Coping with anastomotic leaks: harder as one gets older?

All surgeons are likely to remember their first leak, which they probably justified with a combination of the unshakeable confidence of youth, the advanced age of the patient, and their lowly position on the learning curve. ‘I will get better’, one concludes, and generally one does. However, like all surgeons who join two hollow conduits together, the menace of a failed anastomosis never departs from our practice. Does it become harder to cope as one grow older?

Anastomotic leaks are probably the most feared and dreaded complications in general surgery, but it is an unusual way to think about a complication. We do not fear postoperative pulmonary emboli, although they are certainly more deadly than anastomotic leaks, nor do we dread the far commoner and economically more impactful surgical-site infections. Why then, are leaks so uniquely emotive to the surgeon? Anastomotic leak rate is widely regarded as a key quality marker for performance in colorectal surgery, and leaks certainly occur owing to technical error or poor decision-making. However, it is also accepted that they occur independently of the surgeon’s ability, with renewed interest in other factors such as the microbiome¹.

The prolonged morbidity of these complications deepens their adverse effect, as illustrated by a hypothetical high-volume colorectal surgeon who does 50–100 anastomoses per year, and has 5 leaks. As the median hospital stay after a leak is about 20 days², there will be an inpatient with a leak under their care for about 100 days per year and potentially others who linger for several months. Adding to the sense of frustration and injustice is the opacity of presentation. The operation may have appeared to have been a technical success, and the leak manifests only several days, even weeks after surgery. There is no reliable means of diagnosing it, and we are all familiar with the benign CT imaging in a stable patient with a C-reactive protein level close to 150 mg/l, whose relook uncovers gross contamination with resulting systemic inflammatory response syndrome and prolonged ICU care, and sometimes death. ‘But Doctor, why didn’t you go back sooner?’

Anastomotic leak carries a significant mortality risk, and a colorectal surgeon may accumulate multiple deaths over a career. When the patient dies or never regains good health, it becomes difficult when deep down in one’s heart one cannot be sure whether it was due to imperfect practice or was just unavoidable. Even formal audit may be surprisingly unhelpful in assessing individual ability. Hypothetically, an audit of a surgeon’s last 100 anastomoses may reveal a leak rate of eight per cent, which is reasonable, but the 95 per cent confidence interval may range from two per cent (among the best in the world) to 14 per cent.

With age comes the realization that, even with competence, experience, and humility, one has failed to overcome this ruthless complication, the responsibility for which the patient, their family, your colleagues, and the insurance company all have you listed as suspect no. 1. The surgeon is reluctantly obliged to accept that there is no new technical skill to acquire that might free one from it. As demonstrated with on-call duties³, managing leaks unquestionably gets more demanding with age. They frequently require complex decision-making, late evening or weekend relooks, and, in a private practice setting, one often chooses to take responsibility of care oneself, not leaving it to the surgeon on call. This ensures that the individual surgeon’s responsibility for outcome remains undiluted.

The ageing surgeon thus faces a double whammy: physically it is more demanding to manage the leak and emotionally it is increasingly discouraging as one realizes one cannot stop them happening. The mitigating factor for the young surgeon of the patient being ‘old’ has also disappeared for the surgeon in or near the seventh decade, when the patient is now closer in age to the surgeon and their friends, if not younger. For the ageing surgeon facing another serious leak, there is no positive spin to call upon, and no absolute need to continue to face the challenge as one did in one’s earlier years. Rather, the temptation to stop is powerful. Why not turn to a management role, teaching and workshop supervision, committee work or simply retire if you can afford to?

The surgeon as ‘second victim’ has become an accepted, although controversial, concept⁴. Although all health practitioners can experience this second-victim phenomenon, a study of 125 academic surgeons who experienced an intraoperative adverse event uniformly reported feelings of guilt, anger, shame, and embarrassment⁵. Many wrote long free-text descriptions of their feelings, as if finally hoping that sharing them with empathetic colleagues would help exorcize them. However, colorectal surgeons are potentially set up for the second-victim phenomenon every week, not only with an intraoperative adverse event, but with each anastomosis harbouring the possibility of catastrophic consequences.

In a recent systematic review⁶ of surgeons dealing with a patient death, only seven articles were identified, and all reported either personal perspectives or interview-based opinion. The absence of institutional support was frequently criticized. On the other hand, investigating adverse medical events has become a hot topic, and, notably, there has been a shift towards acknowledging management errors, with hospitals appointing critical incident investigation teams ostensibly aimed at preventing recurrences, but also to appease the patient or family who usually wants an explanation, an apology, and the reassurance that lessons have been learnt. As discussed in a 2018 editorial in this journal⁷, these teams tend to seek accountability by finding a cause and someone to blame. The Dutch authors described how investigations tend to focus on who instead of what was responsible, some even questioning whether the professional’s actions were malicious, with intent to cause harm, or whether there was negligence or reckless behaviour involved. This approach may satisfy some demands, but may hamper full disclosure out of fear of self-incrimination. Meanwhile, the older surgeon finds themself under scrutiny by colleagues who may be 20 years younger and not even surgeons. It is a complex balancing act addressed by Dekker and Breakey’s⁸ concept of a ‘just culture’, aimed at minimizing the negative impact of an incident with restorative rather than retributive justice. In some systems, there are formal channels aimed at helping the second victim to cope and move on⁵, but these are not widespread, and invariably the surgeon must face their demons alone. Like most ageing professionals—think sport—advancing years are cold comfort.

Resilience training has become a popular approach offered by malpractice insurance companies and some professional bodies⁹. These courses aim to help surgeons cope with the emotional turmoil of their job. In a recent webinar from the BJS Academy entitled ‘Overcoming adversity as a surgeon’¹⁰, it was asked whether resilience training was appropriate, or does it simply activate some of the long-held stereotypes of macho surgical toughness? A risk is that it becomes another stick with which to beat surgeons, their being given the message, explicitly or implicitly, that they should not be struggling and should be resilient, and it is a personal failing if they are not¹¹.

The timing of surgeon retirement has been much discussed, studied, and legislated for over many decades, but without any widespread durable acceptance. In a recent eponymously named BJS editorial, Kurek and Darzi¹² reviewed solutions such as mandatory retirement ages or a competency-based approach. However, like others of this genre, they limited the context to surgeon competence. The older surgeon may well be perfectly competent and up to date, and the editorial refers to studies supporting this, but no attempt was made to measure and discuss emotional considerations affecting the ageing surgeon, especially those triggered by a serious complication.

For the present, it seems likely that the individual surgeon will determine their own withdrawal from the front line, unless their colleagues apply pressure. On a personal note, neither author (50 and 66 years) recalls a single colleague who, a year on, has expressed regret at retiring well before the end of their seventh decade. Despite many still being competent, the relief at losing the emotional responsibility of major complications provides the most satisfaction.

Funding

The authors have no funding to declare.

Disclosure

The authors declare no conflict of interest.