I've already written a series of blog posts leading up to my recent kidney surgery - starting with "Kidney donation: why it's well worth considering" to the most recent "Kidney donation: preoperative preparation ... aspects of self-compassion".  Writing this now, I'm happily & successfully over the waterfall of the operation and into the phase of managing the bumping & scraping against a variety of post-operative boulders.  I feel that during the preparation stages of this journey, the early post-operative section of the "kidney donation river" has always been a bit veiled in mists.  Successful donors seem to talk a bit about their decision to donate and how they are now, months or years after the operation ... but the section after the operation waterfall is often dismissed with a sketchy "It wasn't too bad" or "It was a bit hard for a while, but you come through".  All this is helpful, but how can we come through as well as possible?  And being no saint or martyr myself, maybe even "How can we come through with as little suffering as possible?!"

But first a few remarks about the operation itself.  Dearest Catero, my wife, and I had to be at the hospital for 7.30 in the morning ... a bit like arriving for an important, but awkwardly-timed exam.  Once we'd got there, I was taken through lots of final questions & checks, then walked begowned down a long corridor past a line of operating theatres to number 14. Chat with the anaesthetists ... we shared a colleague from my work in persistent pain treatment years ago.  Then ... bang ... out of the conscious universe for four or so hours and waking in recovery.  Bit weird really.  Build up to this for months and then one can't remember anything about it. What kind of party is that?!  

My surgeon was the admirable John Terrace.  He had been warm, confident & knowledgeable at our meeting the day before.  I'm very glad my operation was with him and at a busy transplant centre like the one here in Edinburgh. Bluntly, one wants surgery done by someone who is performing the relevant operation regularly - see Ravi et al's 2014 paper "Relation between surgeon volume and risk of complications ...".  This finding - "practice makes perfect (or at least 'better')" - is no big surprise.  A little more intriguing is the recent observation that, even with a surgeon who does a specific operation regularly, one is likely to come through better if they don't try to master too many other operation types as well.  So the 2016 paper - "Surgeon specialization and operative mortality ..." - commented that "the relative risk reduction from surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures) was greater than from surgeon volume for that specific procedure."  And this rather simplistic picture of "best if surgery is done by a 'super-specialist'" is balanced by the findings (at least for physicians) that years of experience can start to work against you - see "Systematic review: the relationship between clinical experience and quality of health care" - and that other, for example interpersonal, skills are also needed for optimum outcomes - "Association between implementation of a medical team training program and surgical mortality" and "Teaching nontechnical skills in surgical residency: a systematic review of current approaches and outcomes".

Anyway, I woke in recovery.  Even though I'm very groggy, I'm handed the button to my "patient-controlled analgesia (PCA)" system.  Just press and I get a quick shot of morphine.  Mm ... sounds great, but as the Spanish proverb goes "God said 'Take what you want.  Take whatever you want and pay for it.'"  And as Wei et al commented in their recent article on " ... postoperative recovery of gastrointestinal function" - "Opioids, used as analgesics peri-operatively, have a marked effect on time to return of normal gut function. Studies (e.g. Cali et al, 2000) showed a dose related response to amount of morphine given and time to return to normal gut function."  Actually I had very little need for the PCA.  Using a 0 (no pain) to 10 (extreme pain) scale, I spiked to 7 very briefly (possibly trying to shift position in my groggy state).  I gave myself a shot of morphine, but then never needed to use it again (despite regular encouragment to try it a bit more from various members of the hospital staff!) until it was removed a day or so later.  I used virtually no other analgesics over the next days of recovery (just a couple of doses of paracetamol, mostly to keep nursing staff happy) and my pain level never stayed above 4, and mostly kept down in the 0-2 zone.  It's not that I am against painkillers.  Far from it.  But I am against taking medication unnecessarily, especially when there are known side-effect "costs".

I was lucky to experience little wound pain, but it's a somewhat challenging balancing act managing the loosely interlinked cluster of unpleasant sensations one can experience in these first few post-operative days.  So, overlappingly, there's pain, there are gastrointestinal symptoms (distension, nausea, discomfort, lack of function), back achiness/stiffness from inability to shift onto one's side, fatigue and sleep disruption.  Some interventions (e.g. opioids) that benefit one of these problems may make another worse.  And although the hospital staff ask regularly "0 to 10, how bad is your pain?", nobody says "0-10, how bad are your gut symptoms ... or back achiness/stiffness ... or fatigue ... or sleep disruption?"  Apart from the very brief spike at 7, pain wasn't the main symptom that troubled me over these first post-operative days.  Pain (from where the operation was done in my body) was mostly down at 0-2, but gut symptoms and back achiness went up to 6 for chunks of time.  And, no doubt, for other donors the balance between pain/gut/back/fatigue/sleep and possibly other symptoms will be different ... but I think I would have found it helpful to have been aware of these different kinds of "rocks" in the misty post-operative section of the kidney donation river.  It's pretty straightforward to identify which of the pain/gut/back/fatigue/sleep or other post-operative symptoms are most personally relevant to you, and keep track of them using a set of 0 (no distress/difficulty) to 10 (extreme distress/difficulty) scales.

It does seem that "psychological preparation" for what to expect post-operatively is likely to be useful, so Powell et al, in their 2016 Cochrane Review - "Psychogical preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia" - (and Cochrane Reviews are typically pretty cautious about their conclusions) wrote "We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery ... The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay". The authors noted that there's a real need for bigger & better-designed studies, but overall the evidence for the value of pre-surgery preparation is encouraging.

And to explore these issues further, see the next blog post "Kidney donation: more on postoperative management".