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Surgical volumes continue to increase around the world, particularly in major surgery. Treatments for both benign conditions and cancer have improved, and patient expectation has increased, driving surgical volumes.
While surgical technique is key for good outcomes, patient factors and perioperative pathways play an important role. Over the last 20 years, the development of enhanced recovery after surgery (ERAS) and the increasing recognition that what we do to patients around surgery affects them just as much as the surgery itself have led to the development of a new specialty, Perioperative Medicine (POM). Good perioperative care pathways can’t make poor surgery good but can make good surgery optimal.
But all is not well. The increase in patients’ comorbid conditions and increasing age and frailty mean few patients receiving surgery have optimal health and good reserve. Inconsistent perioperative care remains one of the key drivers of poor surgical outcomes, and its adoption remains a barrier to optimizing surgical outcomes around the world.
In the drive for value-based care in the United States, ERAS and POM have been vehicles to win hearts and minds of providers and politicians. Organization of health systems is key as well as the challenge to finance the stakeholders in a fair and transparent fashion from central governments.
The COVID-19 pandemic has created a backlog of major surgery at a time when services are still restricted and beds that otherwise would be used for surgery are being used for emergent admissions. This has refocused health systems on how to get the most surgery done out of a system with limited beds, and so, ERAS and POM are even more important than ever.
This issue of Anesthesiology Clinics is a follow-up from the 2015 issue “Anesthetic Care for Abdominal Surgery” with the aim of updating key articles and complementing it. All articles are written by experts in their field, who have personal experience in surgical pathway creation, implementation, and optimization. An example of using ERAS as a core structure to remap a US health system’s delivery of surgery and perioperative care is included. There is an update of managing the stress response as well as fluids and hemodynamics. Finally, there is a series of individual articles addressing some of the more recent advances in pathways in major surgical specialties, such as cardiac surgery, gynecologic surgery, oncologic surgery, and liver surgery. The recognition of the increasing morbidity and costs in emergency general surgery has led to a massive increase in the literature in the last 5 years, which is summarized succinctly by the authors.