The Day the Surgeon Had a Leak

For me, leak is a 4-letter word that defines a cycle of one or any combination of loss, feeling inadequate, being judged, incompetence - even if not an outlier with overall leak rate - and on top of this a developing identity crisis. There is this unwanted sympathy from colleagues and others. I know from talking to many colleagues that this resonates well with them, each having their own ways of dealing with it. For the patient, it is both a physical and psychological disaster that might cost their life or the quality of it.

There exist many challenges and reasons why anastomotic leak occurs. This topic does not concern the anastomotic leak itself, but the unfair circumstances that the patient and surgeon must confront and a call to mitigate these circumstances.

During the Multidisciplinary Team (MDT) meeting and prior to surgery, patients are extensively discussed by all MDT members and surgeons working together towards the production of the best available scenario to generate the best outcome for the patient. But the MDT is not there when an individual surgeon is in theatre deciding, especially when they might be at or near personal physical and mental capacity after long operating hours. A real-world operating room MDT does not exist when it comes to a time-critical decision making in the operating room.

Typically, in an outpatient department setting (OPD), patients are certainly given choices about different options such as surgery or no surgery. They are warned about all possible complications; however, they really have no choice on the outcome at the end of surgery. They have to trust what the surgeon is telling them about the operation, the anastomosis and all possibilities of stomas and leaks. The outcome of the operation is at the surgeon’s discretion and that is where the potential for the “agency problem” arises i.e., the potential conflict of interest when someone is acting on behalf of another.

In the operating theatre -for instance during an anterior resection in colorectal surgery - unfortunately, the anastomosis must occur at the end of the operation where the surgeon must make a time-critical decision such as performing an anastomosis or otherwise. In the context of high-risk complex surgery, this inevitably means that my circumstances as a surgeon would have changed from the comfort of the MDT and OPD discussions to the reality of a long day of mental and physical pressure from various sources both before and during the operation. This is the time when the most serious decisions are being made!

So, to join or not to join? Temporary or permanent stoma? I am about to make a decision that might impact the absolute existence of another human being. I am sure we all want to do the right thing for the patient, but when we are at or near personal capacity we would tend to fall towards the easier option. That’s nothing to do with competence, it is human performance limitations. Stoma formation is an easier option especially after a long operation with perceived difficulty. I know what I feel at this time; and I know many colleagues that I have worked with or talked to would feel too. A systematic review found that surgeons tend to be poor predictors (either overestimate or underestimate) of important outcomes such as mortality, anastomotic leak, and long-term outcomes (1). One could only imagine how poor the prediction would be when we are at or near maximum personal capacity.

A recent international survey used hypothetical colorectal anastomotic decision-making scenarios among colorectal surgeons. The study demonstrated that variation in surgical decision-making is influenced by the personality of the surgeon (2). A real time anastomotic decision-making experience with uncertainty in action could be challenging to reproduce in clinical studies.

Human beings are subject to all range of heuristics most notably the availability bias. A recent leak is likely to be a factor in a decision for a stoma formation in the next patient (3,4)

Perhaps parallel to this topic is the stark evidence from highly respected professional disciplines on how the court judges opted to the default/easier decision, in this case denying parole for some hopeful prisoners who have been long waiting for it. Their decision making itself was independently affected by the time of day and whether they were fed and watered closer to decision making (5).

In the context of personality traits and critical decisions, how many studies would we still need to prove that surgeons are humans who are individually, under pressure and uncertainty are more likely to make poor decisions?

Anastomotic leak is important not only for the obvious consequences to patients, but also as a metric that surgeons are measured against. On its own, anastomotic leak is a potential gameable metric. Surgeons are judged by anastomotic leak rate, but not their stoma formation rate. I remember one surgeon volunteering in pride telling me he had no leaks in the past 5 years, only to answer “I don’t know” when I asked what his stoma formation rate was. Currently, there is no available measure to combine anastomotic leak rate with stoma formation rate as a ratio for instance, rather than both considered in isolation.

If we set out from the start to achieve the best outcome for the patient as our goal, then the best approach is a team approach. It should not be about the surgeon’s competence, independence or ego. It’s about protecting each one of us surgeons and the patient from the system that has thrown us in this calamitous position. The old-fashioned authority of surgeons has long gone. We all now work in teams but then we are to be individually blamed for complications. We -the surgeons- even play into this. To say “anastomotic leak is surgeon related” and do little about it is a notion that serves no benefit, neither for the surgeon nor the patient.

One way of achieving better outcomes is to have at least two independent surgeons with different risk perception to objectively assess, alongside the operating surgeon, the best outcome for the patient. Physical or virtual presence is a local matter. This has to be a formal documented procedure, not simply a phone-a-friend scenario. More importantly, a complication would not be implicitly or explicitly blamed or shifted on the individual surgeon but will be documented as a team/hospital complication. Everyone has a skin in the game.

I believe this approach has several advantages. The patient gets the best possible outcome knowing that everything was done to achieve just that. The patient would have all available expertise e.g., a laparoscopic/robotic surgeon available in the event an access is needed without having to go through a postcode lottery with the allocated surgeon. The surgeon would have a better quality of life not having to endure a cycle of counting leaks with all possible combinations of shame, incompetence, identity crisis etc. The team/hospital would have less complication rates and increased patients’ satisfaction. Psychological safety and confidence supported by the system is another positive side effect of this approach as surgeons work together, improving both technical and team experience for all involved. It is a win-win situation.

References

1. Dilaver NM, Gwilym BL, Preece R, et al. Systematic review and narrative synthesis of surgeons’ perception of postoperative outcomes and risk. BJS Open. 2020; 4: 16–26

2. Bisset CN, Ferguson E, MacDermid E, et al. Exploring variation in surgical practice: does surgeon personality influence anastomotic decision-making? BJS. 2022 Oct 14;109(11):1156-1163

3. MacDermid E, Young C, Moug S, et al. Heuristics and bias in rectal surgery.

Int J Colorectal Dis. 2017 Aug;32(8):1109-1115

4. MacDermid E , Young CJ and Solomon M. Decision-making in rectal surgery

Colorectal Dis. 2014 Mar;16(3):203-8.

5. Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. Proc Natl Acad Sci USA. 2011 Apr 26;108(17):6889-92.