sometimes it is necessary to allow the effect of Coumadin to wear off while preventing blood clot formation by the use of heparin. Just prior to the operation, the Heparin will be stopped, your blood will clot normally during surgery, and once the operation is over, the heparin (and/or the Coumadin) can be restarted.
Narcotic Pain Killers
A large number of people take prescription painkillers on a frequent basis. The active ingredient in many of these drugs is one of several synthetic derivatives of morphine, and commonly these drugs are known as narcotic analgesics. Again, there are too many brand names to mention, but if you are taking pain killers on a regular basis (that is if you have been taking them for more than several days), there is a good chance you will have problems with pain control postoperatively. I find that many people who take these medications are hesitant to discuss their use for fear of being branded addicts. Of course, there are people who are addicted to narcotic pain pills, but there are also plenty of people who take these drugs for very good reasons. Whatever the case, the use of narcotics on a regular basis induces a tolerance to their effect. In plain English, if you use narcotic painkillers regularly, you will need much higher doses of pain medication postoperatively to control your pain. To save yourself significant discomfort, inform your surgeon and anesthesiologist prior to your operation if you fit into this category. You will be glad you did.
Shaving the Operative Site
People frequently ask if they should shave the area which is to be operated on before coming to the hospital. The answer to this question is simple and straightforward: no you should not. Shaving tends to release bacteria that normally reside in your hair follicles; this increases the incidence of wound infections postoperatively. If your surgeon needs the area of the incision shaved to perform the operation, it will be done after you have entered the operating room. In short, don’t worry about it.
Worst Case Scenarios
This is a topic that is not much fun to talk about; but I will state a simple fact that is designed not to alarm you but rather to inform you. There is no such thing as a minor operation.
What this means in a practical sense is that even routine operations, which are safely performed hundreds of thousands of times each year, will occasionally result in an unexpected death. This may be the result of an unknown drug allergy, a severe transfusion reaction, a heart attack during the operation, a technical error by the surgeon or anesthesiologist, or any number of fluke occurrences. My point is, take a few minutes to consider what you would like to have done if a worst-case scenario arises.
The easiest way to do this is to simply discuss it with a friend or loved one. That way there will be at least one person beside yourself who knows your opinions about death and dying, prolongation of life, use of mechanical life support, placement of breathing tubes and feeding tubes, artificial feeding, organ donation, etc. To formalize this process, you may wish to discuss this with your attorney, who can draft a living will or durable power of attorney for healthcare. This conversation will be superfluous for nearly everyone who reads this book. Unfortunately, accidents do occur in the business of surgery; and to be fully prepared, you must understand all of the possible outcomes.
The Night Before Surgery
You will probably be asked to eat or drink nothing after midnight the evening prior to surgery. This is done so that your stomach will be completely empty before you are given anesthesia. Rarely, anesthesia and endotracheal intubation (the placement of a breathing tube in order to apply inhalation anesthesia) is complicated by vomiting. While sedated, you are unable to protect your airway and lungs, and run the risk of inhaling the stomach juices into your lungs (known as aspiration). If this happens, you run a high risk of developing pneumonia; and this particular type of pneumonia can be hard to treat. The simplest way to prevent it is to have an empty stomach prior to administering anesthesia.
This is a precaution that is taken very seriously by anesthesiologists; so you can be sure that if you do not follow this directive, your operation will be canceled and will have to be rescheduled. The only exception to this rule is that certain medications may be taken with a small sip of water the morning of your surgery. This is a point that should be specifically addressed by your surgeon or anesthesiologist at the last visit before your operation. If you are taking any medications at all, you should ask which to take and which to avoid the morning of surgery. If you have had a bowel preparation before your operation, you may end up having nothing to eat for up to two days before your operation. Again, you should ask which of your medications to take while you are taking the bowel preparation.
If you have diabetes and are taking insulin injections, skipping meals can be very hazardous. However, diabetics run the same risk of aspiration as the rest of the population, and must follow the directive to have nothing to eat or drink after midnight on the evening prior to surgery. It is important, therefore, that the evening insulin dose the night before surgery and the morning dose the day of surgery be adjusted. Please take note: make no adjustment without discussing this issue with your surgeon; and if an endocrinologist treats you, you should get his/her advice as well. Depending upon the insulin preparation you are taking, this can be done in several ways. You will be advised that you should not skip a dose of insulin completely, particularly if your diabetes is difficult to control or you are on high doses of insulin. By the same token, your surgeon or endocrinologist will likely advise you that a regular dose should not be taken on an empty stomach. It is a wise idea to carefully check your blood sugar levels the evening before and the morning of surgery if you have a home blood-glucose meter.
Before undergoing surgery, you should have a very clear understanding of the goal of the operation. Beyond that, it is important to understand the risks associated with the operation and the benefits you hope to achieve. There are very few absolutes in medicine, and this is particularly true when it comes to surgery. Almost no operation can guarantee a cure 100% of the time. Similarly, almost no operation is risk free 100% of the time. Before any operation is performed, your surgeon will weigh the risks and benefits of the procedure in his or her mind. This is done so automatically that you may not realize that it has occurred. It is essential that you understand what you will be subjected to and the goal of the operation. If the goal is to completely cure you of your disease, ask what the chances are that this will actually occur. You may find that you are not willing to undergo an operation with possible debilitating effects if it results in a cure only 30% of the time. Conversely, you may find that you are willing to risk your very life in an operation for even a small chance at a cure.
When talking about the management of expectations, the most important ingredient is knowledge. Fortunately for all of us, tools are now available that allow for the rapid dissemination of information. A few years ago, the advice of a physician was seen as an absolute. In the rare instance when a patient was not comfortable with the treatment options presented, the only recourse was to seek a “second opinion.” While second opinions are still obtained today, many patients now have taken matters into their own hands. There are mountains of information available to every one of us on the Internet. To harvest this information, you do not need to be a computer scientist, you need only be able to explore the World Wide Web. It’s often comforting to do some “homework” regarding your disease and proposed operation in the days or weeks before surgery. Many sites are available on-line that contain this information; and for a few helpful links, you can start by logging on to www.preopguide.com. If you do not wish to search for information online, most local libraries have a few medical desk references available, and even a quick read of a textbook may give your a starting point when discussing your disease with your physician.
One point I wish to emphasize is that you cannot believe everything you read. I suggest that all my patients do some research of their own so that we can have informed conversations about their disease and surgery. However, I also suggest that you do not take the information you have gathered as absolute fact, especially if it contradicts the opinion of your surgeon. Remember again, it takes years of training to develop the knowledge and skills necessary to practice surgery. Along with that training comes the wisdom of literally decades of experience. Authors who propose new treatments, techniques, or approaches to the management of disease may be onto the next big advance, or they may be barking up the wrong tree. Take a second to remember how many times you have heard the news media report that the cure for cancer was at hand, only to find that the new cure did not meet the test of time. I have heard it quoted that upwards of 80% of all new advances reported in the scientific literature do not ultimately change the way diseases are managed. Therefore, if you are discussing with your surgeon some cutting-edge breakthrough that you learned about, which he or she has heard nothing about, chances are very good that the good old way is probably still the best option.
Getting back to the bottom line, my suggestions are these:
1. Ask what the natural course of your disease will probably be if you have no surgery.
2. Ask what your surgeon hopes to accomplish by performing the planned surgery.
3. Ask what the chances are that this goal will be met.
4. Do a little homework so you can participate in the decision making process regarding your disease and your surgery.
5. If you discover new or experimental treatments that your surgeon is unfamiliar with, it is probably because they are, as yet, unproved. My personal bias is to stick with the method that has the best track record over the longest period of time; I believe most surgeons feel the same way. If you are unsatisfied with the tried and true method your surgeon advocates, perhaps you should contact the center at which the newest method has been pioneered to determine if you could receive your care at that institution.
6. Remember, in some cases, the best option is to do nothing. Do not be afraid to decline an operation if you are not convinced it will help you. This being said, remember that just as there are consequences to every action, there are also consequences to every inaction. As long as you are willing to accept the consequences of the decision you and your surgeon reach, you have made the right decision.