More on activity restrictions after surgery

In early January, I blogged about the dearth of evidence about activity restrictions after surgery.

A number of people commented and most agreed that there is little basis for most of the activity restrictions surgeons currently use.

An anonymous reader told me about a 2008 study from Creighton University that generated some interesting data about intra-abdominal pressures associated with some common activities. Here’s a summary of the paper.

What about activity restrictions after surgery?

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology service's description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.



I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I can't think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to 'forever' [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.

Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

Do surgeons still do postop care?

Here's an email I received the other day (edited and posted with the author's permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Do operating room checklists improve outcomes?

The other day Atul Gawande tweeted the following:

I am not against checklists. When I was a surgical chairman, I implemented and used one in both the operating room and the ICU. They do not add costs and may be helpful.

However, the randomized trial that Gawande referred to does not necessarily settle the issue about whether checklists really do reduce complications and deaths.

The paper, published online in Annals of Surgery [full text here], looked at 5,295 operations done in two Norwegian hospitals. The intervention was a 20-item checklist consisting of three critical steps–the sign in before anesthesia, the timeout before the operation began, and the sign out before the surgeon left the operating room. Using a stepped wedge cluster design, patients were randomized to control or the checklist.

Complications occurred in 19.9% of the control patients and 11.5% in those who got the checklist, a significant difference with p < 0.001.

A look at Table 2 finds that of 27 complications or groups of complications, 14 occurred in significantly fewer patients in the checklist group.

Of the significant 14, a few, such as cardiac or mechanical implant complications, could possibly have been prevented by the implementation of the checklist.

For most of the others, the relationship between the use of a checklist and a post-operative complication is tenuous. How could a checklist possibly prevent technical complications like bleeding requiring transfusion, surgical wound dehiscence, and unintended punctures or lacerations?

Here are a few more of the complications that occurred significantly less frequently in the checklist cohort—urinary tract infection, pneumonia, asthma, pleural effusion, dyspnea, and the nebulous categories of "complications after surgical and medical procedures" and "complications to surgery not classified."

What item on a checklist prevents asthma, UTI or any of those on that list?

Embolism, sepsis, and surgical site infection, three complications one would expect a checklist to impact because of reminders to give prophylactic antibiotics and anticoagulation, did not occur at significantly lower rates in the checklist group.

Even the cardiac complication category is open to question because none of the 5 subcategories (cardiac arrest, arrhythmia, congestive heart failure, acute myocardial infarction) differed significantly between the two groups. Only when the 5 were combined did statistical significance emerge.

In the 300-bed community hospital, checklist use was associated with a significantly lower mortality rate than non-use, 0.2% vs. 1.9% respectively (p = 0.02), but no mortality difference was seen in the 1100-bed tertiary care hospital.

The tertiary care institution enrolled 3,811 patients while the 300-bed hospital contributed 1,083. If more patients had been in the latter group, the difference may have disappeared due to the principle of regression to the mean.

Despite the heightened vigilance associated with an ongoing research project, compliance with checklist use was only 73.4%.

Before you go off on me, I will remind you that I do not oppose checklists. Most things we do in medicine are not based on Class 1 evidence.

Just don't tell me that checklists have been proven to reduce complication rates or save lives.

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.

LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.

LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?

Shoulder surgery postop follow-up

I'm almost 6 weeks out from my arthroscopic right rotator cuff surgery. Here's my post about the first part of the journey.

I'm feeling much better. I can now remove the sling while I am sitting. It has to be on when I'm walking, and I still have to sleep in it. It's a bulky thing that prevents me from moving and possibly damaging the healing tendon repairs.

Sling selfie

You can see that I can't raise my arm or move it too close or too far from my body.

Tendons are not as sturdy as ligaments, fascia, or even skin, so they must be given a lot of time to heal. Excess active motion could disrupt the repair. That would be bad.

The problem is that the immobilization causes the shoulder to "freeze." It quickly becomes very stiff. At my physical therapy sessions, the therapist passively moves the arm into places the shoulder does not want it to go. Passive motion does not stress the repair. We go for more range of motion at every visit. It hurts. I'm also doing some carefully selected exercises at home every day.

Some funny things have happened. The other night I dreamed I was playing tennis. I was hitting the ball really well, but I kept thinking, "Mary (my wife) is going to kill me if she finds out."

Last night's dream was about me standing in a large group and explaining over and over how I hurt myself, what the surgery was like, how long the recovery will take and on and on.

I don't need Dr. Freud to help me interpret those dreams.

Later on this week, I'll be able to discard the sling and even starting driving again. The physical therapy will continue for a few more months. I hope to be back to full activity by February.

On the wrong side of the knife

Two weeks ago, I underwent surgery for what proved to be an extensive tear of my right rotator cuff. 

I have never had a major operation before. Here is how it went down.

Back in July, I felt a sharp pain in my right shoulder while playing tennis. Of course, I continued to play that day and for two more weeks. When the pain finally prevented me from playing, I saw an orthopedist who agreed with my guess that it might be a rotator cuff injury. An MRI showed a partial tear of one of the tendons. I was given the option to try conservative treatment or have surgery. I chose the former.

I rested for three weeks and took ibuprofen. I started playing again and was feeling only occasional sharp pain until I fell on my outstretched arm. From that moment, I was unable to raise my right arm above my waist. The pain was intense and unrelieved by medication.

After a week, surgery was inevitable.

The procedure was done arthroscopically through five small incisions. Two completely disrupted tendons were repaired. The anesthesia method was a brachial plexus block which took place after I was sedated.

I woke up with the recovery room feeling fine because the block had not worn off. Even after it did, the pain was tolerable. I stopped taking Percocet after three days. At my first follow-up visit, the surgeon was pleased. That's the good news.

The bad news is I will be in a sling for six weeks and under activity restrictions for 4 months in total.

You have no idea how important your right arm is until you can't use it.

Here are just a few previously simple things that have become much more complicated—typing, shaving, brushing teeth, getting dressed, eating, opening a jar, and most of all, sleeping.

Because the sling must be worn at all times, I have to sleep on my back, which I have never done in my entire life. I have discovered that I am apparently resistant to Ambien. Words can't describe how tired I was those first few days. It was like when I was a resident.

I understand that my situation could have been much worse. It's not a fatal disease, and with physical therapy, I should be OK in a few months.

But my postoperative experience up to now is beginning to affect my usually sunny disposition.

My wife, who is a nurse, has had to call upon all of her skills to get me this far.

But the other day, she said to a friend that as part of the postop care after rotator cuff surgery, the insurance company should include coverage for marriage counseling.