Surgery sometimes leads to complications, but how you spend the months leading up to an operation can make all the difference. By Hatty Willmoth.

If you know you’ve got an operation coming up, what can you do but wait for a surgeon to work their magic?

Well, quite a lot actually – that’s according to consultant orthopaedic surgeon Professor Scarlett McNally.

Currently the deputy director at the Centre for Perioperative Care (CPOC), McNally is a serial committee member, award winner and campaigner for good causes.

Right now, she and the CPOC are encouraging people to prepare for their operations, armed with slogans such as ‘the waiting list should be a preparation list’ and ‘it’s a teachable moment’.

When we sit down to talk over Zoom, McNally wearing her signature red, it’s clear that our chat is squeezed into a bursting day.

And although McNally answers my questions at remarkable speed, her words are full of passion, enthusiasm and insight, and effortlessly peppered with facts and figures. It’s a fascinating 30 minutes.

Prepare for surgery

According to McNally, roughly 10 million procedures are performed in the UK each year. Most of these go without a hitch, but 10-15% of people have complications.

‘Complications’ can mean anything from staying an extra day in hospital, to further treatment, more procedures, or death.

“The problem is,” McNally says, “when they go wrong, that’s dreadful for that patient, and it’s a huge amount of extra resources, expertise, critical care, reoperations, readmissions, extended hospital stays…”

She’s frustrated too, it seems, by how predictable the situation often is. “The people who have complications,” she says, “[are] people who are undernourished, frail, weak, deconditioned, can’t get up to go to the toilet, [or likely to] fall in the hospital and break something”.

In other words, the condition a person is in before an operation makes all the difference.

“[Surgery is] a huge event for the body,” she says. “It’s so traumatising. And it’s ridiculous that people just turn up as if it’s just getting a bus somewhere.

“It should be preparing for a marathon. If you sign up for the London Marathon in April, no way are you just going to turn up there in your old trainers.”

McNally passionately recommends that people use the months leading up to an operation to prepare as well as they can. And as part of that preparation, “nutrition is absolutely fundamental”.

Did you know that breathing training before surgery could prevent postoperative pneumonia?

Frailty, obesity and muscles

Eating enough protein to maintain or build muscle, she says, is a good start.

When trying to heal, our bodies use protein from our muscles to help make more of the compounds we need.

Those who are frail, on the other hand, are four times more likely to have complications after surgery. It even makes a difference during the operation itself.

“The soft tissues are just a bit thinner and the muscle isn’t so squidgy [when someone is frail],” she says. “You can just tell if someone’s covering their metal with a beautiful solid lump of steak that will bring in a good blood supply.”

That doesn’t mean being heavier is better; obesity is also an issue, she says.

“Obesity increases risks of operations a little bit. Not as much as people think, but things are slightly more likely to go wrong. It makes the operations more difficult.

“You have to push harder to get the tissues in the right place; you’re more likely to traumatise something.

“The skin hasn’t got such a good blood supply if it’s got more layers. It’s more difficult for anaesthetists to find the [right] place in the back.

“Literally, the instruments are a bit slimy, and they fall on the floor, and it is more difficult to operate and the operations do take longer.

“It’s not a huge difference, but it is enough to make a difference, and it’s more difficult to get people up and managing afterwards. So obesity is a problem. It is a risk factor and it is modifiable.”

Obesity and frailty can also co-exist: ‘sarcopenic obesity’ is when people are obese but have very weak muscles.

“That’s a slightly different problem,” says McNally. “It’s not just that because someone’s fat that they’re well-nourished; they can be badly nourished as well.”

Specific nutrient deficiencies

Patients can also feel weak because of nutrient deficiencies, most commonly anaemia (iron deficiency).

“Anaemia is absolutely key,” says McNally. “If you’re anaemic, your risk of complications is three times higher.”

Much of that figure, she explains, is influenced by external factors, but even accounting for those, anaemia elevates risk by at least 20%.

McNally says that part of the problem is that doctors try to address anaemia by prescribing iron tablets, but these are “horrible to take” and if taken incorrectly can be rejected by the body, disrupt iron absorption and cause diarrhoea.

We can get iron from food such as red meat, liver and kidney beans, she says, but many people don’t know how address anaemia with diet.

She also mentions that 20% of people over the age of 65 are deficient in vitamin B12, but many don’t realise because “it’s so slow to come on”.

Vegans are particularly at risk, she says, because it can be challenging to eat enough vitamin B12 on a plant-based diet.

These deficiencies can make patients feel weak, and slow down their post-operative recovery.

Patients may feel dizzy or faint when standing up, says McNally, and if they do get up, they’re more likely to fall over. They may also feel sick and tired.

She says: “It’s the weakness that’s the problem and it leaves people in hospital – and hospitals are dangerous places. The person next to you coughing could kill you.”

If you’re waiting for an upcoming surgery then, it’s important to eat well to make sure you’re meeting all your nutritional needs, especially with good sources of protein, iron and vitamin B12.

Exercise: a miracle cure

In 2015, McNally was the lead author of a paper called Exercise: the miracle cure, published by the Academy of Medical Royal Colleges.

“Every single medical Royal College and the Faculty of Public Health, and the Royal College of Nursing are on our board,” she says, “so this is what the medical professionals believe.”

The paper outlined how exercise could be a ‘miracle cure’ for individuals by preventing and treating diseases and, in turn, help ‘cure’ the NHS by reducing demand.

McNally says: “[Exercise] can reduce your risk of dementia by 30%, and of type 2 diabetes by about 40%, and of stroke by 30%. So it really, really is a miracle cure.”

But that’s just as primary prevention. “As part of treatment, if you’ve got type 2 diabetes or a heart condition or something, doing exercise improves it,” she says.

“You’re less likely to have a complication like kidney failure from your diabetes, or to need an amputation [if you exercise regularly]. It’s fantastic.

“And it works not only in your heart and lungs, getting oxygen around your body; it has an effect on metabolism, so that you absorb sugar differently, and it has an effect on inflammation.

“Exercise reduces your chance of your cancer coming back. Now, people just need to know that!”

When it comes to surgery specifically, McNally says: “The risk of complications is four times greater if someone is physically inactive.”

But the relationship between exercise and improved surgical outcomes isn’t linear: “The best improvement or reduction in your risk is going from no exercise at all to just a bit.”

In other words, if you already lead an active lifestyle, doing a little more exercise might not make much of a difference.

However, for the 27% of adults in England who do no exercise at all, McNally says it’s really important that they start moving.

Older people, she says, “should be going up and down stairs, breaking up their sitting time, and doing little walks”.

And ideally, she recommends everyone aim for 150 minutes a week of an activity that gets you out of breath, such as brisk walking, cycling, swimming or jogging.

“That’s good for your heart and lungs to get you through the anaesthetic,” she says.

As well as cardio, strength training can be beneficial. We’ve already touched on how building muscle can help with the healing process, but stronger legs and arms can also help people get up and moving after surgery.

“Older people need to do strength training as well,” says McNally, “because that builds up your bone strength, so you’re less likely to break something.”

The systemic issues

All of these are lifestyle changes that people have to make themselves – which might be part of the problem.

“A lot of the way that we do healthcare is just too passive,” says McNally. “Lots of people almost have been trained not to take responsibility.”

But this is an instance when people have to take the initiative to improve their health, because doctors struggle to effectively prescribe the changes needed.

McNally explains that patients must be assessed before surgery takes place, for example to check for nutritional deficiencies.

This is when they may be given advice to reduce their risk of complications, but in most cases this is too little too late, she says.

If an operation must be done in an emergency, for instance if a patient has broken their hip, a preoperative assessment has to take place very soon before the surgery.

Yet even with a planned operation, McNally says the assessment usually happens a few weeks before surgery, rather than taking advantage of the months that a patient may spend on the waiting list.

This timing makes sense in terms of blood tests for example, which may not be relevant if performed months in advance.

However, it also means that patients may not have enough time to change their diet, implement an exercise regime, and improve their health before an operation takes place.

That’s why McNally wants patients to be assessed in two stages. “We need to use the assessment as part of treatment, to put an intervention in place,” she says. “I’m a surgeon, I like fixing stuff.

“Lots of doctors, they want to do the tests and then: ‘Oh, it’s okay, we’ve ruled out cancer.’ ‘Oh, thank you very much, doctor.’ But I want to fix something. I want to change something.”

Until the system is changed, however, patients on the waiting list may have to take it upon themselves to take action towards reducing their risk of complications.

A nutritional failure?

When it comes to making nutritional improvements, the challenge can be even greater for those trying to follow official guidance.

“Public Health England, about 10 years ago, printed something called the Eatwell Plate, saying that 35% of your calories should come from carbohydrates,” says McNally.

“But the problem is, the carbohydrate gets converted to sugar; it’s an instant hit of sugar. And that has two effects.

“One is your body produces insulin and stores [the carbohydrates] as fat, and it’s very efficient at storing fat.

“And the second is two hours later you feel hungry again.”

But doctors tend to stick to the Eatwell recommendations, she says; it doesn’t help that “we don’t get much nutrition in medical school”.

So, for those tasked to change their diets by NHS doctors, it can be a real struggle.

“People don’t stick to diets,” says McNally. “It’s really difficult to stick to a low-calorie diet that’s full of carbohydrates – lots of people can’t.

“Whereas, if you eat protein or fat, you feel full and you don’t feel hungry in a little while. So, for some people, they’d be better on a low-carbohydrate diet.”

Intermittent fasting, she believes, is also “not in the mainstream enough”.

Key advice to optimise your operation

When asked what people should do while they wait to have an operation, McNally says: “There are seven things proven to reduce your risk of complications.” These are:

1. Nutrition: eat well, with a diet full of vegetables and protein, in a way that supports a healthy weight. “That’s what your body needs to be able to heal,” she says.

2. Stop smoking and avoid smoking atmospheres. “If you smoke, your risk of complications is twice as high,” she says.

3. Exercise: aim for 150 minutes a week; improve cardio fitness and build strength.

4. Cut out – or at least cut down – alcohol and illicit drugs. “Alcohol is a toxin and it alters where you store fat,” says McNally. “It is more toxic than people realise, and it messes up your brain a bit, so try and really cut down.”

5. Medication review: at the age of 65, 50% of UK adults have two or more medical conditions, and by 75 years old it is 70%, says McNally. These figures get worse, she says, with social deprivation, starting about 10 years younger. “There’s a lot of people on lots and lots of tablets,” she says, “and they all interfere with each other, and some of them are just for side-effects of the other ones. So you really need to have a proper medication review. I think that’s a big one; polypharmacy is just huge.”

6. Psychological preparation: McNally describes the ideal mind-set. “I’m going to do this. I really want this operation. I’ve worked for it. I’m going to fit my exercise in, and I’m going to eat well; I’m going to prepare. Psychologically, I’m ready. I’m ready. Bring it on.”

7. Practical preparation: sort out what to wear, what to bring to the hospital, and how to make returning home as smooth as possible. “What can I do? What do I deserve? I’ve spent all my life earning money and paying taxes, so you know what, I’m going to get a taxi back from the hospital, because so-and-so can only collect me on a Friday and I want to get out as soon as I can.”

Following these steps – even before the doctors recommend them – can improve the chances of a smooth and successful surgery.

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