Undergoing surgery places physiological stress on the body, but stress can also have an impact on surgery outcomes. Though there has been increased discussion about this phenomenon and system-based quality improvement efforts, more work is needed to minimize the negative effects of stress on surgery outcomes. Stress in both patients and clinicians must be examined and addressed.
Research has shown that high psychological and physiological stress responses in patients prior to surgery result in poorer outcomes in otherwise healthy men undergoing simple elective surgical procedures 1. Such psychological stress has been associated with a chronic inflammatory response which tends to hamper postsurgical healing.
Patient anxiety and depression in patients can also negatively impact surgical outcomes. A recent study which sought to assess this in a large cohort of patients found that preoperative depression and anxiety negatively affect surgical outcomes in female patients undergoing major surgery 2.
Another recent study sought to further elucidate the link between preoperative psychological variables and interventions and early surgical outcomes. Overall, trait and state anxiety, state anger, active coping, intramarital hostility, and subclinical depression, were found to complicate recovery. In contrast, dispositional optimism, religiousness, anger control, an external locus of control, and low pain expectations were identified as promoting healing. Psychological interventions in the form of guided relaxation, couple support visits, and psychiatric interviews have further been found to promote patient recovery following surgery 3.
Stress in patients is not the only factor impacting surgery outcomes. Research has demonstrated that acute mental stress in clinicians negatively impacts their surgical performance. In particular, stress-induced negative intraoperative interpersonal dynamics may lead to performance errors and undesirable patient outcomes. A recent research report further confirmed a clear negative relationship between negative responses, both emotional and behavioral, to acute intraoperative stressors and provider performance on surgical outcomes 4.
Drawing on theory and evidence from reviewed studies, some research has pointed to the utility of the Surgical Stress Effects framework, illustrating how emotional and behavioral responses to stressors can influence individual surgical provider performance, team performance, and patient outcomes. Although coping strategies are not explicitly taught during surgical training, a framework for categorizing surgical stress may help clinicians develop effective coping strategies 5.
Since stress has been shown to adversely impact multiple aspects critical to optimal performance, advancements in wearable technology have been put forth to reduce barriers to observing and monitoring stress during surgery 6. A number of options are continuously being developed to this end.
Into the future, an increasingly clear understanding of the impacts of intraoperative stressors may be critical to reducing adverse events and improving outcomes. This will include a better understanding of key surgical stressors, their impact on surgeon performance, and surgeons’ coping strategies. In addition, it will be important to keep quantifying the association of preoperative depression and anxiety symptoms on postoperative complications, length of stay, pain levels, and the incidence of readmission. Future research efforts are certain to continue to minimize the effects of stress on surgery outcomes.
1. Linn, B. S., Linn, M. W. & Klimas, N. G. Effects of psychophysical stress on surgical outcome. Psychosom. Med. (1988). doi:10.1097/00006842-198805000-00002
2. Geoffrion, R. et al. Preoperative Depression and Anxiety Impact on Inpatient Surgery Outcomes: A Prospective Cohort Study. Ann. Surg. (2021). doi:10.1097/AS9.0000000000000049
3. Mavros, M. N. et al. Do psychological variables affect early surgical recovery? PLoS One (2011). doi:10.1371/journal.pone.0020306
4. Chrouser, K. L., Xu, J., Hallbeck, S., Weinger, M. B. & Partin, M. R. The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework. American Journal of Surgery (2018). doi:10.1016/j.amjsurg.2018.02.017
5. Wetzel, C. M. et al. The effects of stress on surgical performance. Am. J. Surg. (2006). doi:10.1016/j.amjsurg.2005.08.034
6. Grantcharov, P. D., Boillat, T., Elkabany, S., Wac, K. & Rivas, H. Acute mental stress and surgical performance. BJS open (2019). doi:10.1002/bjs5.104