“Is the patient nil-by-mouth”?

A few months ago, I anaesthetised a patient for a routine operation. He was nervous, as many of them are, and had made the decision to forego his evening meal the night before surgery, and drink nothing after 6pm the previous day in order to be “extra safe” for his anaesthetic. When he told me, I responded with an outward smile and an inward eye-roll, popped out and came back with a glass of apple juice for him to drink, and a gentle explanation of how prolonged fasting is actually bad for his recovery.

Aspiration under anaesthesia is extremely rare in Europe, but it’s difficult to get accurate figures. Incidence for elective cases is around 1:5000 to 1:10,000. According to a UK Royal College of Anaesthetists audit, obstetrics is even lower with only 12 cases between 2013-2016, equating to around 5 cases per million pregnancies.

Ellen Petry Leanse in conversation with Dr Rebecca Kraus for the BJS Lecture "Cultivating excellence: a fireside chat" at the 2025 Swiss Society of Surgery's annual meeting.

Change takes time – in all fields, including surgery. Yet, innovation is highly prized. The latest tools and technologies are celebrated and heavily invested in. But not all improvements require new technology.

For example, robotic pancreatic surgery is being adopted worldwide at a cost of millions in capital investment and ongoing expenses. Evidence shows it is mostly non-inferior to the standard of care.1–4 Another example is histotripsy for liver tumors, which has been rapidly purchased across multiple centers since FDA approval in 2023, spreading like mushrooms after the rain. Evidence is limited to technical feasibility, with no proof of superiority over standard care.5 Both technologies are used only in selected patients. By contrast, high-volume anesthesiology care for hepato-pancreato-biliary (HPB) surgery is associated with15% lower odds of 90-day major morbidity (OR 0.85, 95% CI 0.76–0.94), requires no capital investment, no recurring costs, and applies to all patients.

We are not debating or questioning the benefits of these technologies or the need to invest in new treatments. Rather, we would like to ask: if we are so willing to spend vast sums on new technology, why are we far less inclined to redesign how operative teams are organized?

Correspondence to: Yuzhou Zhu (e-mail: Zhuyuzhou@scu.edu.cn)

Colorectal Cancer Center

Department of General Surgery

Correspondence to: Fredrik Wärnberg (e-mail: fredrik.warnberg@vgregion.se)

Department of Surgery

Sahlgrenska University Hospital

Forget “New year, new me.” Atomic Habits by James Clear isn’t about wishful resolutions or grand transformations. It’s about the quiet power of small actions that compound into radical change. The central thesis?