Skill of the Surgeon

[Dgreenbee]

Many people on this forum have had a lot of pain and other post op troubles with which to deal, yet some have had a pretty smooth ride. I am wondering why there is so much difference. Could it be the skill of the surgical team? What do you think

 

[mainframe]

I think we all come to the surgery in varying degrees of health which most likely contributes to different bumps in the road we face. My first surgery I was a workout fiend for year prior to surgery. I didn't exhibit any symptoms. I breezed through surgery. My second surgery, my failing bovine tissue valve went downhill faster than I or the doctors would have liked. I went into surgery in pretty rough condition. I barely survived and was in the hospital much, much longer than most. All this despite having one of the best surgeons in the country. Ultimately it's hard to tell prior to surgery what will happen.

 

[Ovie]

Agree with mainframe. You read different stories because they are all from different people. Age, weight, health, etc.

I've asked the question myself, this is a support group, you're going to see more people seeking advice, or opinions on certain situations, such as things that are going wrong and someone wanting knowledge or comfort on something that may have happened. If something is wrong with me, I want to know what others experienced if they too had the same issues. It's give and go, and I think this is a community that cares, so we like to share when things are good, but also bad.

IMO I believe there are more skilled surgeons than others, some that can do a better job than what someone else may have got elsewhere, but I think you know when you've got a skilled surgeon, they may not be the best in the world, or ranked. But that does not take away from how good they are at what they do.

Surgeons are like athletes, you've got your best players, but you've got all the rest of the team that's still playing at the same level as those players too.

 

[Bill B]

Yes, what determines why some people cruise and others have more issues is more likely their underlying state of health. I don't think things like pain, fever, fluid accumulation, whether arrhythmias develop, whether you have an intraoperative MI or a hundred other complications that can occur after a routine AVR have much to do with the surgeon. But whether a complex repair of a more complex problem is done successfully or not so succsssfully might.

 

[TheGymGuy]

Yes, what determines why some people cruise and others have more issues is more likely their underlying state of health. I don't think things like pain, fever, fluid accumulation, whether arrhythmias develop, whether you have an intraoperative MI or a hundred other complications that can occur after a routine AVR have much to do with the surgeon. But whether a complex repair of a more complex problem is done successfully or not so succsssfully might.

I can add something to this, as I have seen this in person. My AVR and ascending aorta replacement was on Tuesday and one room over there was a guy whose AVR and ascending aorta replacement was on Wednesday. Both him and I had same surgeon and I am guessing surgical team (though, I do not know that for a fact). We had the same procedure at the same hospital only 1 day apart. He was about a decade older, but also in decent physical shape (not at all overweight, actually on the skinnier side), a recreational runner, works out at home with dumbbells, in my opinion in favorable health. Yes, I did do a complete physical assessment on a man that I've just met at the hospital - it's just my style. One thing I do not remember asking was whether he had symptoms prior or not. His recovery was about 1, at most 2 days behind mine, and he looked a little beat up by the surgery (when this truck hits you, it hits you hard). I stopped by his room several times and tried to encourage him. His visitors were really fired up by visits and I asked them to support and encourage him, which I know they did. I was checking out on day 3 for me which was day 2 for him and he was walking a complete lap little before noon. I remember that on day 2 I was taking many short, medium and long walks already. Even so, he was just a little behind and in my mind, being in favorable physical shape beforehand will really speed up the recovery. I mean, it is just one ingredient to this complicated, complicated recipe, but this is one ingredient that you actually have personal control over.

 

[ElectLive]

...being in favorable physical shape beforehand will really speed up the recovery. I mean, it is just one ingredient to this complicated, complicated recipe, but this is one ingredient that you actually have personal control over.

Complicated indeed, and so many ingredients interacting in different ways. Unfortunately, for those of us who like to have control of everything, chance (luck, fate, etc) is equally to blame. I'd put my ingredients in 3 categories. Most important is the patient and underlying health. Next in line is the surgeon and his or her entire team - and I do think there is a trickle down effect of excellence. Least important, more often than not, is chance, but chance can have just as big of an impact as anything else, if not more so, in some cases.

The Cleveland Clinic is very forward with pointing out the importance of surgical excellence, even in higher risk patient groups. They publish an enormous amount of statistical outcomes every single year, and usually compare key parts to the STS national database. Now, if they are a few percentage points better than the national average, obviously there are surgical teams out there who are a few percentage points lower too. For the very "safe" procedures, like an isolated AVR, it may not make much of a difference for the extreme majority. But for the more complicated cases, like an acute aortic dissection, the disparity can be drastically different - ranging from a 2 to 3 percent mortality risk in the hands of the best to a 15 percent or more risk in lesser hands.

But, you simply cannot ignore chance either. Heart sugery, even at its best, just is not a perfect science. Literally anything can happen to anyone. More so, complications and recovery from heart surgery are even more imperfect. You know, I had an interesting discussion with my surgeon about the mortality rate he quoted me. I was coming at the question from the perspective of a pretty young, healthy individual who wanted to believe I was in the best possible position for successful surgery, so I thought that my odds should actually be better than what he quoted me, since there were no doubt much higher risk candidates that formed the bulk of his patients. He just sort of smiled and said something to the effect that I while I was certainly right in theory, in practice, not so much. Once a heart is stopped, guarantees are off the table.

I tell you what, though, maximizing the variables we do have control over certainly helps insulate us all against chance that goes the wrong way. With a top tier surgeon and a patient in good physical and mental state, the odds are extremely low for the majority of our procedures that much will go wrong. And what's the point in worrying about chance anyway, it affects everything we do, we're just as likely to be impacted outside the OR.

 

[Magnacruz]

Interesting topic. Sure, a surgeon's competence can affect the outcome, but there are a lot of other factors as well. I think the condition and age of the patient can make a big difference. I believe it is more random than anything simply because open heart surgery is not an exact science. Maybe it is just coincidence, but I have had more problems with mechanical valves than tissue. I pretty well breezed through my first AVR (tissue) age 25, but my second surgery (same surgeon this time mechanical at age 32) I had more pain, and longer rehab. My next AVR (mechanical at age 38, one of the best surgeons at the Cleveland Clinic), I had a tremendous amount of pain especially in my back after surgery. I took more pain pills after that surgery with less effect than any other surgery. I believe that I came home with an infection which led to Bacterial Endocardis a few months late, but I don't know for sure. My next AVR (tissue, age 38, same Cleveland Clinic Physician) was the longest surgery, but rehab went well and pain was not an issue. My AVR at age 53 (mechanical, same Cleveland Clinic physician) had the longest rehab period. I was not in good physical shape for that one because I waited longer than I should have to have it done. There was some pain but it was not excessive.

 

[Jeff Edmonton]

Well, I have not had 5 surgeries (wow), but I did lose my mother in 79 from OHS. Being prepare mentally and having the surgery before perminant damage is done to your heart is pinnicle. These surgeons are far and few between, when they reach this level of expertise they are more or less equal. With advanced technology, video conferencing, automation and advancements in anastesiaolgy they are way ahead of the game.
What is critical is having a good relationship with the right GP, have a personally objective to get checked out regularly and know and not ignor symptoms. Those that are caught to late, we rarely hear about because they have not survived.

 

[Greg a]

Well, I have not had 5 surgeries (wow), but I did lose my mother in 79 from OHS. Being prepare mentally and having the surgery before perminant damage is done to your heart is pinnicle. These surgeons are far and few between, when they reach this level of expertise they are more or less equal. With advanced technology, video conferencing, automation and advancements in anastesiaolgy they are way ahead of the game.
What is critical is having a good relationship with the right GP, have a personally objective to get checked out regularly and know and not ignor symptoms. Those that are caught to late, we rarely hear about because they have not survived.

JEFF NAILED IT as usual......I should have been like his mother was "died from complications following OHS" but the skill of my Doctors (three cardiac surgeons working together) saved my life .....it is the doctor that faces a complication and can handle it that I want in that roon !!!

 

[Dgreenbee]

I have been thinking a lot about what makes some recoveries quicker and easier than some others. I agree that the general health of the patient is a major factor and that the skill of the surgical team also plays a role. Also, plain old luck is a factor. I also think there are two things a person can do to help themselves. One is walking. In the hospital one should walk around the ward several times per day and at home, go for a good walk each day. The other thing is to have a very positive outlook. Refuse to see yourself as a victim. You are a lucky person who has gotten some great help from the surgeon, medical team, nurses, hospital, and family. Make the most of that support.

 

[Duffey]

I believe the skill of the surgeon, and the team he has assembled, is probably responsible for 75% of the outcome. The other factor I believe, is the severity of the valve, and the affect it has on other body organs, before replacement. Of course, if one is in poor medical shape beforehand, due to smoking or morbid obesity, that will significantly impact a normal post-op recovery.

 

[GordoAVR]

One third is all about the skill of surgical team; one third depends on the condition and attitude of patient; one third is old fashioned luck and God's good Grace.

 

[Lynlw]

Its an interesting question, and you got alot of good opinions on it. Since you seem to be talking more about the relatively smaller complications and not life or death, for a routine valve replacement /graft since there are probably about 100,000 valve replacements each year in the US and the success rates are about 98% for everyone combined, my thoughts are there are alot of good surgeons who can do valve replacements/ grafts and after the recovery the vast majority will have a very good life, no matter who their surgeon is or where they went. especially if you are relatively healthy going into an elective surgery. Some surgeons compare their job to that of a plumber once the heart is stopped, changing out bad parts for new improved ones. and as El mentioned chance or luck plays a part, you can go to the best surgeon, and be in great shape, but things can go really wrong, or you might be in rough shape and end up at a place with out as much experience, and do amazing.

Now if you are asking about the rarer more complicated surgeries, like some of the more complex CHDs or multiple REDOS or very sick patients with several other medical problems,emergency surgeries etc., who you chose to let operate can make a bigger difference in the outcome, experience really matters knowing what to do and what NOT to do and not having to stop and think IF something isnt going right, but just automatically go to plan B.
Since you seem to be asking more about the difference in peoples recovery even with very success outcomes, things like different kinds of pain, fever, fluid problems, slower recovery in the beginning, Of course the surgeon plays a part, but the whole team together including the patient, and their experience taking care of heart patients probably makes a differene in all the little things that add up in ways you probably dont even realize

The "best" surgeons tend to (of course NOT always) surround themselves with the best teams and probably dedicated CICUs and "heart floors, so the staff just take care of and become experts in taking care of heart patients and not all kinds of patients so know what to watch for and what to do if something isnt right and hopefully catch it intime before it becomes a larger problem.
Another role the surgeon's experience can make a difference in is surgeons that do these and much more complicated surgeries day in and out, often gain speed so the patients not only might spend less time in the OR, but even more important to recovery, less time on the heart/lung machine which can make a difference in how long or short or complete, your recovery can be.
Besides how young/old, healthy the patient is going into surgery, IMO attitude can make a difference too, believing you will do great and be willing to do everything they tell you to do to the best of your ability as often as you can , unless there are some complications out of your control, usually helps you recovery quicker. If you go into it thinking you will die or have terrible complcations it probably doesnt help.

I think where you have your surgery and their routine probably makes a difference especially in the first week or so in ways you dont even realize or can plan for. for example, many teams believe pain control is one of the most important things they can do to help with recovery. They work with the patient (who this is a time to be honest, if you hurt say so dont act brave or suck it up) to make sure they are in as little "pain" as possible but still mentally with it enough to do all the jobs a patients has to do. Some places will put you on a pain pump in the beginning, or at least give you that option during the pre op testing/talking day and a combo of IV or oral meds.Of course if you ask beore hand they probably will all say they are great with pain control and really dont want you to be in pain, but once you are recoverying you see that might not be true or at least wasn't passed down.
Of course even in the same center "luck" can even come down to who your nurse is each day/shift and their attitudes about pain. Some work hard to make sure you arent in pain andgive you what you need when it is time, others seem to think they are doing you a big favor waiting until you ask for pain meds and not giving them when it is time. Of course than can be a problem since if you wait to be in enough pain to ask for your meds, you are often chasing the pain instead of keeping on top of it. Its good to work with the patient and you dont want to drug them up more than needed, but you shouldnt be made to feel like you are a baby(well wimp not baby since babies seem to have pretty high tolerences for post op pain from our experiences) or junky because you dont want to be in more pain than you need to be.

Then again pain is relative, some people just have high thresholds of "pain" what is really painful to one person another person might not think it was that bad.
Another thing that can make a diffference in the amount of pain you are in, that is different in different centers, can be the choice of chest tubes. There are all different kinds of chest tube systems and beside the number of chest tubes you start out with, what kind they use can make a difference in how painful they can be. Some places use the large stiff chest tubes hooked up to the large box with chambers and water, usually sitting on the floor, other use much thinner softer tubes that can be hooked up to a little bulb and all kinds in between. Not only can the larger tougher tubes cause more pain inside banging around, especially when you are moving around or walking and when they come out, so could cause more irritation than softer smaller tubes. Would it make enough difference or even cause more fluid to build from the irritation? I dont know but I would think it could in people who tend to, but it can make it a bigger project just to get up and do your laps, especillay if you are hooked up to IV's catheters oxygen etc, its one more big thing to lug around. Of course there are sometimes you can't use the smaller systems, if you can it can probably make the recovery easier.
Another pain some people have is stomach pain, often caused or made worse at aleast by pain meds. Some places are mcuh better at keeping an eye on that, giving some kind of fiber before it becomes a problem. Others wait until the person is constipated and in pain then try to help it.
One of the other things that can be different between doctors/centers is meds. Some places automatically give certain meds to most heart patients, just "incase", while others only give them IF they have to, like a Amiodarone that has ALOT of bad side effects and even the manufacturer says to give as a last resort IF a peson is in Afib and other meds didnt work. Some surgeons/centers treat it like it is as safe as tylenol. There are other drugs that come with nasty side effects that maybe if a person chose a different surgeon/center they might not have even been put on, so wouldnt have that side effect and need more drugs to take care of those side effects.
So I guess my answer would be the surgeons skill plays some parts, the rest of the staff and what is normal procedure probably plays a large part part of this beside things i gave examples of sometimes its a matter of is even tho they might seem mean or pushing to to hard, some places /nurses really keep on you to get out of bed early, make sure you are doing all your walking and breathing exercises etc IF you aren't motivating yourself, others might wait a day or so to have you walking around etc.and of course the patient plays a part, not only in choosing when and where to have surgery and working as hard as they can, but perception can make a difference, There are people who most people would think they had an AWFUL time, run into all kinds of complications, need more surgeries etc, but if you asked they say it wasnt too bad and then others to the outside world looks like they really were lucky as far as size and number of incisions, recovery, complications, but to them it was the worse experience possible and they think they had it terrible. Some people also can worrry more than others so focus on every little thing and stress themselves out so the whole experience was bad with all kinds of complications in their mind, which is really all that mattters, when others seem to go with the flow more and even if they have a bad bump or too, looking back even a month later thought since they were home in roughly the average time and feel pretty good, they had a good surgery and recovery.
So I probably made this even more confusing than when you asked

 

[Dgreenbee]

Good explanation

Good explanation

That was a very thorough and complete explanation. You are very knowledgable. I am one of the very fortunate people who had a very easy time. I do believe my surgeon was part of an excellent team working in a first rate facility. I also think that I was in pretty good health, had a positive attitude and helped myself by walking a lot. I must say here, though it is a bit off topic, that I am very grateful for the care and service provided by the Canadian medical system. I have had superb attention for the entire time, from the first diagnosis through the hospitalization and the post operative care. It has not cost me, I have not filled out any paperwork, I have not had to ask any insurance company for permission. My care has not been mangled by bureaucracy, I have not government interference in my life, I have not gone before any death panels.

 

[Luana]

Pain is subjective; we each have our own experience of it. I found most things that I've read that people found painful, for example having chest tube removed, not painful at all. I also had a thoracotomy incision for AVR, which is done through muscle and was told it would be more painful. I found pain after surgery to be minimal. I don't think post surgery pain is related to the surgeon. It is related to you tolerance level for pain and the pain medication you're receiving.

 

[Purdue]

My opinion...each person is different even if there was a way to have (2) people go through the same procedure, same time, same surgeon, same everything. Impossible but you get the idea. Once completed, each body heals differently and I found through research and views of hospital employees how different people are. Example: I'm 44 and experienced pain after surgery. Fierce pain and 70 + men around me in rooms had little to no pain on the same procedure. Nerve endings are duller or don't exist is one explanation. Also...someone may cough too much and rip open work while others have no issue. I think there are so many variables present in this type of situation that even if everyone had the same skilled doctor do the work (same day, same time, same staff, etc., etc.), the outcome would still be wildly different. Lastly and directly to the question. I would think the skill of the doc's team is 100% tied to post surgery experiences. I was one of four people who had surgery one morning and the only one who did not need to go back to the operating table hours later to fix problems. Would be neat to dissect that situation and find out if it was really skill level of the doc. Good question posed here.

 

[clfhangr]

Determining factors of recovery from surgical procedures.
1. Age of patient. Know from experience of close to 25 years of different surgeries that I did not bounce back as fast as at age 40 that I did at 25. I will update you with my recovery time period now at 47 after I go in on May 7th for a total root and avr replacement. I had an avr done at age 40.

2. Physical condition and symptoms present at time of surgery. Granted if you are a runner or lifter and in good physical condition at the time of surgery that is going to be a great benefit to your recovery. But the fact of the matter is a lot of valve replacement surgeries are done after damage has been done to the heart or a patient is in congestive heart failure. I hope to be able to speak to this one as well in a few weeks as at the time of my first avr I was in congestive heart failure with a load of symptoms and I have elected to get my current issue (4.9 aaa and regurgitation on my mechanical valve) fixed before I get to a point of being compromised by it. Currently I am strong and healthy and look forward to a good recovery.

3. Emotional wellbeing. I believe that this category is paramount to a complete recovery and can be a huge factor in the long road ahead. Be realistic to your situation and be prepared for possible setback will benefit you when they do happen. And yes they do happen. You just can't let them side track you at the time. Yeah I know easier said than done. Been there done that and have learned the hard way. This forum and group is an excellent resource for preparing for a surgery of this magnitude and I am so thankful I have found it for my second surgery as I did not have anything like this for my first.

4. Underlying medical conditions secondary to the heart valve disease. There are many things going on in the human body that can greatly impact the healing progress when recovering from a surgery of this magnitude. I for one have had a kidney transplant and my renal function is solid and stable but the fact of the matter is it is far from my normal system that I had years ago and the underlying inflamation that accompanies my renal disease can hinder the healing process.

In a nut shell it comes down to this we are all different with a completely different genetic structure and we should not compare our recoveries to on another as each one of those will be different as well. What we should do and what I see happening in this forum is we learn from one anothers experiences and we prepare ourselves for our up coming surgical event as best we can and draw love and support from our fellow valve replacement survivors. (Yeah I said survivors because that is what we are. And we should all be proud of that)

Enough of my ramblings I hope everyone has a great week.