Surgery

Of all areas in medicine, surgery is probably the least scientific. Most decisions about operations have more to do with the personal taste of individual doctors, the arbitrary consensus of professional bodies, or just the fashion of the moment than with hard fact. For obvious ethical reasons, operations are almost never tested by controlled experiment, but are instead developed on an ad hoc basis and then taught to others--including trainees--more or less on the job. This means that many surgeons become enthused by new techniques before they know what they're doing or even whether the procedure is going to do any good at all. Since 1998, the number of operations performed on the wrong body site or the wrong patient has increased dramatically. The JCAHO is an independent commission that evaluates and accredits about 18,000 healthcare organizations and programs in the U.S. In 1998, the JCAHO issued a Sentinel Event Alert after 15 "wrong site" surgery cases were reported to it. By the time the current report was released, this number had skyrocketed to 150. According to the new figures, orthopedic/podiatric operations were the most common procedures linked to errors, accounting for 41% of the cases that were analyzed. General surgery procedures accounted for 20% of the cases, neurosurgery operations for 14%, and urologic surgery operations for 11%. The remaining cases involved other procedures such as dental/oral operations. Fifty-eight percent of cases occurred in an outpatient surgical setting, 29% in an inpatient operating room, and 13% in other inpatient settings. Most of the errors involved operations on wrong body parts or sites, but 13% involved operations on the wrong patient and 11% involved the wrong surgical procedure.

Besides not knowing when to put down the knife, surgeons of all persuasions underestimate the single risks involved in every type of surgery, no matter how "routine." Although emergency procedures have far higher mortality rates, a number of elective procedures also carry high risks, especially from complications after surgery. A high proportion of deaths occur because routine procedures aren't followed properly. In studies of deaths within a month of surgery, it was found that many patients are needlessly dying after routine surgery. It was found that deaths from deep vein thrombosis and blood clots in the lungs were commonplace, simply because procedures that would have counteracted the problem weren't administered. Many deaths were due to preoperative preparations or even the surgery itself being undertaken too hastily, or to too much I.V. fluid being given the patient during surgery, causing heart attacks. A considerable number of deaths were caused by the surgeon's lack of familiarity with the operation.

Many treatments are faddish, adopted in a flurry of enthusiasm and soon discarded in favor of the next new possibility when evidence proves the original procedures don't work. Just consider the history of treatment for back pain. Earlier, in this century, sacroiliac joint disease was believed the culprit in many cases of back pain, leading to fusion (the joining of one vertebra to another) of the sacroiliac joints. This was followed by such treatments as the removal of the coccyx, injections for slipped discs, lengthy bed rest, traction, and even nerve stimulation--all, in their turn, discarded. The latest fad to be discredited is steroid injections in the facet joints (the cartilage covering of the bony junction between two vertebrae). Recent evidence revealed that injecting steroids is no better than injecting salt water. The most common cause of sacroiliac joint pain is from a reactive muscle pattern related to the ileo-cecal valve being impaired from a constipated colon. This pattern caused the sacrum to subluxate (move out of its normal position relative to the pelvis) and causes pain in the sacroiliac joint, especially on the right side. Harvard Medical School once performed one of the few studies to see whether surgeons get it right when they recommend surgery. The Harvard researchers looked at the track record of a number of doctors in diagnosing one of the most common procedures--removal of nonmalignant moles. In all, the correct diagnosis was made in less than half the cases. Dermatologists--who should be able to do this with their eyes closed--got the diagnosis right only two-thirds of the time, while other types of doctors were only half as good as that. Like the diagnosis, the appropriate procedure was carried out only half of the time.

Anesthesia

Perhaps the first to feel the effects of forced unconsciousness was the English chemist, Sir Humphry Davy, who in his small private laboratory in 1808, prepared and inhaled nitrous oxide, "laughing gas." By 1831, two other chemical drugs, ether and chloroform, were known to put people to sleep, and they were first used, not surprisingly, by dentists. Indeed, it was the dentist, W.T.G. Morton who first introduced the magic of anesthesia to medical doctors. Variations of as small as a fraction of one percent in the dosages of certain anesthesia can be lethal to the patient on the table. So the anesthesiologist draws on two sets of drugs. The first set is designed to work rapidly, but briefly, to get the patient under as quickly as possible. The second is designed to keep the patient under for a long period of time. It begins with an injection into the vein, a small amount of a member of the first set of drugs, sodium pentothal, to test the waters, so to speak, to see if the patient can tolerate more. Then, an anesthetizing dose of the same substance is added. Sodium pentothal works quickly and induces unconsciousness in the patient in a matter of seconds. Extremely soluble in the fat-oil of cell membranes, it rapidly leaves the bloodstream and pentrates the brain. But the duration of unconsciousness is brief. If not followed by another, longer lasting drug, the patient will wake up in 5 or 10 minutes after the injection. Sodium petothal, being so soluble in oil, diffuses rapidly out of the brain, cutting short its action, and is transported by the circulatory system to the fatty deposits in the body. Hoarded by the fat cells of the body, the blood levels of sodium pentothal drop. And with little of it left in the brain, the patient wakes up. The individual is still groggy though, and in fact, will continue to be groggy for some time. The sleepy feeling is the result of the low levels of the drug remaining in the blood while the liver slowly breaks it down. The drug is still present, but the concentration is not high enough to induce sleep or anesthesia.

Once the patient is under from the sodium pentothal, the anesthesiologist moves quickly before the patient wakes. The next drug is delivered--one that will put the patient out for a longer time. The drug is usually in a gaseous or vaporized form and is breathed through the lungs. You'll usually be given a fluoride-based anesthetic, because fluoride is virulent enough to throw you into an immediate coma. Nitrous oxide may be used with a supplementary gas such as Halothane or Isoflurane (contains fluoride). The vapors are extremely soluble in fat and flow past the lining of the lungs and into the bloodstream in a matter of seconds. There they flow into the brain and destroy enzymes, causing rapid unconsciousness. The fat-soluble gases keep the patient asleep, but only if they are constantly fed into the lungs. To avoid a situation where the patient wakes up during surgery, phenobarbital, a long-acting barbiturate, may be administered. Phenobarbital exists in the blood primarily in the water-soluble form and is only slightly soluble in muscle and fat. Unlike sodium pentothal, phenobarbital has some difficulty passing though the blood-brain barrier. Thus, it may take many minutes for phenobarbital to build up concentrations in the brain sufficient enough to induce unconsciousness. It circulates in the bloodstream in concentrations sufficient to keep the individual sedated or drowsy for several hours until it is either broken down by the liver or dumped out with the urine. The great amount of the drug that persists in the bloodstream largely accounts for the hangover that lasts for several hours or even days after it has been administered into the body.

Standard Operating Procedure

Getting it wrong is nothing new with surgeons. In the United States, some 6 million operations and invasive tests are performed every year. Some 20,000 normal appendixes are mistakenly removed every year. In fact, with the vast bulk of surgery patients often go under the knife unnecessarily. Most children with chronic secretory middle ear infection undergo operations needlessly, as do women undergoing a D & C (dilatation and curettage of the lining of the uterus) after miscarriage, hysterectomy, and even patients undergoing coronary bypass surgery. Bypass surgery might relieve symptoms in some patients, but there is no proof anywhere that this surgery actually prolongs life. In many cases, particularly routine surgery, experienced surgeons supervise juniors, who get to practice routine procedures.

Bypass Surgery

Coronary bypass operations are one of the most unnecessary operations of all. In one study involving researchers from fourteen major heart hospitals around the world, up to one-third of all bypass operations were found to be unnecessary and to hasten the death of the patient. One-third of the patients, considered low-risk cases, might have lived longer if they had received drug therapy rather than surgery, not to mention lifestyle changes and herbal/nutritional therapy. Heart surgeons have known this since the 1970s, when several major studies revealed that bypass surgery does not improve survival except among patients with severe coronary disease, particularly to the left ventricle. It did, however, appear to relieve severe angina (chest pain). The National Institutes of Health has estimated that 90% of American patients who undergo bypass surgery receive no benefits. The bypass seems to be surviving better than its patients. The death rate is as high as 23% in the United States. It is one of the best-paying surgical procedures, earning surgeons some $40,000 per operation. This translates into an overall U.S. medical bill of $8 billion a year to treat just 200,000 people. Bypass surgery may be the most appropriate choice only for those with triple-vessel disease (when two-thirds of each artery is blocked). Although this covers just 10% of all heart condition patients.

Back Pain

Treatment for back pain also demonstrates how knife-happy many surgeons are without much in the way of evidence that operations will do any good. If there is a specific problem correctly identified--such as spinal deformity or fracture or disc rupture--then surgery can help, but not for simple relief of unspecified back pain. But, in most cases, medicine has shown a shocking lack in diagnosing and treating back problems, often making the problem worse. Dramatic surgical successes, unfortunately, apply to only some 1% of patients with low back disorders. Our failure is in the remaining 99% of patients with simple backache, for whom, despite new investigations and all our treatments, the problem has become progressively worse. For back patients who undergo surgery, 15 to 20% will fall into the category of the failed back--the official name given to people with chronic, considerable back pain that doctors can't fix. Up to 400,000 patients, go under the knife in the United States every year--that translates into up to 80,000 Americans every year who will emerge from back surgery in considerably more pain than before they went to their doctor. Many causes of disastrous residual pain are caused by inappropriate surgery for back pain.

The most popular operations include laminectomy, in which a disc and nearby bone are removed, to give the nerve branching off the central spinal cord more space to move without getting trapped or compressed by the spine; and fusion, in which one vertebra is surgically joined to another, in order to minimize what has usually been diagnosed as too much movement between the vertebrae. After fusion, this segment of the spine will not move at all. According to numerous studies, removing discs only relieves back pain in about half of all patients. And, with primarily disc removal, surgery wasn't indicated for two-thirds of them. Three out of four studies comparing operations with those without lumbar spinal fusion surgery found no advantage for fusion; complications, including chronic pain, were common. In more than half of all such cases, the missed diagnosis or the surgery itself caused a condition called lateral spinal stenosis, or narrowing of a portion of the spine, causing compression of the spinal cord or an abnormally tight fit. Finally, post surgical scarring (epidural fibrosis) can itself cause failed surgery and chronic pain. Surgeons cause nerve-root injury as the nerve is being separated from a herniated disc, causing scarring and therefore long-term pain and pressure on the nerve. Damage to the dura matter or the cauda equina (membranes covering the spinal cord) from poor surgical technique yielding possibly catastrophic results completes the list.

Breast Surgery

Besides being unnecessary, a large number of surgical procedures still widely used are clearly obsolete. The most obvious example is treatment for breast cancer. Surgical treatment of breast cancer hasn't advanced one single step in the past century. Over a period of one hundred years, breast cancer treatment has evolved from no treatment to radical treatment and back again to more conservative management, without having affected mortality. Although most official agencies recommend breast-conserving measures for breast cancer caught early, many surgeons persist in performing a mutilating operation developed in the nineteenth century and never reviewed to see if it is still applicable to patients today--or indeed if it ever worked at all. The Lancet reviewed 8,000 cases of radical mastectomies, simple mastectomies, or simple removal of the tumor, found no difference in survival rates among the patients who had received any of these procedures. Another study undertaken by the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania, over nine years, found there was no difference in survival rates among those who had undergone lumpectomy, with or without radiation, and those who had received a total mastectomy. Despite all the publicity about the safety of lumpectomies, many doctors still think the more they cut out, the better off a woman is, and refuse to offer breast-conserving surgery to the majority of women with early breast cancer. The more affluent and well educated the woman, the greater the chances of her breast being saved. Besides your education or ability to pay, where you live has a lot to do with whether you get to keep your breasts. Women are more likely to be offered conserving surgery in the Northeast or Middle Atlantic States than in the South, in urban rather than rural areas, and in the larger hospitals with more facilities. Higher rates of conservation surgery also occur in those seventeen states with informed consent laws requiring doctors to offer breast-cancer patients information about their treatment options.

Hernia Repair

Although a good hernia repair is as difficult as the most complex abdominal surgery, senior surgeons leave this kind of surgery, which they consider routine and boring, to trainees to cut their professional teeth on. In some countries, interns are allowed to go it alone after only six hernia repairs. This is perhaps one reason for its dismal success rate. It is four times more dangerous to have a hernia operation than to go without one if you're over sixty-five. Up to one-fifth of operations have to be repeated within five years--a recurrence rate that rises to one in every two by the third operation. There is also no professional consensus about the best procedures.

Prostate Surgery

In too many instances, surgeons rush in with the scalpel too early, when simple watchful waiting (monitoring the situation to see if it gets worse) is called for. This is the case with prostate cancer. The commonest form of cancer (and surgery) for men over forty, involves the prostate, the gland that lies just below the base of the bladder. Because it is so close to the bladder and urethra, problems in this area invariably cause problems with urination. Although the incidence of prostate cancer hasn't really gone up, the incidence of aggressive treatments such as radiation and surgery has--by a whopping 36%. Nevertheless, the rates of prostatectomy increased by nearly 35% per year between 1983 and 1989. A third of men in the European Community have prostate cancer, but only 1% die of it. Particularly in men over seventy, patients are more likely to die with their prostate cancer than of it. There is plenty of evidence that most prostate cancer doesn't spread. Among men over seventy, radical prostatectomy not only isn't better than watchful waiting, but can also be downright harmful. Survival rates can be higher in groups for whom nothing is done, compared with groups undergoing surgery. Many patients who undergo surgery die from a number of major heart-related complications within a month after they've had their operation.

Besides not improving survival, having any sort of medical treatment, whether with drugs or surgery, negatively affects your quality of life. Even young men--those who reach their sixties--with slow-growing prostate cancer are likely to live as long as men without tumors. In one University of Connecticut study, only 9% of patients with low-grade cancer had died, even after fifteen years. Even those with higher-grade tumors may be better off without having radical surgery, as the years lost may not outweigh the significant problems associated with treatment. Radical intervention and screening may simply bring to light many cancers that would otherwise remain dormant--and harmless--if left undetected. There is also some worry in certain medical circles that radical surgery to treat prostate cancer (and breast cancer) may only succeed in spreading the condition. Doctors have assumed that the poor survival rate had to do with the deadly ability of prostate cancer to spread. But it has now been discovered that surgeons are accidentally spreading cancer cells to other parts of the body while performing the surgery.

Hysterectomy

Hysterectomy is second only to Cesarean section on the list of most common operations in the United States. If you are a woman in America, you've got a one in three chance of losing your uterus by the time you're sixty. Hysterectomy outranks all others when it comes to the most unnecessary of surgical procedures. Three-quarters of all hysterectomies are performed on women under fifty for highly dubious reasons. Although the only viable reasons for performing a hysterectomy are uterine or endometrial cancer or uncontrollable bleeding after childbirth, these account for only about 10% of all procedures performed. The remaining 90% of hysterectomies are carried out for a number of questionable purposes: fibroids, endometriosis, bladder prolapse, tipped uterus, heavy periods or unexplained period troubles, which are often given the fanciful gynecological appellation--pelvic congestion.

There are enormous variations in the rates of hysterectomy between individual doctors or areas of the country, with the highest rates often among black or poor American women. Hysterectomy is often used to "prevent" ovarian cancer in women who have had uterine cancer even though only 2 in every 1,000 women who've had a hysterectomy will go on to develop ovarian cancer, and the disease itself is rare. Less than 2 of every 1,000 fibroids and less than 3% of abnormal endometrial cells, will progress to cancer. Since hysterectomy carries a mortality rate of 1 per every 1,000 procedures--a risk that increases with age--and serious complications occur fifteen times more frequently than that, the risk of contracting cancer is far less than the risk of dying or being seriously injured from the operation. In fact, in abdominal hysterectomies, side effects can occur in more than 40% of operations. These side effects can include bowel problems, urinary retention or incontinence, and the risk of a fatal blood clot, particularly in women after menopause, can occur in one in every 6,000 operations. One-third to nearly one-half of all women undergoing hysterectomy or removal of ovaries reports a decrease in sexual response. If a woman's ovaries are removed at the same time, she will experience severe menopausal symptoms. Most symptoms that are used as an indication for hysterectomy, can be treated with supplemental natural progesterone cream, herbal therapy, nutritional guidance and internal cleansing procedures.

Transfusions

Perhaps the biggest risk you face when you have an operation has nothing to do with the scalpel or the anesthesia. The U.S. Red Cross now admits that even in the direst of emergencies, blood transfusions oftentimes only add to complications or increase a patient's chances of dying. Transfusions are still routine in most surgical procedures and emergencies--in many cases without any medical justification whatsoever for its use or any guidelines as to when it is necessary. Like so many other practices in medicine, the guidelines doctors follow when deciding whether or not to give a transfusion have been adopted with very little in the way of scientific evidence. An estimated one-third to three-quarters of those given blood are transfused inappropriately to treat a diminished volume of blood or a low nutritional status (anemia). The Red Cross Blood Services admitted that there is gross overuse of blood products like albumin and plasma and also whole blood or red blood cells. An Office of Technology Assessment Task Force report estimated that as much as 20% to 25% of red blood cells, 90% of albumin, and 95% of fresh-frozen plasma transfused into patients is not needed.

A common transfusion determinant is the measurement of hemoglobin. Medicine uses the same determinant for men and women, even though women naturally have lower red blood cell counts than do men. "Iron deficiency anemia continues to be among the leading reasons for transfusions, even though it rarely warrants them," said the report. A survey of 1,000 American anesthesiologists concluded that there were "wide variations in transfusion practices" among anesthesiologists, based on "habit rather than scientific data." One such habit is the automatic administration of blood before operations in patients whose hemoglobin level is below 10 grams per 100 milliliters of blood. The practice apparently arose from a misreading by a hematologist of a study performed on dogs, which was accepted as gospel and preached to an entire generation of anesthesiology students. Premature infants probably get more transfusions than any other body of patients in hospitals, mostly from premature cutting of the umbilical cord. Transfusion is automatic if a baby is less than 1,500 grams (3 pounds), a practice that has little in the way of evidence. Blood components are also routinely irradiated, supposedly to reduce the risk of patients with immune-system problems rejecting the foreign blood. This irradiated blood may have too high a concentration of potassium, which could be especially hazardous to babies and pregnant mothers.

Besides giving blood for the wrong reasons, doctors often give out the wrong blood. In a study of 4,000 hospital hematology laboratories, one-third of the labs that responded reported multiple incidents in which their patients received the wrong blood. In most cases, the patient was given the wrong blood while on the ward or in the operating room. The study concluded that the wrong blood is given in one of every 6,000 red cell units given. Other research has found most errors have been found to arise when blood samples are inadequately documented or when information about which blood to be given to which patient is incorrect. Transfusions have never been subjected to proper scientific study--that is, a randomized, double-blind trial--to see if indeed there are any benefits. Even if you believe that giving and getting blood is warranted, the number of blood-borne diseases you can contract from other people might well change you mind. There is a considerable risk of contracting hepatitis from donated blood. It is estimated that hepatitis from transfusions develops in 7% to 10% of blood recipients from unpaid donors in the United States. This incidence multiplies three to four times among recipients of blood from paid donors. This translates to up to 230,000 new cases of hepatitis in the United States every year. The reason for the epidemic of cases is that there is, to date, no test reliable or sensitive enough to detect the agents that cause the disease. In fact, most cases of hepatitis-C are due to blood transfusions or needle sharing among drug users.

Doctors now wonder whether intravenous immunoglobulin, a protein given to stimulate the immune system, can actually trigger hepatitis-C. Since 1991, a screening test has been developed for the hepatitis-C virus, showing that one in 2,000 blood donors supposedly is positive for hepatitis-C antibodies. However, even this screening test isn't necessarily going to protect you. Besides hepatitis, the risk of contracting human T-cell leukemia from blood is ten times higher than the risk of contracting HIV. This risk skyrockets when you consider that many blood recipients, including premature babies, are given the blood components from what can be, on average, as many as nine donors. Blood transfusion has been linked with organ system failure, recurrence of cancer, a high risk of postoperative infection, and graft-versus-host disease--a condition affecting the joints, heart, and blood cells in which the recipient rejects the transfused blood.

Besides the various diseases you can contract from someone else's blood, if you're a cancer patient a blood transfusion may depress your immune system, causing or in some way aiding a recurrence. In one study, the recurrence rate for patients with cancer of the larynx more than four times as great among those who received blood transfusions. Of those receiving transfusions with cancer of the oral cavity, pharynx and nose, recurrence rate was more than double those without transfusions. A poorer outcome was also experienced in patients receiving blood transfusions after surgery for lung cancer as well as for those with colon, rectal, cervical, and prostate cancers. There also is a higher incidence of recurrence if a patient received whole blood rather than red blood cells alone. Having a transfusion during an operation also increases your chances of infection. In patients undergoing major abdominal surgery, blood transfusion has been the most significant contributor to organ system failure. Besides lowering your chances of surviving, you can suffer side effects from blood that are every bit as severe as the worst reaction to a drug. Although the usual reactions include hives, fever, or chills, some patients experience a severe reaction in the lungs, sometimes fatal, with some kinds of plasma, a risk that is higher than previously thought. There are also substantial risks of general infection and life-threatening allergic reactions, as well as of contracting a sexually transmitted disease such as cytomegalovirus (CMV). Blood, like fingerprints, is uniquely--untransferably--individual.

The unavoidable, biological fact is that each person's blood contains a multiplicity of antibodies, antigens, and infectious agents, many of which have yet to be identified by scientists and cannot presently be detected. "Pure blood" is finally understood by courts to be imaginary. Doctors have successfully transfused patients with their own blood, donated ahead of time, for all sorts of major surgery, including coronary bypasses, congenital heart surgery, or cancer. Another procedure, called hemodilution, maintains the amount of fluid circulating around the body through artificial fluid-volume expanders. Adult patients can undergo rapid loss of a third of the total volume of blood and not go into irreversible shock if hemodilution is adequate. Open-heart operation patients demonstrated that they have improved outcomes once blood transfusion was stopped and volume expanders were substituted.

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