Book Review

Complications in Surgery

N Engl J Med 2006; 354:2398-2399June 1, 2006

Article

Complications in Surgery
Edited by Michael W. Mulholland and Gerard M. Doherty. 826 pp., illustrated. Philadelphia, Lippincott Williams & Wilkins, 2006. $159. ISBN: 0-7817-5316-3

A complication is an unwelcome problem that, like an inebriated ex-spouse at a wedding party, is not an essential part of a disease or its treatment. Some complications of disease — and even of treatment — may be the unavoidable consequences of variations in pathology and homeostasis. Other complications may be the result of the physician's errors. No treatments present more opportunities for iatrogenic complications than do surgical procedures.

Complications in Surgery, edited by Michael Mulholland and Gerard Doherty, is intended to be the definitive reference book for any physician who is dealing with such problems. The book is the successor to Lazar Greenfield's Complications in Surgery and Trauma (Philadelphia: Lippincott Williams & Wilkins), which was last revised in 1989. At the time, Greenfield was the chairman of surgery at the University of Michigan; Mulholland is the current chairman. Not surprisingly, most of this book's contributors are members of the faculty of the University of Michigan Medical School. The other contributors are from more than a dozen other institutions; among them, Washington University in St. Louis is the most represented.

This book, which focuses on complications of general surgery and its close relatives in cardiothoracic, vascular, transplantation, and pediatric surgery, contains only brief references to complications of trauma. New surgical procedures such as thoracoscopy, endovascular interventions, and laparoscopy have their own chapters. The chapter on laparoscopy is particularly comprehensive.

The first section of the book addresses institutional issues such as surgical training, the competency of surgeons, and the assessment of quality. The chapters about process and outcome measures of quality provide the reader with excellent overviews of the National Surgical Quality Improvement Program and the relationships between outcomes and the volume of procedures. Although teamwork is mentioned in the preface, a detailed discussion of this topic (and the principles of high reliability espoused by Karl Weick, who is also at the University of Michigan) is not included in the book. The authors discuss changes in the practice of surgery, but not those changes that are directly connected to complications.

Subsequent sections address specific types of complications; these sections are organized according to discipline, organ system, and in general, procedure. The authors focus on complications encountered during an operation and the postoperative recovery phase. They also describe patients who are at high risk for complications and recommend ways to minimize those risks. Late complications and the failure to cure an anatomical problem are sometimes addressed. Topics having to do with tertiary care (such as cardiac and transplantation surgery) are thoroughly covered. Many of the chapters are impressively comprehensive.

The book primarily presents the view of surgical complications as seen by surgeons in tertiary referral centers. Hence, its discussion of complications of lung resection includes herniation of the heart, but not those complications associated with the positioning of the patient for a thoracotomy. Aortic cusp entrapment is covered in the discussion of cardiac surgery, but complications associated with pacemakers are not. The occurrence of Nelson's syndrome (pituitary enlargement) after adrenalectomy is covered, but optimal insulin control in the patient with diabetes is not. Finally, the book describes angiosarcoma of the breast after lumpectomy with radiation therapy, but not error-free management of pathological specimens.

Surgeons would like to think that all complications are the result of extenuating circumstances that challenge their expertise. Unfortunately, some complications — such as retained foreign bodies, operations on the wrong body part, and inadequately secured drains or tubes — are caused by avoidable errors. It is ironic that this book does not address those complications, which surgeons can control most easily. Yet, a system-based approach to patient safety makes the solutions to these problems equally interesting.

In Complications in Surgery, the treatment of subject matter is uneven. The authors address some topics by discussing complications of surgical procedures and others by describing complications of nonsurgical treatments for which surgical consultation is required. In other instances, they cover a topic by describing complications of diseases and their surgical management. Most conspicuously, a discussion of complications in colorectal surgery is found in the chapter about appendectomy. Like the procedures that produce complications, this book's discussions of complications would benefit from a standardized approach.

In this book, first-class scholars of surgery present a traditional approach to the management of complications. These complications, which are either extensions of the patient's disease and treatment or complex challenges that are referred to the master surgeon, are discussed according to organ system, sometimes extremely well. The authors explain how board-certified general surgeons in clinical practice can avoid complications, especially ones that are technical; how they can deal with iatrogenic complications, especially in an emergency setting; and how they can address complications — created by colleagues in other specialties — that require intervention by someone trained in the disciplines of general surgery. A more consistent and system-based approach would make this the definitive book for such surgeons, but Complications in Surgery contains plenty of useful material just as it is.

John R. Clarke, M.D.
Drexel University College of Medicine, Philadelphia, PA 19102
jclarke@linc.cis.upenn.edu