What are the contraindications to surgery?

Contraindications to Surgery

Surgery is contraindicated in any condition where the risks of surgical intervention outweigh the potential benefits, particularly when considering mortality, morbidity, and quality of life outcomes. 1

Absolute Contraindications

• Patient-Related Factors:

  • Patients who abuse drugs, are addicted to alcohol, or have uncontrolled mental illness and lack the ability to understand the risks, benefits, and consequences of surgery 1
  • Pregnancy, particularly for procedures requiring anticoagulation, due to risks of fatal hemorrhage to the fetus and potential birth malformations 2
  • Active infection or acute disease events (e.g., vaso-occlusive crisis, acute chest syndrome in sickle cell disease) for any elective, non-urgent procedure 1
  • Inadequate laboratory facilities for proper perioperative monitoring 2
  • Unsupervised patients with senility, alcoholism, psychosis, or other conditions limiting patient cooperation 2

• Cardiovascular Contraindications:

  • Uncontrolled or severe cardiovascular disease that significantly increases perioperative risk 1, 3
  • Recent myocardial infarction without appropriate risk stratification 3
  • Decompensated heart failure 1, 3

• Hematologic Contraindications:

  • Hemorrhagic tendencies or blood dyscrasias that significantly increase bleeding risk 2
  • Inadequate anticoagulation management for patients requiring chronic anticoagulation 2

• Procedure-Specific Contraindications:

  • For metabolic/bariatric surgery: Type 1 diabetes, clear failure of pancreatic β-cell function, BMI <25 kg/m², and gestational diabetes 1
  • For intraocular refractive surgery: active uveitis, uncontrolled autoimmune disease, uncontrolled mental illness, and unrealistic patient expectations 1

Relative Contraindications

• Cardiovascular Risk Factors:

  • Poorly controlled hypertension (≥160/100 mmHg) increases perioperative risk and should be controlled before elective surgery 4
  • Patients aged ≥75 years have greater risk of perioperative myocardial infarction and major adverse cardiovascular events (9.5% vs 4.8% for younger adults) 3
  • Patients with coronary stents have higher risk of major adverse cardiovascular events (8.9% vs 1.5% for those without stents) 3

• Pulmonary Factors:

  • Severe pulmonary disease without optimization increases risk of postoperative pulmonary complications 5
  • Pulmonary hypertension increases perioperative mortality risk 6

• Hepatic Dysfunction:

  • Significant hepatic dysfunction or cirrhosis increases bleeding risk and impairs wound healing 1
  • Optimization of hemodynamics with reduction of pulmonary vascular resistance and improvement of cardiac output should be pursued before mechanical circulatory support 1

• Other Considerations:

  • Major comorbid illness that limits life expectancy to less than 2 years (advanced malignancy, severe liver disease, severe lung disease) 1
  • Functional monocularity for procedures with risk to vision 1
  • Significant eyelid, tear film, or ocular surface abnormalities for ophthalmic procedures 1

Preoperative Risk Assessment

• Cardiovascular Risk Assessment:

  • The Revised Cardiac Risk Index identifies individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events 3
  • Patients unable to climb ≥2 flights of stairs (<4 metabolic equivalent tasks) may benefit from additional cardiac testing if results would change management 3
  • Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 3

• Cardiopulmonary Exercise Testing:

  • Provides comprehensive evaluation of cardiac failure (by assessing anaerobic threshold), myocardial ischemia, stroke index, pulmonary artery hypertension, and pulmonary function 5
  • Superior to conventional preoperative tests for predicting risk in patients undergoing major intra-abdominal surgery 5

Special Populations

• Patients with Diabetes:

  • For metabolic surgery in patients with type 2 diabetes, contraindications include BMI <25 kg/m², gestational diabetes, and other specific types of diabetes 1
  • Careful preoperative assessment of cardiovascular risk factors is essential as only 5.6% of diabetic patients achieve all triple therapeutic goals for HbA1c, blood pressure, and total cholesterol 1

• Patients with Sickle Cell Disease:

  • Active sickle cell crisis or acute chest syndrome contraindicates elective surgery 1
  • Preoperative transfusion/exchange should be considered based on procedure risk and individual patient characteristics 1

Risk Mitigation Strategies

• Perioperative Medication Management:

  • Routine perioperative use of low-dose aspirin does not decrease cardiovascular events but increases surgical bleeding 3
  • High-dose β-blockers (e.g., 100 mg metoprolol succinate) 2-4 hours before surgery increase risk of stroke (1.0% vs 0.5%) and mortality (3.1% vs 2.3%) and should be avoided 3
  • Statins should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 3

• Preoperative Exercise:

  • High-quality evidence supports preoperative exercise for patients scheduled for cardiovascular surgery 7
  • Circumstantial evidence suggests preoperative exercise is effective for thoracic, abdominal, and major joint replacement surgery in high-risk patients 7
  • The "Better in, Better out" perioperative exercise protocol may benefit vulnerable patients at risk for prolonged hospitalization, complications, or death 7

Remember that contraindications should be carefully weighed against the potential benefits of surgery, with particular attention to the impact on mortality, morbidity, and quality of life outcomes.