The Impact of Postoperative Complications on Long-term Quality of Life After Curative Colorectal Cancer Surgery The effects of preoperative preparation on postoperative outcomes: the moderating role of control appraisals. Somatic and Psychologic Predictors of Long-term Unfavorable Outcome After Surgical Intervention A 1-year prospective study of individual variation in distress, and illness perceptions, after treatment for breast cancer. The association between preoperative mental distress and patient-reported outcome measures in patients treated surgically for cervical radiculopathy. Sensory information, instruction in a coping strategy, and recovery from surgery. Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers. The Influence of Preoperative and Postoperative Psychological Symptoms on Clinical Outcome after Shoulder Surgery: A Prospective Longitudinal Cohort Study Personality Predictors of Dimensions of Psychosocial Adjustment After Surgery Influence of the type of anaesthesia on post-operative subjective physical well-being and mental function in elderly patients. Depression, healing, and recovery from coronary artery bypass surgery. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial Altering patients' responses to surgery: an extension and replication. A brief relaxation intervention reduces stress and improves surgical wound healing response: A randomised trial Personal control interventions: short- and long-term effects on surgical patients. Effect of a Preoperative Intervention on Preoperative and Postoperative Outcomes in Low-Risk Patients Awaiting Elective Coronary Artery Bypass Graft Surgery Does Preoperative Psychologic Distress Influence Pain, Function, and Quality of Life After TKA?
Objective : To investigate the effect that complications have on patients ' long-term quality of life ( QoL ) after curative colorectal cancer surgery .  Background : Colorectal cancer surgery is a high risk , with approximately 1 in 3 patients suffering a complication . The long-term consequences of postoperative complications are important but have poorly been documented . Methods : The MRC-CLASICC trial ( laparoscopic-assisted vs open surgery for colorectal cancer ) included prospect i ve evaluation of QoL using vali date d scoring question naires : EORTC QLQ-C30/CR38 and EQ5D . These were used to compare QoL at 3 , 6 , 18 , and 36 months to baseline values for patients categorized into 2 groups : ( i ) those suffering any complication and ( ii ) those suffering any of 5 common complications ( wound , chest , anastomotic leak , hemorrhage , and cardiac event ) . Results : A total of 614 of 794 CLASICC patients were suitable for inclusion . Complications occurred in 215 ( 35.0 % ) patients , including : wound complications ( 61 , 9.9 % ) , chest infection ( 50 , 8.1 % ) , anastomotic leak ( 27 , 4.4 % ) , hemorrhage ( 14 , 2.3 % ) , and cardiac event ( 26 , 4.2 % ) . Significant long-term differences in QoL between patients with and without complications were found for Physical and Social Function , Role Functioning , and Body Image on EORTC QLQ-C30/QLQ-CR38 analysis and Mobility , Self-care , and Pain/Discomfort on EQ5D analysis . No significant differences were seen for emotional/cognitive functioning , global QoL , financial difficulties , or future perspectives . Risk factors of age , gender , ASA ( American Society of Anesthesiologists ) grade , and stoma moderated the impact of complications in the short- to medium-term QoL , but had less influence on long-term QoL. Conclusions : Postoperative complications have adverse effects on long-term QoL , particularly for Physical , Role and Social Functioning , and Body Image , as well as for Mobility , Self-care , and Pain/Discomfort . These findings should inform future preoperative counseling and health care planning OBJECTIVE To test the proposal that external health locus of control and self-efficacy would moderate the effects of a psychological preparation for surgery on outcomes for surgical heart patients . MAIN OUTCOME MEASURES Psychological distress , pain , serum cortisol , and tumor necrosis factor alpha . DESIGN A total of 80 coronary artery bypass graft patients were given st and ard care plus a psychological preparation or st and ard care alone using a single-blind methodology with r and om assignment . Data on psychological and biological functioning were collected at admission ( baseline ) and discharge . RESULTS As predicted , external health locus of control and self-efficacy moderated the effect of the preparation on all outcomes . Results indicated that for high external health locus of control , the preparation was related to lower distress for people with high self-efficacy compared with those with low self-efficacy . When external health locus of control was low , the preparation was related to lower distress for those with lower self-efficacy . CONCLUSION These findings caution against the use of preparations and education for surgical patients without accounting for control appraisal Objective : To identify somatic and psychologic predictors of pain , functional limitations , global perceived recovery , and quality of life 6 months after surgical intervention . Summary Background Data : Recent studies have indicated that chronic pain after surgical intervention is more common than previously assumed . Several demographic and somatic predictors of long-term unfavorable outcome have been identified , but little is known about the contribution of psychologic risk factors . Methods : A prospect i ve cohort study , including 625 patients undergoing elective surgery at the University Hospital Maastricht , The Netherl and s , was conducted between February and August 2003 .  Psychologic question naires were completed preoperatively and acute postoperative pain was recorded until 4 days after the operation . Six months later , all patients received follow-up question naires to assess pain , functional limitations , global perceived recovery , and quality of life . Multivariable logistic regression analyses were used to estimate relative risk of poor outcome in terms of pain , functional limitations , and global recovery . Multivariable linear regression analysis was used to assess associations with quality of life at 6 months . Results : The most important somatic predictors of unfavorable outcome were duration of the operation and high levels of acute postoperative pain . Patients reporting high levels of pain 4 days after the operation and patients undergoing an operation of longer than 3 hours were at risk for increased pain , increased functional limitations , poor global recovery , and reported lower levels of quality of life 6 months after the operation . Psychologic variables that influenced long-term outcome were preoperative fear of surgery and optimism . Fear of the long-term consequences of the operation was associated with more pain , poor global recovery , and worse quality of life 6 months later , whereas optimism was associated with better recovery and higher quality of life . Conclusions : This study was the first to identify the joint contribution of somatic and psychologic factors to chronic pain , functional limitations , and quality of life 6 months after surgical interventions . It replicates previous findings that intense acute postoperative pain is a risk factor for long-term adverse outcome and also identified additional risk factors , namely , long duration of the operation , ASA status , and preoperative fear of surgery OBJECTIVE The primary objective was to conduct a detailed analysis of individual variation in psychological morbidity in the year following surgery for breast cancer . The salience of the patients ' " illness perceptions " to morbidity was examined as a secondary objective . METHODS Psychological morbidity was assessed with the  General Health Question naire ( GHQ-28 )  in a prospect i ve study of 371 women having surgery for primary breast cancer . Patients also completed the  Illness Perception Question naire ( IPQ ) , Mental Adjustment to Cancer Scale ( MAC ) and the Eysenck Personality Scales ( EPS ) .  Assessment s were made postoperatively and at 3 , 6 and 12 months after surgery . RESULTS Whilst descriptive statistics indicated a general reduction in mean distress over the 12-month follow-up , close analysis showed that a quarter of all patients maintained clinical ly significant levels of distress throughout the period . Patients with chronically elevated distress were characterised by higher levels of neuroticism , greater symptom awareness , more pain and poorer self-rated general health . In the regression analysis , psychological morbidity across the 1-year follow-up was predicted principally by the immediate postoperative state of distress , IPQ symptom awareness and the perceived time line of the illness , general health and , to a more minor extent , by neuroticism . CONCLUSION There is marked individual variation in psychological morbidity in the year following breast cancer surgery , which is reliably predicted by the patient 's immediate postoperative state of distress , her perception of the impact of the symptoms and the time line of the disease . Subgroups of patients with chronically high distress are characterised by factors including personality and negative perceptions and beliefs about their illness BACKGROUND CONTEXT Previous research indicates that there might exist a link between the experience of pain and mental distress . Pain can possibly trigger anxiety and chronic pain , as well as also depression . On the other h and , anxiety and depression might also be risk factors for painful conditions and more pronounced subsequent disability and thus , the pathways may be bidirectional . Exp and ed knowledge of how different factors affect pain and function may help surgeons in preoperative decision-making . PURPOSE The aim of this study was to evaluate the impact of potential preoperative risk factors with special reference to mental distress . STUDY DESIGN / SETTING This is a prospect i ve outcome study in a cohort from a multicenter r and omized controlled trial comparing anterior cervical decompression and fusion with disc replacement . PATIENT SAMPLE The sample included 151 patients with cervical radiculopathy planned for surgery . OUTCOME MEASURES Surgical outcome was evaluated with Neck Disability Index ( NDI ) , health related quality -of-life with European Quality of Life-5 Dimensions , and pain with visual analogue scale for arm and neck . Mental distress was preoperatively measured with the Hospital Anxiety and Depression ( HAD ) scale . METHODS Preoperative data regarding possible risk factors for poor outcome were analyzed in multiple linear regression models with postoperative NDI and change of NDI as dependent factors . Patients with high preoperative levels of anxiety or depression ( H-HAD ) , indicating mental distress , were compared with patients scoring low/moderate levels ( L-HAD ) regarding patient-reported outcome measures  ( PROMs ) preoperatively and at 1- and 2-year follow-up . RESULTS Outcome data were available for 136 patients at the 2-year follow-up . No statistically significant difference in any outcome data could be demonstrated between the two surgical treatment groups . Mental distress was the variable most strongly associated with NDI at 2 years in the regression analysis . There were 42 patients classified as H-HAD and 94 as L-HAD . The average improvement in NDI was 16.9 in the H-HAD group and 26.3 in the L-HAD group , p=.02 . The H-HAD patients showed a tendency for poorer baseline data and worse outcome overall in all PROMs at follow-up at both 1 and 2 years . CONCLUSIONS Preoperative mental distress measured with HAD was associated with worse outcome overall . More research is needed to investigate whether patients with mental distress may achieve better results if other treatments are offered , either as non-surgical treatment alone or as an adjunct to surgery A study of 81 cholecystectomy patients evaluated the relative contributions of instruction in a specific coping strategy and two types of informational interventions on subjective and objective indicators of recovery from surgery . The two experimental factors in the 2 × 3 × 2 factorial design were instruction in coping activities ( present or absent ) and information ( description of typical sensations , description of typical events , or no information ) . The nonexperimental factor was preoperative fear ( high or low ) . Self-report of moods , severity of pain , and bother of ambulation were the subjective indicators . Analgesics received , amount of ambulation , length of postoperative hospitalization , and time after hospital discharge before patients ventured from their homes were the objective indicators .  Instruction in coping activities , description of sensations , and description of events all were found to dampen negative moods postoperatively for patients relatively fearful before surgery . Description of typical sensations significantly reduced the length of postoperative hospitalization and time after hospital discharge before patients ventured from their homes . Another sutdy of 68 herniorrhaphy patients , using the same design , result ed in only minor effects for any of the three interventions . Explanations for the different results between studies are offered OBJECTIVE Women with gynecological cancers have reported poor health-related quality of life ( QOL ) , with complex physical and psychological needs post-surgery and during chemotherapy treatment . There are no studies reporting interventions addressing these needs post-hospital discharge in this population . METHODS Patients were r and omized into two groups . The intervention group received 6 months of specialized care by an Advanced Practice Nurse ( APN ) ; in addition , women with high distress were evaluated and monitored by a psychiatric consultation-liaison nurse ( PCLN ) . The attention control group was assisted with symptom management by a research assistant . The effects of the 6-month intervention were evaluated using self-report question naires at baseline ( 24 - 48 h after surgery ) , 1 , 3 , and 6 months post- surgery . QOL assessment s included the Center for Epidemiological Studies -Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale , and the Short-Form Health Survey ( SF-12 ) . The sample for the longitudinal analysis included 123 who completed QOL outcome measures  across three occasions post-surgery . RESULTS The APN intervention result ed in significantly less uncertainty than the attention control intervention 6 months after surgery . When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group , the sub-group had significantly less uncertainty , less symptom distress , and better SF-12 mental and physical QOL over time . CONCLUSION Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect Background Psychological symptoms are highly prevalent in patients with shoulder complaints . Psychological symptoms in patients with shoulder complaints might play a role in the aetiology , perceived disability and pain and clinical outcome of treatment . The aim of this study was to assess whether preoperative symptoms of distress , depression , anxiety and somatisation were associated with a change in function after shoulder surgery and postoperative patient perceived improvement of pain and function . In addition , the change of psychological symptoms after shoulder surgery was analyzed and the influence of postoperative symptoms of psychological disorders after surgery on the change in function after shoulder surgery and perceived postoperative improvement of pain and function . Methods and Findings A prospect i ve longitudinal cohort study was performed in a general teaching hospital . 315 consecutive patients planned for elective shoulder surgery were included . Outcome measures included change of Disabilities of the Arm , Shoulder and H and ( DASH ) score and anchor questions about improvement in pain and function after surgery . Psychological symptoms were identified before and 12 months after surgery with the vali date d Four-Dimensional Symptom Question naire ( 4DSQ ) . Psychological symptoms were encountered in all the various shoulder diagnoses . Preoperative symptoms of psychological disorders persisted after surgery in 56 % of patients , 10 % of patients with no symptoms of psychological disorders before surgery developed new psychological symptoms . Preoperative symptoms of psychological disorders were not associated with the change of DASH score and perceived improvement of pain and function after shoulder surgery . Patients with symptoms of psychological disorders after surgery were less likely to improve on the DASH score . Postoperative symptoms of distress and depression were associated with worse perceived improvement of pain . Postoperative symptoms of distress , depression and somatisation were associated with worse perceived improvement of function . Conclusions Preoperative symptoms of distress , depression , anxiety and somatisation were not associated with worse clinical outcome 12 months after shoulder surgery . Symptoms of psychological disorders before shoulder surgery persisted in 56 % of patients after surgery . Postoperative symptoms of psychological disorders 12 months after shoulder surgery were strongly associated with worse clinical outcome Objective Although many studies have examined the relationship between personality factors and adjustment after surgery , most of them have had very short follow-up periods . The present prospect i ve study examines whether preoperative psychodynamic assessment of personality traits enhances prediction of various areas of psychosocial adjustment assessed at least 1 year after surgery . Methods In 53 patients undergoing pelvic pouch surgery for ulcerative colitis , we examined the relationship between personality traits measured before surgery , and postoperative psychosocial adjustment assessed at a median of 17 months postoperatively , controlling for the effect of surgical functional outcome . Personality traits were assessed with the Karolinska Psychodynamic Profile ( KAPP ) .  Surgical functional outcome scales  and the Psychosocial Adjustment to Illness Scale ( PAIS )  were used . Results Problems with sexual satisfaction , perfectionistic body ideals , lack of alexithymia , and poor frustration tolerance predicted poor postoperative adjustment in various areas , beyond what was predicted by surgical functional outcome alone . Moreover , moderate preoperative levels of alexithymia were beneficial to postoperative adjustment in the area of psychological distress . Conclusions The findings suggest that the preoperative assessment of the patient 's long-term sexual functioning and satisfaction , the importance attached to his or her appearance , level of alexithymia , and general capacity to tolerate frustration and set-backs in life , might alert both the surgeon and the patient to potential risk factors for poor postsurgical adjustment St and ardized behavioural observations were used to establish the influence of the type of anaesthesia on the mental function and the subjective physical well-being in 60 patients , all men , following urological surgery . The patients were r and omized to two groups , receiving spinal or general anaesthesia .  For evaluation of the influence of pre-operative physical condition on post-operative mental function , a supplementary group of 34 patients with pre-existing cardiovascular and /or pulmonary disorders was included in the study . These patients all received spinal anaesthesia . The patients were observed from the day before surgery until 4 weeks after . In all patients a short-lasting temporary decline in mental function was observed . The outcome was not influenced by the type of anaesthesia . In the two groups receiving spinal anaesthesia the decline in post-operative mental function and subjective sense of well-being was most pronounced in patients with a compromised physical condition pre-operatively . Four weeks after surgery , no signs of mental deterioration were present ; however , the subjective sense of physical well-being had not fully returned BACKGROUND Effects of postoperative depression on recovery from  coronary artery bypass grafting  have not been widely studied . OBJECTIVES To evaluate emotional and physical recovery after bypass surgery and investigate associations between depressive symptoms and infections and impaired wound healing in patients with high and low levels of depressive symptoms . METHODS A nonr and omized , comparative , longitudinal design was used to study 72 bypass surgery patients without serious noncardiac comorbidities who were available for follow-up after discharge . Patients completed question naires to assess depressive symptoms , emotional recovery , and physical recovery within 48 hours after extubation , at discharge from the hospital , and 6 weeks later and performed 6-minute walk tests at the last 2 times . Infections and impaired wound healing ( as indicated by positive cultures , antibiotic treatment , or extra treatments , such as debridements or incisions and drainage ) were identified by chart audit . RESULTS At discharge , patients with higher depressive symptom scores ( indicating more symptoms ) reported poorer emotional recovery ( P<.001 ) and poorer physical recovery ( P=.007 ) and achieved shorter walking distances ( P<.001 ) than did patients with lower scores ( indicating fewer symptoms ) . Six weeks after discharge , emotional and physical recovery remained lower in patients with more depressive symptoms ( P<.001 ) . Infections and impaired wound healing were more common among patients with higher depressive symptom scores ( 46 % ) than among patients with lower scores ( 19 % , P=.03 ) . CONCLUSIONS After bypass surgery , depressive symptoms are associated with infections , impaired wound healing , and poor emotional and physical recovery Abstract Objective : To assess the medical and psychosocial effects of  early hospital discharge after surgery for breast cancer on complication rate , patient satisfaction , and psychosocial outcomes . Design : R and omised trial comparing discharge from hospital 4 days after surgery ( with drain in situ ) with discharge after drain removal ( mean 9 days in hospital ) . Psychosocial measurements performed before surgery and 1 and 4 months after . Setting : General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population . Subjects : 125 women with operable breast cancer . Main outcome measures : Incidence of complications after surgery for breast cancer , patient satisfaction with treatment , and psychosocial effects of short stay or long stay in hospital . Results : Patient satisfaction with the short stay in hospital was high ; only 4 % ( 2/56 at 1 month after surgery and 2/52 at 4 months after surgery ) of patients indicated that they would have preferred a longer stay . There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups ( median 8 v 9 days respectively , P=0.45 ) or the incidence of wound complications ( 10 patients v 9 patients ) . The median number of seroma aspirations per patient was higher for the long stay group ( 1 v 3.5 , P=0.04 ) . Leakage along the drain occurred more frequently in short stay patients ( 21 v 10 patients , P=0.04 ) . The two groups did not differ in scores for psychosocial problems ( uncertainty , anxiety , loneliness , disturbed sleep , loss of control , threat to self esteem ) , physical or psychological complaints , or in the coping strategies used . Before surgery , short stay patients scored higher on scales of depression ( P=0.03 ) and after surgery they were more likely to discuss their disease with their families ( at 1 month P=0.004 , at 4 months P=0.04 ) . Conclusions : Early discharge from hospital after surgery for breast cancer is safe and is well received by patients . Early discharge seems to enhance the opportunity for social support within the family . Key messages Early discharge from hospital after breast cancer surgery does not lead to an increase in the incidence of wound infection or seroma formation A short stay in hospital , with support from community nurses on the patient 's return home , is acceptable to patients Psychosocial rehabilitation is not influenced by early discharge Recovery in the family environment may facilitate discussion of the illness Patients recovering from surgery for breast cancer need not spend more than three days in hospital provided that they are in good physical condition and there is adequate nursing support available in the This study of 58 cholecystectomy and 57 herniorrhaphy patients was design ed to determine the reliability of the effects of preoperative preparation on postoperative recovery that were observed in a previous study . The preoperative preparation consisted of information that focused on the typical subjective sensory experiences of surgical patients in combination with instruction in postoperative exercises . The effects of prehospital admission preparation , restatement postoperatively of preparatory information , and adding temporal orienting information to the preparatory information on postoperative course were also examined . The main results of the original study were replicated . In the cholecystectomy sample , the preoperative information intervention significantly reduced length of postoperative hospitalization and length of time posthospital discharge before patients ventured from home . Temporal orienting information reduced feelings of helplessness postoperatively in the cholecystectomy sample . Consistent with the original study , only trends for effects were observed in the herniorrhaphy sample Psychological stress has been shown to impair wound healing , but experimental research in surgical patients is lacking . This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients . This r and omised controlled trial was conducted at a surgical centre . Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy ; exclusion criteria were cancellation of surgery , medical complications , and refusal of consent . Seventy five patients were r and omised and 15 patients were excluded ; 60 patients completed the study ( 15 male , 45 female ) . Participants were r and omised to receive st and ard care or st and ard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery . In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing . Change in perceived stress from before surgery to 7-day follow-up was assessed using question naires . Intervention group patients showed a reduction in perceived stress compared with the control group , controlling for age . Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients ( difference in means 0.35 , 95 % CI 0.66 - 0.03 ; t(43)=2.23 , p=0.03 ) . Changes in perceived stress were not associated with hydroxyproline deposition . A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients . The intervention may have particular clinical application for those at risk of poor healing following surgery A r and omized 2 X 3 X 2 factorial design was used to evaluate the short- and long-term effects of interventions that provided different means of exerting personal control over postoperative experiences in a sample of 121 black and 47 white hysterectomy patients . One variable was the presence or absence of the description of the experience in concrete sensory terms ; the second variable was instruction in a cognitive-coping strategy , instruction in a behavior-coping strategy , or no instruction ; and the third variable was experimental or control information about the posthospital experience . There was support for the coping processes that concrete sensory information was expected to stimulate , but no significant effects on resumption of usual life activities as was expected . The behavioral-coping technique was associated with a reduction in pain medication . The cognitive-coping technique was associated with reports of better physical recovery during hospitalization , but longer hospitalization . Posthospitalization recovery data , collected 2 , 4 , and 12 weeks after discharge , showed a different pattern of effects for the interventions than observed during hospitalization In Ontario , Canada , the discrepancy between the high dem and for  coronary artery bypass graft surgery ( CABG )  and the low immediate supply results in waiting lists . In 1990 , a consensus panel of cardiologists and surgeons developed criteria to ensure that high-risk patients were given priority for this procedure ( 1 ) . Each patient receives an acuity score that corresponds to a recommended maximum delay . Aggregated acuity scores of 4 , 5 , 6 , and 7 indicate elective status and represent a waiting time ranging from greater than 14 days to a maximum of 6 months . The mortality rate for patients awaiting CABG  has been shown to be remarkably stableapproximately 0.5 % to 0.6 % per year over the past 10 years ( 2 ) . Despite this , however , evidence shows that patients ' functional and psychological status can deteriorate during the wait for surgery ( 3 - 5 ) . Through its effects on the autonomic nervous system , emotional stress also influences catecholamines , myocardial oxygen dem and , and platelet aggregation ; this may affect morbidity during the waiting period ( 6 - 8 ) . Such factors as preoperative anxiety and little social support have adverse psychological effects during extended preoperative waiting periods and , in addition , have been found to predict poor physical recovery from heart surgery ( 9 ) . Therefore , psychological factors and physical deconditioning , both of which occur during the waiting period ( 10 - 12 ) , may negatively affect patients ' in-hospital course , including length of stay . Because waiting for health services will probably continue to be a reality in publicly funded health care systems that value universal access , careful study of simple , affordable methods to improve patient outcomes during the waiting period is warranted . We examined the effect of a minimum 8-week , multidimensional , preoperative intervention on the presurgery and postsurgery outcomes of patients awaiting elective CABG . We hypothesized that a combination of exercise training , education , and social support would affect patients ' physical and psychological readiness for surgery and thereby reduce postoperative length of hospital stay . We further hypothesized that the effectiveness of the preoperative intervention would be sustained into the first 6 months of the postoperative period . Methods Patients Patients were recruited from the waiting lists of all seven cardiovascular surgeons operating in the Hamilton Health Sciences Corporation surgical center , Hamilton , Ontario , Canada . Each year , approximately 1300 open-heart surgeries are performed in this center . Roughly 60 % of patients awaiting CABG have elective status and are placed on the waiting list . During the time of our study , elective waiting times ranged from 3 weeks to greater than 20 weeks . Approximately 40 % of elective patients are usually awaiting first-time  CABG ( nonvalve replacement ) . Only patients awaiting a first CABG whose surgery date s were at least 10 weeks away were approached to participate in our study . Patients were excluded if they were having combined CABG and valve surgery , if their ejection fractions were less than 0.40 , if they could not attend the exercise classes because of geographic inaccessibility , or if they were unable to participate because of physical limitations . After these inclusion and exclusion criteria were applied , our pool of potential participants was approximately 250 patients per year . We intended to select low-risk patients because it is not common to test an exercise intervention in patients awaiting CABG . Design We design ed a two-group r and omized , controlled trial . Eligible patients were r and omly assigned to 8 weeks of multidimensional preoperative intervention or to usual care . Those assigned to usual care were followed by their primary care physicians , cardiologists , or surgeons . During the waiting period , the intervention group received individualized , prescribed exercise training twice per week in a supervised environment ; education and reinforcement ; and monthly nurse-initiated telephone calls to answer questions and provide reassurance . After surgery , patients in both the treatment and control groups were given the opportunity to join the existing cardiac rehabilitation program ( Appendix ) . Outcomes The primary outcome was postoperative length of hospital stay . Secondary outcomes were peak exercise performance , health-related quality of life , social support , anxiety , and utilization of health care services . Measurements were taken at baseline , 1 week before surgery , 6 to 8 weeks after surgery , and 6 months after surgery . All of the secondary outcome variables were measured at baseline and 1 week before surgery . At 6 weeks and 6 months after surgery , only exercise performance , quality of life , and social support were measured . Determination of Sample Size Sample size was determined by using 19941995 data on length of stay in our surgical center . According to a r and om sample of 20 patients undergoing elective CABG , the mean total length of stay SD was 9.4 3.5 days . On the basis of these data , and accounting for a loss of 10 % to 15 % of patients , we determined that a sample size of 125 patients per group had sufficient power ( 0.8 ) to detect a 1-day reduction in hospital stay ( = 0.05 ) . Procedures The Research Ethics Board of McMaster University ( Hamilton , Ontario ) and the study hospital approved the study . On a weekly basis , staff at each of the surgeon 's offices supplied the names of patients who were scheduled to wait at least 10 weeks for surgery . Patients were telephoned , and the study was explained to them . The recruitment officer was completely c and i d about the r and om assignment and the treatments that would be offered to each group . Within 1 week after giving verbal consent , patients came to the clinic to provide written informed consent . At this visit , we collected complete baseline data and patients underwent an exercise test . Baseline data included demographic information ( age , sex , socioeconomic status , living arrangements , education , and employment status ) ; medical history ; past and present smoking status ; and history of myocardial infa rct ion , angina , congestive heart failure , and diabetes . Baseline data were also collected on anxiety , health-related quality of life , utilization of health care services , and social support . Data later obtained from medical records included total length of hospital stay , length of postoperative stay , number of hours spent in the intensive care unit ( ICU ) before receiving a discharge order , and actual hours spent in the ICU . R and omization and Blinding The study coordinator r and omly assigned patients to study groups by using a concealed r and omization process . A consultant prepared the r and omization schedule , and assignments were sealed in opaque envelopes that were opened in sequence after consent and baseline data were obtained . Patients were not blinded to their group assignments . However , the patients ' physicians ( cardiologists , surgeons , and general practitioners ) were blinded to group assignment and were not informed of it at any point in the study by patients or health care staff . Persons involved in offering the intervention ( nurses , kinesiologists , dietitians ) were aware of the patients ' group assignments but had no role in determining the patients ' readiness for discharge from the ICU or from the hospital ; therefore , they did not directly affect the primary outcome . Assessment of Outcomes Data on length of stay were collected by individual chart review . Total length of stay and total length of ICU stay were easily determined by using admission and discharge date s. However , after discussion with the cardiovascular surgeons before the study began , we realized that total length of ICU stay would misrepresent patients ' postoperative progress . On many occasions , the patient is ready for discharge from the ICU but bed or staffing issues substantially delay his or her actual departure . Therefore , we collected data on length of ICU stay in hours and , more particularly , in hours until order for ICU discharge . This required detailed chart review to locate time in and time out information as well as the time that the physician 's discharge order was given . Although the physicians often did not record the times of their orders , these data were found in nurses ' ICU notes . In approximately 5 % of cases , the data were not retrievable and the mean time until order for discharge was imputed . Exercise performance was measured by using a symptom-limited , upright-cycle ergometer exercise test .  General health-related quality of life was measured by using the Medical Outcomes Study 36-item Short Form Survey ( SF-36 ) ( 13 ) .  Social support was measured by using the  Interpersonal Support Evaluation List  ( 14 ) , and the total scale score was used in analysis . Anxiety was measured with the Spielberger StateTrait Anxiety Inventory ( 15 ) , from which both a trait score and a state anxiety score were computed . The total score from the Health Services Utilization Question naire ( 16 ) was computed and used in the analysis ( Appendix ) . Statistical Analysis All analyses were performed by using the SPSS statistical package ( 17 ) , versions 6.0 and 8.0 ( SPSS , Inc. , Chicago , Illinois ) . We analyzed data on patients whose status was elective from study entry until 1 week before surgery ( n = 220 ) . Data were complete for the primary outcome variables . When a measurement tool did not supply an approach for dealing with missing data , we used an imputation strategy , the hot deck approach ( 18 ) , in which the score from a matched patient in the same group is substituted for the missing score . The defining characteristics for matching patients were age , sex , and number of bypasses required . At the measurement point 6 months after surgery , 78 % of patients returned for all final assessment s. Follow-up to establish vital status was complete for all patients . Data on length of stay are usually positively skewed . Therefore , we selected the MannWhitney test for Background Preoperative psychologic distress is considered to be a risk factor for clinical dissatisfaction stemming from persistent pain and physical limitations after elective orthopaedic procedures such as lower-extremity arthroplasty . However , the degree to which psychologic distress , specifically in the form of anxiety and depression , influences surgical results has been poorly characterized . Questions / purpose sWe analyzed the effect of preoperative psychologic distress on changes in pain , function , and quality of life 1 year after elective TKA . Methods In this prospect i ve cohort study , we assessed patients who underwent TKAs in 2009 and 2010 . Before surgery , patients completed the  Folstein Mini Mental Test  , the  Hospital Anxiety and Depression Scale ( HAD ) , The  Knee Society Score © , the  WOMAC quality -of-life question naire  , and the  VAS for pain .  The patients were divided into two groups based on the degree of psychologic distress on the HAD Scale , and the groups were compared in terms of the above-listed clinical outcomes tools 1 year after surgery using multivariate linear models . Two hundred sixty-three patients met the inclusion criteria , and 202 ( 77 % ) completed the study protocol . Results The presence of preoperative psychologic distress did not influence 1-year postoperative pain assessment ( average reduction in pain , 40.33 ; 95 % CI , 36.9–43.8 ; p = 0.18 ) . The only factor influencing change in pain experienced by patients was the preoperative pain recorded ( R2 = 0.31 ; β = −0.82 ; p < 0.001 ) . The patients experiencing preoperative psychologic distress obtained poorer outcomes in function ( R2 = 0.16 ; β = −5.62 ; p = 0.001 ) and quality of life ( R2 = 0.09 ; β = −0.46 ; p < 0.001 ) 1 year after receiving TKA . Conclusions The presence of preoperative psychologic distress is associated with worse 1-year outcomes for function and quality of life in patients undergoing TKA .  Interventions design ed to reduce psychologic distress may be indicated for patients to undergo this type of surgery , and incorporation of these data into discussion s with patients may facilitate informed and shared decision making regarding the surgical treatment of knee osteoarthritis . Level of Evidence Level II , therapeutic study . See the Instructions for Authors for a complete description of levels of evidence
Two-thirds of the studies found that patients who suffered surgical complications had significantly worse postoperative psychosocial outcomes even after controlling for preoperative psychosocial outcomes , clinical and demographic factors .
Surgical complications appear to be a significant and often long-term predictor of patient postoperative psychosocial outcomes .
The results highlight the importance of attending to patients ' psychological needs in the aftermath of surgical complications
OBJECTIVE Surgical complications may affect patients psychologically due to challenges such as prolonged recovery or long-lasting disability .
Psychological distress could further delay patients ' recovery as stress delays wound healing and compromises immunity .
This review investigates whether surgical complications adversely affect patients ' postoperative well-being and the duration of this impact .