I enjoyed reading Prof. Sessler's1editorial view regarding the long-term consequences of anesthetic management. Prof. Sessler reviewed the changes in anesthetic practice that have occurred in the past few decades, which have led to significant improvement in patient care and reduction in perioperative morbidity and mortality.

I was surprised, however, that there was no mention of the changes that have occurred in surgical practice during this period. The trend toward minimal invasive surgery in many surgical subspecialties has profoundly changed the stress that the patient undergoes during surgery and afterward. Laparoscopy has replaced laparotomy, and video-assisted thoracoscopy has replaced thoracotomy. Procedures such as angiographic-guided stent insertion for management of aortic disease and endovascular obliteration for cerebral arteriovenous malformation have reduced the number of large open operations that are performed in the operating rooms. In cardiac surgery, we now have off pump coronary artery bypass and minimal invasive valve replacements. Many operations have become ambulatory procedures, such as arthroscopies or extracorporeal shock wave lithotripsy. Minimal invasive procedures cause less bleeding, less tissue injury, less stress to the body, and are less painful. Thus, less blood and fluid are administered, less opioids are given, the patient is mobile sooner, and all complications are reduced.

In the 1970s, when perioperative death from anesthetic cause was estimated as 1-10:10,000 anesthetics,2,3the 10,000 anesthetics were given for open operations that were performed in those days. Today, when we estimate death in 10,000 anesthetics, the number includes relatively smaller procedures. Moreover, the same “open surgery” had a different meaning 30 yr ago than today. Advances in surgical techniques, such as electric cutting and coagulation, staplers instead of hand-made anastomosis, and skin stitching, have changed the course of open surgery. Preoperative imaging, such as magnetic resonance imaging or isotope mapping, mammographic wire localization, and sentinel node technique, enables the surgeon to focus on the diseased area and avoid large exploration on the operating table. In addition, in some cases, the radical approach for cancerous diseases did not show a better outcome than less radical surgery, and some operations were changed as a result, for example, radical mastectomy.4 

In general, anesthesia is coupled with surgery, for better or worse. To fully understand and analyze the changes and advances in anesthesia, we need to know what happened in surgery during that time. The credit for reduced morbidity and mortality can be attributed to all parties taking care of the patient.

Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. m_barak@rambam.health.gov.il

Sessler DI: Long-term consequences of anesthetic management. Anesthesiology 2009; 111:1–4
Marx GF, Mateo CV, Orkin LR: Computer analysis of postanesthetic deaths. Anesthesiology 1973; 39:54–8
Harrison GG: Death attributable to anaesthesia: A 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041–6
Cotlar AM, Dubose JJ, Rose DM: History of surgery for breast cancer: Radical to the sublime. Curr Surg 2003; 60:329–37