Bladerunners

BMJ 2007;335:515 (8 September), doi:10.1136/bmj.39317.669213.4E
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Review of the week
Harold Ellis, emeritus professor of surgery, King's College London
A new textbook on surgical complications is a timely aid for modern surgeons faced with multiple risk factors, Harold Ellis finds
How do you judge a good surgeon? Certainly not by appearance. The only person at Westminster Hospital when I was there who looked like a surgeon—tall, distinguished, beautifully dressed, hair just greying at the sides, long tapering fingers—was the hospital barber. What you must take into account is diagnostic skill, ability to communicate, empathy with patients, research ability, and, of course, technical skill in the operating theatre. Don't judge a surgeon by mortality figures: the better the surgeon, the stickier the patients referred to him or her. Overly cautious surgeons may never lose a patient, but a lot of "bad" patients might be denied the chance of relief through surgery.
Also important, but difficult to quantify, is how good surgeons are at avoiding complications and, if and when they occur, how good they are at spotting them and dealing with them quickly and effectively. As surgery becomes ever more sophisticated and its scope expands, so the chance of complications increases. Patients who would have been denied surgery when I retired from surgical practice in 1989—with their bad hearts or terrible chests or seemingly hopeless pathology—may now be submitted to life saving surgery. Audits now show up complications that would not have arisen then, simply because the patient would have been deemed inoperable and would have died.
Today we know far more about the incidence of postoperative complications; and their management has become more standardised and more efficient. For example, audits such as the National Confidential Enquiry into Patient Outcomes and Deaths in England and Wales and the Scottish Audit of Surgical Mortality have provided essential information on the incidence of severe complications. Guidelines laid down by bodies such as the Association of Anaesthetists of Great Britain and Ireland and the National Institute for Health and Clinical Excellence (NICE) give important pointers to safer practice. For example, NICE advises the use of two dimensional ultrasonography as an aid to placement of central venous catheters, which reduces the likelihood of pneumothorax and other complications of this common procedure.
Any number of modern textbooks of surgery, from both sides of the Atlantic, cover diagnosis and management in splendid detail and, of course, deal with the complications of surgery. However, you can search library shelves in vain for a modern text that is devoted to the diagnosis and management of this important topic. The two editors—surgeons on the transplantation unit at Hammersmith Hospital, London—have assembled a large and international team of contributors, covering the surgical specialties as well as anaesthetics, gastrointestinal medicine, and imaging, and also including a medical historian and a medicolegal ethicist. Its chapters cover pretty well every aspect of this broad subject.
Despite today's sophisticated surgery and the array of modern antibiotics, hospital infection remains a serious and indeed an apparently increasing problem. We are warned in the long chapter on this topic that hospital acquired infections account for 5000 deaths a year in the United Kingdom and cost the NHS £1bn (1.5bn; $2bn) a year. They more than double the length of the average stay in hospital and add £3000 to the cost of the average case. The book has a good account of necrotising fasciitis (although some colour photographs would have been useful). However, the two hospital acquired infections that appear so often in our newspapers—methicillin resistant Staphylococcus aureus and Clostridium difficile induced pseudomembranous enterocolitis—deserve fuller treatment in future editions.
Apart from these drawbacks the book provides surgeons with a splendid account of today's diagnostic and therapeutic arsenal in managing surgical complications, including such wonders as imaging controlled percutaneous drainage of deeply placed fluid collections and catheter embolisation of spurting blood vessels.
As is often the case with today's medical texts a chapter on medicolegal issues concludes this nicely produced and illustrated and easy to read book.
As surgery becomes ever more sophisticated and its scope expands, so the chance of complications increases
Surgical Complications: Diagnosis and Treatment
Eds Nadey Hakim, Vassilios Papalois
Imperial College Press, £123, pp 1061
ISBN 978 1 86094 692 9