- Email: [email protected]
Use of breathing exercises and enforced mobilization after colorectal surgery
Letters to the Editors A next step for assessing the global burden of surgical disease
3. Jamison DT, World Bank, and Disease Control Priorities Project. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press; 2006. doi:10.1016/j.surg.2011.02.002
To the Editors: We commend the work of Haynes et al1 on the remarkable results presented in their paper regarding measuring surgical outcomes using the Surgical Apgar Score at 8 hospitals in diverse international settings. We agree it can be useful to measure the postoperative outcome of patients in low- and middle-income countries, and potentially utilize the Surgical Apgar score as a measure of surgical outcomes. Another focus that warrants continued attention is perhaps more data that can highlight the immense need for surgical care in impoverished settings. One third of the worldÕs population lives in poor health expenditure countries (#$100 per head per year) and they undergo only 3.5% of all operative procedures.2 The disparity in surgical access is huge, and the numbers many use to quote surgical disability-adjusted life-years are at best rough estimates.3 Given the low percentage of operative procedures that are performed in low-income countries, those who serve in low- and middle-income countries commonly believe that patients in both rural and urban areas often do not even reach a district facility for prompt medical or surgical attention. These patients without access to surgical care also constitute the ‘‘global patient population’’ and should be part of our discussion about ‘‘global surgical outcomes.’’ The real ‘‘global surgical outcome’’ that perhaps ought to be measured is the numbers who die from treatable surgical conditions outside of the hospital owing to a lack of access. Further research focused in this direction to highlight disparities will be valuable in lobbying for continued funds and support at an organizational and policy level. Jeffrey J. Leow, MBBSa T. Peter Kingham, MDa,b Adam L. Kushner, MD, MPHa,c a Surgeons OverSeas (SOS) b Department of Surgery, Memorial Sloan-Kettering Cancer Centre c Department of Surgery, Columbia University New York New York, NY E-mail: [email protected]
References 1. Haynes AB, Regenbogen SE, Seiser TG, Lipsitz SR, Dziekan G, Berry WR, et al. Surgical outcome measurement for a global patient population: validation of the Surgical Apgar Score in 8 countries. Surgery 2011;149:519-24. 2. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139-44.
632 SURGERY
Use of breathing exercises and enforced mobilization after colorectal surgery
To the Editors: I read with interest the article by Adamina et al1 in the June 2011 issue of the Journal concerning enhanced recovery programs after colorectal surgery. The authors performed a meta-analysis and made recommendations on individual elements that should be part of an enhanced recovery program. Some of these recommendations are based on solid evidence derived from randomized trials or meta-analyses, while others are based on less robust evidence. I take this opportunity to discuss the use of breathing exercises and enforced early mobilization as strategies to optimize postoperative recovery. The authors considered these interventions as key components of patientsÕ postoperative care; however, there is little evidence in the literature regarding their benefit in this patient population. The use of breathing exercises in the postoperative period (deep breathing and coughing exercises, incentive spirometry, or positive-pressure devices) aims to prevent the development of pulmonary complications by promoting expansion of the lungs and facilitating the clearance of pulmonary secretions.2 Several randomized controlled trials have evaluated the effectiveness of these interventions in patients undergoing abdominal surgeries; however, these trials were often methodologically flawed and results were conflicting and inconsistent.3-6 In the most recent systematic review on this topic, which included only trials performed with true randomization, Pasquina et al4 concluded that the efficacy of breathing exercises to prevent pulmonary complications remains unproven. Because breathing exercises are costly4 and often cause further pain and discomfort to patients, their routine use is not justified. Enforced early mobilization is considered an important component of enhanced recovery programs. Authors often justify its importance by citing findings of the several studies showing the negative physiologic effects of prolonged bed rest (eg, muscle loss, impaired pulmonary function, and increased risk for thromboembolic events).7-10 These studies, however, only offer evidence that bed rest is harmful and should not be prescribed.11 The best way to manage patient mobilization after colorectal surgery is still unknown. Enforcing patients to mobilize early makes physiologic sense; however, several key research questions regarding the clinical effects of this intervention remain unanswered. Do patients benefit from undergoing a specific program
Letters to the Editors 633
Surgery Volume 151, Number 4
of enforced early mobilization rather than mobilizing at will (ie, at a frequency and intensity they fell comfortable with)? Does enforced early mobilization have a positive effect on short-term recovery outcomes (eg, recovery of bowel function, postoperative complications, or time to achieve discharge criteria)? Does enforced early mobilization have an effect on long-term recovery outcomes (eg, convalescence, postoperative fatigue, or postoperative quality of life)? What is the relative contribution of enforced mobilization to an enhanced recovery program? At present, the recommendation that patients should be enforced to mobilize early is still arbitrary and not evidence-based. The theoretical benefits of enforced early mobilization should not preclude clinical trials assessing whether patients truly benefit from this intervention. Julio Flavio Fiore, Jr, PT, MSc Melbourne School of Health Sciences The University of Melbourne, Melbourne Victoria, Australia E-mail: [email protected]
References 1. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011;149:830-40. 2. Stiller KR, Munday RM. Chest physiotherapy for the surgical patient. Br J Surg 1992;79:745-9. 3. Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther 1994;74:3-10. 4. Pasquina P, Tramer MR, Granier JM, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest 2006;130:1887-99. 5. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144:596-608. 6. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications. Chest 2001;120:971-8. 7. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41. 8. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17. 9. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-77. 10. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961-9. 11. Allen C, Glasziou P, Mar CD. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354:1229-33. doi:10.1016/j.surg.2011.07.034
General surgery residency and international medical graduates: A perspective from Greece
To the Editors: We read with great interest the Editorial by Itani et al1 published in Surgery. The authors discuss the effects of physician migration to the United States and propose potential solutions that balance national interest and global demand. In 2008, Greece had 6 practicing physicians per 1000 in population according to the Organization for Economic Cooperation and Development (OECD).1 This was the greatest figure among the OECD members; the OECD average was 3.2 practicing physicians per 1000 population.1 The oversupply of physicians in Greece creates serious problems, such as overprescription of drugs, unnecessary surgical procedures, and complications.2,3 However, in the United States, there is a shortage of physicians and a need of international medical graduates (IMGs).1 Young, Greek physicians that have succeeded to the Educational Commission of Foreign Medical Graduates (ECFMG) examinations and are willing to match a general surgery residency in the United States cannot complete their whole program. It is obvious that research during or before residency (2 years), as well as a fellowship (2 years) are strongly recommended for a general surgery resident (5 years) to achieve the high standards required for his or her clinical and academic success. We propose to the ECFMG to either give a visa waiver or extend the maximum duration of training time allowed under a J1 visa from 7 years to the minimum of 9, especially for countries such as Greece, which already hold the record of the greatest number of physicians per capita. Konstantinos P. Economopoulos, MD Dimitrios Linos, MD, FACS Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA Department of Surgery, ‘‘Hygeia’’ Hospital, Athens, Greece E-mail: [email protected]
References 1. Itani KM, Hoballah J, Kaafarani H, Crisostomo AC, Michelassi F. Could international medical graduates offer a solution to the surgical workforce crisis? Balancing national interest and global responsibility. Surgery 2011;149:597-600. 2. Economou C. Greece health system review. Health Syst Transit 2010;12:1-177. 3. Mossialos E, Allin S, Davaki K. Analysing the greek health system: a tale of fragmentation and inertia. Health Econ 2005;14:S151-68. doi:10.1016/j.surg.2011.12.020
3. Jamison DT, World Bank, and Disease Control Priorities Project. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press; 2006. doi:10.1016/j.surg.2011.02.002
To the Editors: We commend the work of Haynes et al1 on the remarkable results presented in their paper regarding measuring surgical outcomes using the Surgical Apgar Score at 8 hospitals in diverse international settings. We agree it can be useful to measure the postoperative outcome of patients in low- and middle-income countries, and potentially utilize the Surgical Apgar score as a measure of surgical outcomes. Another focus that warrants continued attention is perhaps more data that can highlight the immense need for surgical care in impoverished settings. One third of the worldÕs population lives in poor health expenditure countries (#$100 per head per year) and they undergo only 3.5% of all operative procedures.2 The disparity in surgical access is huge, and the numbers many use to quote surgical disability-adjusted life-years are at best rough estimates.3 Given the low percentage of operative procedures that are performed in low-income countries, those who serve in low- and middle-income countries commonly believe that patients in both rural and urban areas often do not even reach a district facility for prompt medical or surgical attention. These patients without access to surgical care also constitute the ‘‘global patient population’’ and should be part of our discussion about ‘‘global surgical outcomes.’’ The real ‘‘global surgical outcome’’ that perhaps ought to be measured is the numbers who die from treatable surgical conditions outside of the hospital owing to a lack of access. Further research focused in this direction to highlight disparities will be valuable in lobbying for continued funds and support at an organizational and policy level. Jeffrey J. Leow, MBBSa T. Peter Kingham, MDa,b Adam L. Kushner, MD, MPHa,c a Surgeons OverSeas (SOS) b Department of Surgery, Memorial Sloan-Kettering Cancer Centre c Department of Surgery, Columbia University New York New York, NY E-mail: [email protected]
References 1. Haynes AB, Regenbogen SE, Seiser TG, Lipsitz SR, Dziekan G, Berry WR, et al. Surgical outcome measurement for a global patient population: validation of the Surgical Apgar Score in 8 countries. Surgery 2011;149:519-24. 2. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139-44.
632 SURGERY
Use of breathing exercises and enforced mobilization after colorectal surgery
To the Editors: I read with interest the article by Adamina et al1 in the June 2011 issue of the Journal concerning enhanced recovery programs after colorectal surgery. The authors performed a meta-analysis and made recommendations on individual elements that should be part of an enhanced recovery program. Some of these recommendations are based on solid evidence derived from randomized trials or meta-analyses, while others are based on less robust evidence. I take this opportunity to discuss the use of breathing exercises and enforced early mobilization as strategies to optimize postoperative recovery. The authors considered these interventions as key components of patientsÕ postoperative care; however, there is little evidence in the literature regarding their benefit in this patient population. The use of breathing exercises in the postoperative period (deep breathing and coughing exercises, incentive spirometry, or positive-pressure devices) aims to prevent the development of pulmonary complications by promoting expansion of the lungs and facilitating the clearance of pulmonary secretions.2 Several randomized controlled trials have evaluated the effectiveness of these interventions in patients undergoing abdominal surgeries; however, these trials were often methodologically flawed and results were conflicting and inconsistent.3-6 In the most recent systematic review on this topic, which included only trials performed with true randomization, Pasquina et al4 concluded that the efficacy of breathing exercises to prevent pulmonary complications remains unproven. Because breathing exercises are costly4 and often cause further pain and discomfort to patients, their routine use is not justified. Enforced early mobilization is considered an important component of enhanced recovery programs. Authors often justify its importance by citing findings of the several studies showing the negative physiologic effects of prolonged bed rest (eg, muscle loss, impaired pulmonary function, and increased risk for thromboembolic events).7-10 These studies, however, only offer evidence that bed rest is harmful and should not be prescribed.11 The best way to manage patient mobilization after colorectal surgery is still unknown. Enforcing patients to mobilize early makes physiologic sense; however, several key research questions regarding the clinical effects of this intervention remain unanswered. Do patients benefit from undergoing a specific program
Letters to the Editors 633
Surgery Volume 151, Number 4
of enforced early mobilization rather than mobilizing at will (ie, at a frequency and intensity they fell comfortable with)? Does enforced early mobilization have a positive effect on short-term recovery outcomes (eg, recovery of bowel function, postoperative complications, or time to achieve discharge criteria)? Does enforced early mobilization have an effect on long-term recovery outcomes (eg, convalescence, postoperative fatigue, or postoperative quality of life)? What is the relative contribution of enforced mobilization to an enhanced recovery program? At present, the recommendation that patients should be enforced to mobilize early is still arbitrary and not evidence-based. The theoretical benefits of enforced early mobilization should not preclude clinical trials assessing whether patients truly benefit from this intervention. Julio Flavio Fiore, Jr, PT, MSc Melbourne School of Health Sciences The University of Melbourne, Melbourne Victoria, Australia E-mail: [email protected]
References 1. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011;149:830-40. 2. Stiller KR, Munday RM. Chest physiotherapy for the surgical patient. Br J Surg 1992;79:745-9. 3. Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther 1994;74:3-10. 4. Pasquina P, Tramer MR, Granier JM, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest 2006;130:1887-99. 5. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144:596-608. 6. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications. Chest 2001;120:971-8. 7. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41. 8. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17. 9. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-77. 10. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009;144:961-9. 11. Allen C, Glasziou P, Mar CD. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354:1229-33. doi:10.1016/j.surg.2011.07.034
General surgery residency and international medical graduates: A perspective from Greece
To the Editors: We read with great interest the Editorial by Itani et al1 published in Surgery. The authors discuss the effects of physician migration to the United States and propose potential solutions that balance national interest and global demand. In 2008, Greece had 6 practicing physicians per 1000 in population according to the Organization for Economic Cooperation and Development (OECD).1 This was the greatest figure among the OECD members; the OECD average was 3.2 practicing physicians per 1000 population.1 The oversupply of physicians in Greece creates serious problems, such as overprescription of drugs, unnecessary surgical procedures, and complications.2,3 However, in the United States, there is a shortage of physicians and a need of international medical graduates (IMGs).1 Young, Greek physicians that have succeeded to the Educational Commission of Foreign Medical Graduates (ECFMG) examinations and are willing to match a general surgery residency in the United States cannot complete their whole program. It is obvious that research during or before residency (2 years), as well as a fellowship (2 years) are strongly recommended for a general surgery resident (5 years) to achieve the high standards required for his or her clinical and academic success. We propose to the ECFMG to either give a visa waiver or extend the maximum duration of training time allowed under a J1 visa from 7 years to the minimum of 9, especially for countries such as Greece, which already hold the record of the greatest number of physicians per capita. Konstantinos P. Economopoulos, MD Dimitrios Linos, MD, FACS Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA Department of Surgery, ‘‘Hygeia’’ Hospital, Athens, Greece E-mail: [email protected]
References 1. Itani KM, Hoballah J, Kaafarani H, Crisostomo AC, Michelassi F. Could international medical graduates offer a solution to the surgical workforce crisis? Balancing national interest and global responsibility. Surgery 2011;149:597-600. 2. Economou C. Greece health system review. Health Syst Transit 2010;12:1-177. 3. Mossialos E, Allin S, Davaki K. Analysing the greek health system: a tale of fragmentation and inertia. Health Econ 2005;14:S151-68. doi:10.1016/j.surg.2011.12.020