Medical procedures, unnecessary, surgery, operations, arthroscopy, cholecystectomy, gallbladder, prostatectomy, overtreatment, Prostate Cancer Intervention Versus Observation Trial (PIVOT), complications

Is This Procedure Really Necessary?

Is This Procedure Really Necessary?

© 2012 Dr. Dale Peterson &

For most of my medical career I’ve advised anyone considering a medical procedure to remember that minor surgery is a medical procedure being done on someone else. Every medical procedure carries an element of risk. The fact that a procedure is considered routine doesn’t mean that complications will not occur. It’s therefore imperative that anyone who is advised to have surgery ask, “Is this procedure really necessary?

Several years ago I was asked to review the medical record of a woman who had died unexpectedly. She had been in good health, but on a Saturday morning she experienced chest discomfort. She decided that it would be best to have the symptom evaluated and so went to a hospital emergency room. An electrocardiogram was run and blood was drawn to check for evidence of a heart attack. The studies were normal, but she was advised that her blood would need to be retested a few hours later to be absolutely certain that the vague discomfort she had experienced had not been due to a heart attack. She was given the option of going home and returning in the afternoon to have her blood redrawn or staying at the hospital under observation until the second series of tests was completed. She opted to stay at the hospital, a decision that would have fatal consequences.

A second set of blood tests was drawn early Saturday afternoon. While they were being processed in the laboratory a nurse thought that she saw a change in the woman’s heart tracing. The nurse called a cardiologist who, rather than waiting for the test results, opted to perform a “routine” coronary catheterization procedure to put the heart attack question to rest. The coronary arteries were found to be normal at the time of the arteriogram and the second set of blood tests also came back showing that the chest discomfort had not been related to the heart.

As she was preparing to leave the hospital the woman suddenly experienced severe crushing chest pain. She was rushed back to the cath lab where it was discovered that the lining of an artery had been bruised during the first procedure. This had triggered bleeding that resulted in a clot that completely blocked the bruised artery causing a major heart attack.

As a stent was being placed to reopen the blocked artery the woman’s heart stopped and resuscitative measures including chest compression were needed to revive her. Several ribs were broken in the process. Since blood thinners had been given as part of the catheterization protocol the fractures resulted in massive internal bleeding. She never regained consciousness and died two days later.

Her death was tragic, all the more so because the cardiac catheterization procedure had been unnecessary. Had the physician simply waited approximately thirty minutes for the second set of blood test results he would have known that the woman’s chest discomfort had not been caused by a heart attack. Had she chosen to go home rather than be monitored in the hospital while waiting for the test to be run she would, in all likelihood, still be alive today.

Most physicians have a very cavalier attitude about surgical procedures. Stopping by the physician’s lounge one evening while making hospital rounds I overheard a conversation between a flamboyant surgeon who had immigrated to the United States from Great Britain and a pediatrician.

“What’s wrong?” asked the surgeon, “you look flustered.”

“It’s a boy upstairs,” she replied. “He’s obviously sick, but all of his test results have come back normal. He doesn’t have anything!”

“Tut, tut, Susan,” the surgeon responded. “Of course he has something. It’s just like surgery . . . every patient needs surgery - you simply have to determine which one!”

While few physicians would be so brash as to suggest that everyone requires surgery, there is an unspoken belief that surgery will resolve health challenges when other options have failed. Surgery is often viewed as a way to find a definitive answer about the state of a person’s health when uncertainty exists, as in the case of the woman with the vague chest pain.

I learned early in my medical career that an unnecessary surgical procedure can have disastrous consequences. During my internship I was involved in the care of a rather obese woman in her mid-seventies. She had slipped on her porch and fallen, sustaining a large bruise that involved her lower left back, hip and buttock.

X-rays had not revealed any broken bones, so she was treated conservatively with bed rest and alternating cold and warm compresses. The attending physician considered discharging her on a Friday afternoon, but since she was living alone and had not recovered to the point that she could easily care for herself, he decided to keep her in the hospital over the weekend.

On Saturday morning an aggressive young surgeon noted that the woman’s red blood count had fallen from the level that had been present upon admission. This was not an unexpected finding. The large bruise indicated that significant bleeding had occurred. It was entirely predictable that her red blood count would fall as the volume of blood that had bled into the fatty tissue was replaced in her circulatory system by water.

In spite of the facts that there was a logical explanation for the drop in the red blood count and that the woman had been improving each day, the surgeon opted to perform an exploratory surgery to be certain than she was not continuing to bleed internally. The operation failed to uncover any ongoing bleeding, but the procedure had dire consequences. The woman developed post-operative complications. Her condition declined and she died in the hospital.

U.S. physicians pride themselves in practicing “evidence-based” medicine. They argue that while other healing disciplines use approaches that are unscientific and unproven (an assumption that has no basis in fact), medical doctors provide treatments that have been rigorously tested and found to be scientifically valid. The truth is that very few medical procedures have ever undergone a scientific evaluation to determine their merit. When procedures have been put to the test, more often than not they have come up lacking.

The most famous example is a study that was done to test the effectiveness of arthroscopic knee surgery. It was performed at the Baylor College of Medicine and published in the New England Journal of Medicine in July, 2002.

180 patients with knee pain due to osteoarthritis were divided into three groups. One group received debridement, a procedure in which worn, torn, or loose cartilage is smoothed or removed. The second group was treated with lavage, meaning that loose pieces of cartilage were washed out. The third group was given an unthinkable treatment. Small incisions were made in the skin to simulate those required for arthroscopy, but nothing was done to their knees.

The people involved knew that they might receive a placebo surgery rather than an actual arthroscopy. It had been difficult to find people willing to participate under those conditions. Nearly half of those who had qualified to enter the study refused when they learned that they might not receive debridement or lavage.

The patients were followed for two years during which time they were unaware of which procedure they had received. Patients in all three groups reported moderate improvements in pain and ability to function. Neither of the intervention groups reported less pain or better function than the placebo group. In fact, the placebo patients reported better outcomes than the debridement patients at certain points during follow-up. In spite of the evidence that arthroscopy is no more effective than a placebo for osteoarthritic pain it is still commonly performed.

For nearly half a century children who developed tonsillitis had their tonsils removed. For a time tonsillectomies were so commonplace and taken so lightly that a physician might use a family’s kitchen table to remove a child’s tonsils in the home. Many children with completely normal tonsils found themselves on the operating table during summer vacation for a prophylactic tonsillectomy (removal of normal tonsils to prevent an episode of tonsillitis during the school year).

It is now recognized that the vast majority of those tonsillectomies were unnecessary. Tonsils are on the front line of the body’s fight against infectious disease. They swell when an infection occurs not because they are defective, but because they are attempting to contain the infection and prevent it from spreading from the throat to the entire body.

Fortunately, tonsillectomies are no longer performed routinely. There are times when an abscess or chronic infection dictates their removal, but the number of tonsillectomies performed annually dropped from 1.4 million in 1959 to 240,000 in 1987.

The gallbladder remains a favorite surgical target. There are times when a cholecystectomy (gallbladder removal) is necessary. Blockage of the common duct that empties bile from the gallbladder and digestive enzymes from the pancreas into the small intestine is not only painful, it is potentially fatal. If the gallbladder is diseased it should be removed, but many of the nearly half million cholecystectomies performed in the United States each year are done simply because individuals are experiencing vague abdominal pain. It matters not that the gallbladder appears perfectly normal.

By injecting a radioactive substance, hepatobiliary iminodiacetic acid (HIDA) that is taken up by the liver and excreted through the bile ducts a determination of bile flow can be made. The original intent of performing a HIDA scan was to determine whether the cystic duct (the tube carrying bile in and out of the gallbladder) or common duct was obstructed. Unfortunately, many physicians today use HIDA scans not to check for obstruction, but to decide how efficiently bile is flowing. If the gallbladder is slow to fill or if it empties incompletely it is said to be poorly functioning. The finding that a gallbladder is functioning poorly is then used to justify its removal. I have yet to have someone explain to me how removing a poorly functioning gallbladder improves or restores its performance.

I’ve been consulted by many individuals who were still experiencing their abdominal pain after undergoing cholecystectomies because their gallbladders had been found to be poorly functioning. If a gallbladder appears normal and bile flow is not obstructed I strongly encourage the person experiencing abdominal pain to ask, “Is this procedure really necessary?”

Thanks to Prostate Specific Antigen (PSA) screening over 240,000 men are found to have prostate cancer each year. Nearly all of them quickly choose to have a medical procedure such as surgery or radiation performed. While many of them will experience life-changing adverse effects such as urinary incontinence, chronic diarrhea, or sexual dysfunction, few will benefit from the procedure. Studies have found that fifty men must undergo aggressive procedures to potentially save one of them from dying of prostate cancer. That means that procedures used to treat early and asymptomatic prostate cancer will have no effect on the outcome of the disease 98 percent of the time.

The futility of early prostate cancer detection and treatment was confirmed by a study that was published in the New England Journal of Medicine this month. The Prostate Cancer Intervention Versus Observation Trial (PIVOT) involved 731 men who had been found to have prostate cancer through PSA screening. All were asymptomatic and would not have known that prostate cancer was present had they not had a PSA blood test. Half of the men received surgery to remove their prostate gland and half of them agreed to wait and see what happened.

The investigators had hoped to enroll 2,000 men in the study, but they were unable to find enough men who were willing to take a watch and wait approach. That in itself is revealing, as it indicates how anxious people in our society are to undergo medical procedures.

The men were followed for an average of ten years. Over that period 47 percent of those who received prostate surgery died as did 50 percent of the men who weren’t treated. This is not surprising, since most men diagnosed with prostate cancer are nearing their life expectancy. The number of men who died from prostate cancer is of interest. 5.8 percent of the men who received surgical treatment subsequently died of prostate cancer as opposed to 8.4 percent of the men who did not. This is not a significant difference, especially in light of the difference in quality of life between the two groups. Surgery did improve overall mortality rate in men with PSA levels greater than 10.0 as the death rate was 13.2 percent lower in the surgical group.

Predictably, physicians have been quick to reject the significance of the study. They argue that the number of men involved was too small to meaningful. They suggest that prostate surgery today is more advanced than it was when the PIVOT study was begun in 1994 and is therefore less likely to lower the quality of life and more likely to cure the disease.

The PIVOT study, however, is not the only one to suggest that aggressive treatment of asymptomatic prostate cancer is unlikely to affect the disease outcome in the vast majority of men. Men who do not have high PSA levels or other indicators of tumor aggressiveness should weigh their options carefully and ask, “Is this procedure really necessary?”

Coronary artery bypass surgery is another procedure that is performed far too often. It is viewed by many as the only option for someone who has developed coronary artery disease. As in the case of prostate cancer, individuals found to have narrowed coronary arteries are told that they must be treated invasively if they are to have a chance of survival.

I was recently consulted by a man who experienced symptoms of a heart attack when he became dehydrated while working outside in triple digit heat. He had gone to a major heart hospital for evaluation. Studies confirmed that a heart attack had occurred. A coronary arteriogram was performed and without any discussion of the results bypass surgery was scheduled. Because he felt he was being pushed to rush into major surgery without time to consider his options he checked himself out of the hospital against medical advice.

I reviewed his arteriogram with him. One of the arteries was completely blocked, which was consistent with having had a heart attack. Fortunately, the artery had been compromised for quite some time. The diminished blood flow had caused his body to do its own “bypass” by creating new arterial branches to bring blood to the area from a different artery. This had significantly limited the damage caused by the heart attack. The arteriogram also revealed that he was not in imminent danger of having another heart attack.

Having experienced the heart attack, the man was highly motivated to change his lifestyle and take whatever measures necessary to stop the progression of his coronary disease. After leaving the heart hospital he had learned that Dr. Caldwell Esselstyn of the Cleveland Clinic had demonstrated successful reversal of coronary artery disease through a vegetarian diet. He had adopted a vegan diet, had begun walking 30 minutes daily, and had been drinking enough water to keep his urine pale so as to avoid another episode of dehydration. As a result he was already seeing a reduction in his blood pressure and significant weight loss.

No one at the heart hospital had reviewed his arteriogram results with him. No one had suggested that non-surgical options for the management of coronary artery disease were available. As he put it, “When I arrived at the heart hospital I was placed on an assembly line designed to take me through bypass surgery.” He avoided the operation by asking, “Is this procedure really necessary?” In so doing he may have saved his life.

Surgery, particularly major surgery, takes a toll on the body. The mortality rate for individuals with disease in two or three coronary arteries that is treated non-surgically is less than 1 percent per year. In contrast, the annual mortality rate following a double bypass is 2.7 percent and that following a triple bypass operation is 3.3 percent. Those numbers rise to 10 percent if the patient is over the age of seventy and to nearly 20 percent if the person undergoing surgery is over the age of eighty.

It is important to keep an open mind when faced with a decision to undergo a medical procedure. There are circumstances in which a medical procedure can be life-saving. There are others in which the procedure can dramatically improve one’s quality of life. On the other hand, there are times when a medical procedure will adversely affect the subsequent quality of life and times when it will hasten or directly cause one’s death. The most important step in making a wise decision regarding whether or not to submit to a medical procedure is to ask, “Is this procedure really necessary?” If the answer is no, it is almost always best to forego the procedure and seek other options.

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