The Ritual of Preoperative Consultation: Essential or Superfluous?

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What are the benefits of preoperative evaluation in patients scheduled for elective noncardiac surgery?

I was awakened from some dogmatic slumbers when I moved to Mobile, Alabama. As an internist, I was used to being consulted for the purpose of assigning risk in patients scheduled to undergo noncardiac surgery. The colloquial term here for the same evaluation was still the archaic “clearance,” somehow intimating that my history, physical examination, and sage advice meant surgery would be free of any and all complications.

But there is a more fundamental question to address than terminology. Data have demonstrated that for low-risk procedures (e.g., cataract surgery) routine preoperative medical testing does not benefit patients or improve outcomes.¹ In fact, larger studies from the Cochrane Database (n = 21,531 cataract surgeries) corroborated a lack of benefit.²

OK, cataract surgery is not the same as abdominal surgery in a patient with diabetes and heart disease. So, what about preoperative evaluation before more complicated surgery in patients who have established comorbid conditions? This month’s “Top Paper” reveals some surprising answers.³

UNEXPECTED RESULTS OF
PREOPERATIVE EVALUATION
The authors used a database to identify a cohort of 269,866 patients aged 40 years or older scheduled to undergo major elective noncardiac surgery (not urgent or emergent). Thirty-eight percent, or 104,695 individuals in this group, received consultation before surgery. What was the benefit of consultation? There was an increase in 30-day and 1-year mortality in these patients. In addition, hospital stays were longer and accompanied by more general and pharmacologic (stress) testing.

These data are surprising and will have a major impact. Every year 234 million people undergo surgery worldwide.³ The 5 reasons to evaluate any of these individuals before surgery are:
•Better documentation of comorbid diseases.
•Risk stratification.
•To optimize management of any underlying medical conditions.
•To initiate interventions to decrease risk (e.g., smoking cessation).
•To defer or cancel surgery if risks exceed benefits.³

All this makes good medical sense, so why the “disconnect” suggested by this study? The authors proposed some potential flaws in their design. First, consultation, for unknown reasons, decreases the use of epidural anesthesia. Epidural anesthesia is associated with improved survival. Second, beta-blocker use was higher in the consult group. That specific prescription has been controversial and can lead to an increase in surgical mortality and stroke. Third, the final data did not include those patients in the consult group who had surgery cancelled to prevent serious operative complications. Finally, urgent or emergent surgeries were not included.

IS LESS MORE?
The heading above the title of this “Top Paper” was “Less Is More.” Although, I do not recommend preoperative evaluation before cataract surgery, I am still not convinced that the service has lost its entire luster. That said, it would not be surprising to find that excess beta-blocker use, a decrease in epidural anesthesia, and over-utilization of pharmacologic stress testing that necessitates invasive procedures (heart catheterization, percutaneous stenting, or heart surgery) may attenuate the benefits of preoperative medical assessment. As primary care physicians, we should reflect on what we recommend before surgery, especially after appreciating this study’s disturbing results.