Five
Operations You Don't Want to Get
What To Do Instead
By CURT PESMEN,
HEALTH MAGAZINE, CNN
Maybe
I'm the wrong ex-patient to be telling you this: Experimental surgery
erased Stage III colon cancer from my shell-shocked body six years ago.
But even I've got to admit that all is not well in America's operating
rooms: At least 12,000 Americans die each year from unnecessary surgery,
according to a Journal of the American Medical Association report. And
tens of thousands more suffer complications.
The fact is, no matter how talented the surgeon, the body doesn't much
care about the doc's credentials. Surgery is a trauma, and the body
responds as such -- with major blood loss and swelling, and all manner
of nerve and pain signals that can stick around sometimes for months.
Those are but a few reasons to try to minimize elective surgery. And
I found even more after talking with more than 25 experts involved in
various aspects of surgery and surgical care, and after reviewing a
half-dozen governmental and medical think tank reports on surgery in
the United States. Here's what you need to know about five surgeries
that are overused and alternative solutions that may be worth a look.
Hysterectomy
There's long been a concern, at least among many women, about the high
rates of hysterectomy (a procedure to remove the uterus) in the United
States. American women undergo twice as many hysterectomies per capita
as British women and four times as many as Swedish women.
The surgery is commonly used to treat persistent vaginal bleeding or
to remove benign fibroids and painful endometriosis tissue. If both
the uterus and ovaries are removed, it takes away sources of estrogen
and testosterone. Without these hormones, the risk of heart disease
and osteoporosis rises markedly. There are also potential side effects:
pelvic problems, lower sexual desire and reduced pleasure. Hysterectomies
got more negative press after a landmark 2005 University of California,
Los Angeles study revealed that, unless a woman is at very high risk
of ovarian cancer, removing her ovaries during hysterectomy actually
raised her health risks.
So why are doctors still performing the double-whammy surgery? "Our
profession is entrenched in terms of doing hysterectomies," says
Ernst Bartsich, M.D., a gynecological surgeon at Weill-Cornell Medical
Center in New York. "I'm not proud of that. It may be an acceptable
procedure, but it isn't necessary in so many cases." In fact, he
adds, of the 617,000 hysterectomies performed annually, "from 76
to 85 percent" may be unnecessary.
Although hysterectomy should be considered for uterine cancer, some
90 percent of procedures in the United States today are performed for
reasons other than treating cancer, according to William H. Parker,
M.D., clinical professor of gynecology at UCLA and author of the '05
study. The bottom line, he says: If a hysterectomy is recommended, get
a second opinion and consider the alternatives.
What
to Do Instead
Go Knife-Free. Endometrial ablation, a nonsurgical procedure that targets
the uterine lining, is another fix for persistent vaginal bleeding.
You've been waiting at the doctor's office for over an hour past your
appointment. Sound familiar? Pick up on the signs that it's time to
dismiss your doctor so that you can start getting the care you deserve.
Focus on Fibroids. Fibroids are a problem for 20 to 25 percent of women,
but there are several specific routes to relief that aren't nearly as
drastic as hysterectomy. For instance, myomectomy, which removes just
the fibroids and not the uterus, is becoming increasingly popular. And
there are other less-invasive treatments out there, too.
In France in the early 1990s, a doctor who was prepping women for fibroid
surgery -- by blocking, or embolizing, the arteries that supplied blood
to the fibroids in the uterus -- noticed a number of the benign tumors
either soon shrank or disappeared, and, voila, Jacques Ravina, M.D,.
had discovered uterine fibroid embolization.
Since then, interventional radiologists in the United States have expanded
their use of UFE (typically a one- to three-hour procedure), using injectable
pellets that shrink and "starve" fibroids into submission.
Based on research from David Siegel, M.D., chief of vascular and interventional
radiology at Long Island Jewish Medical Center, New Hyde Park, New York,
15,000 to 18,000 UFEs are performed here each year, and up to 80 percent
of women with fibroids are candidates for it.
Another new fibroid treatment is high-intensity focused ultrasound,
or HIFU. This even less invasive, more forgiving new procedure treats
and shrinks fibroids. It's what's called a no-scalpel surgery that combines
MRI (an imaging machine) mapping followed by powerful sound-wave "shaving"
of tumor tissue.
Episiotomy
It can sound so simple and efficient when an OB-GYN lays out all the
reasons why she performs episiotomy before delivery. After all, it's
logical that cutting or extending the vaginal opening along the perineum
(between the vagina and anus) would reduce the risk of pelvic-tissue
tears and ease childbirth. But studies show that severing muscles in
and around the lower vaginal wall (it's more than just skin) causes
as many or more problems than it prevents. Pain, irritation, muscle
tears, and incontinence are all common aftereffects of episiotomy.
Last year the American College of Obstetricians and Gynecologists released
new guidelines that said that episiotomy should no longer be performed
routinely -- and the numbers have dropped. Many doctors now reserve
episiotomy for cases when the baby is in distress. But the rates (about
25 percent in the United States) are still much too high, experts say,
and some worry that it's because women aren't aware that they can decline
the surgery.
"We asked women who'd delivered vaginally with episiotomy in 2005
whether they had a choice," says Eugene Declercq, Ph.D., main author
of the leading national survey of childbirth in America, "Listening
to Mothers II," and professor of maternal and child health at the
Boston University School of Public Health. "We found that only
18 percent said they had a choice, while 73 percent said they didn't."
In other words, about three of four women in childbirth were not asked
about the surgery they would soon face in an urgent situation. "Women
often were told, 'I can get the baby out quicker,'" Declercq says,
as opposed to doctors actually asking them, 'Would you like an episiotomy?'"
What to Do Instead
Communicate. The time to prevent an unnecessary episiotomy is well before
labor, experts agree. When choosing an OB-GYN practice, ask for its
rate of episiotomy. And when you get pregnant, have your preference
to avoid the surgery written on your chart.
Get Ready With Kegels. Working with a nurse or midwife may reduce the
chance of such surgery, experts say; she can teach Kegel exercises for
stronger vaginal muscles, or perform perineal and pelvic-floor massage
before and during labor.
Angioplasty
Every year in the United States, surgeons perform 1.2 million angioplasties,
during which a cardiologist uses tiny balloons and implanted wire cages
known as stents to unclog arteries. This Roto-Rooter-type approach is
less invasive and has a shorter recovery period than bypass, which is
open-heart surgery.
The problem: A groundbreaking study of more than 2,000 heart patients
indicated that a completely nonsurgical method -- heart medication --
was just as beneficial as angioplasty and stents in keeping arteries
open in many patients.
The bottom line: Angioplasty did not appear to prevent heart attacks
or save lives among nonemergency heart subjects in the study.
What to Do Instead
Take the Right Meds. If the study is right, medications may be as strong
as steel. "If you have chest pain and are stable, you can take
medicines that do the job of angioplasty," says William Boden,
M.D., of the University of Buffalo School of Medicine, Buffalo, New
York, and an author of the study. Medicines used in the study included
aspirin, and blood pressure and cholesterol drugs -- and they were taken
along with exercise and diet changes.
"If those don't work, then you can have angioplasty," Boden
says. "Now we can unequivocally say that."
Of course, what's right for you depends on the severity of your atherosclerosis
risks (blood pressure, cholesterol, triglycerides) along with any heart-related
pain. The onus is also on the patient to treat a doc's lifestyle recommendations
-- diet and exercise guidelines -- just as seriously as if they were
prescription medicines.
Heartburn Surgery
A whopping 60 million Americans experience heartburn at least once a
month; 16 million deal with it daily. It's no wonder that after suffering
nasty symptoms (intense stomach-acid backup or near-instant burning
in the throat and chest after just a few bites), patients badly want
to believe surgery can provide a quick fix. And, for some, it does.
A procedure called nissen fundoplication can help control acid reflux
and its painful symptoms by restoring the open-and-close valve function
of the esophagus. But Jose Remes-Troche, M.D., of the Institute of Science,
Medicine, and Nutrition in Mexico, reported in The American Journal
of Surgery that symptoms don't always go away after the popular procedure,
which involves wrapping a part of the stomach around the weak part of
the esophagus.
"That may be because surgery doesn't directly affect healing capacity
or dietary or lifestyle choices, which in turn can lead to recurrence
in a hurry," he says.
The surgery can come undone, and side effects may include bloating and
trouble swallowing. Remes-Troche believes it's best for very serious
cases of long-standing gastroesophageal reflux disease, or GERD, or
for those at risk of Barrett's esophagus, a disease of the upper gastrointestinal
tract that follows years of heartburn affliction and can be a precursor
to esophageal cancer.
What to Do Instead
Make Lifestyle Changes. A combination of diet, exercise, and acid-reducing
medication may help sufferers beat the burn without going under the
knife. But it's a treatment that requires perseverance.
"It took me four years of appointments, diets, drugs, sleeping
on slant beds -- and even yoga -- to keep my heartburn manageable,"
says Debbie Bunten, 44, a Silicon Valley business-development manager
for a software firm, who was eager to avoid surgery. "But I did
it, and am glad I did."
Another technological development can make a heartburn diagnosis easier
to swallow -- a tiny camera pill that beams pictures of your esophagus
(14 shots per second) through your neck to a receiver or computer in
the doctor's office; it passes harmlessly out of your system four to
six hours later. The device can be used instead of standard endoscopy
to screen chronic-heartburn sufferers for various esophageal complaints,
including GERD, which can develop into the potentially precancerous
Barrett's esophagus. Unlike an endoscopy, in which you're sedated and
a lighted tube is snaked down your throat, a capsule camera leaves you
wide awake and is finished within 20 minutes, says Pillcam guru David
Fleischer, M.D., a staff physician in gastroenterology and hepatology,
and professor of medicine at Mayo Clinic College of Medicine. If anesthesia
makes you sick, the capsule camera may be for you.
Lower-Back
Surgery
Since the 1980s, operations for lower-back pain and sciatica have increased
roughly 50 percent, from approximately 200,000 to more than 300,000
surgeries annually in the United States. That rise is largely due to
minimally invasive advances that include endoscopic keyhole tools used
in tandem with magnified video output.
To its credit, surgery (endoscopic or the traditional lumbar-disc repair)
does relieve lower-back pain in 85 to 90 percent of cases, docs say.
"Yet the relief is sometimes temporary," says Christopher
Centeno, M.D., director of the brand new Centeno-Schultz Pain Clinic
near Denver, Colorado. And that adds up to tens of thousands of frustrated
patients who find the promise of surgery was overwrought or short-lived.
What to Do Instead
Try Painkillers and Exercise. Despite the relentless nature of lower-back
pain, the most common cause is a relatively minor problem -- muscle
strain -- not disc irritation, disc rupture, or even a bone problem,
experts say. Despite its severity, this type of spine pain most often
subsides within a month or two. That's why surgery, or any other invasive
test or treatment beyond light exercise or painkillers, is rarely justified
within the first month of a complaint. Even pain caused by a bulging
or herniated disc "resolves on its own within a year in some 60
percent of cases," orthopedists claim.
"Seventy to eighty percent of the time we can get to a concrete
diagnosis, find a way to manage pain, and get patients off the drugs
without surgery," Centeno says. "Or, more appropriately, never
start the drugs."
"We used to prescribe 30 days bed rest for patients with herniated
discs, but that was 15 to 20 years ago," says Venu Akuthota, M.D.,
medical director of the Spine Center at University of Colorado Hospital
and associate professor of medicine at the University of Colorado School
of Medicine. "Actually, movement is very helpful for treating back
conditions. Nowadays, we prescribe moderate, low-impact exercise, like
walking, or working out on an elliptical trainer or treadmill."
Learn About Stem Cells. I've seen the future of back surgery firsthand.
And it looked to me, from behind my surgical mask, as if a woman's bare
behind was doing much of the work. Up close, huddled inside the Centeno-Schultz
Pain Center, I joined a team of M.Ds., a Ph.D., and two nurses to witness
orthopedic history in vivo: an adult stem cell transplant to help bones
and joints grow anew.
In the midst of the huddle, Centeno, the back-and neck-pain specialist,
is plunging a needle that looks big enough to use on a horse deep into
the hip bone of a 54-year-old weekend athlete and skier who's been forced
to the sidelines by injury and long-term lower-back pain. The patient
is tired of pain pills but wary of major surgery. Instead she's undergoing
one of the first ASC orthopedic transplants in the nation.
The harvested stem cells will be used to grow millions of new ones that
will be implanted in her back to spur and regenerate more youthful,
healthy joint tissue -- if all goes as planned in this part of an ongoing
study approved by a medical research institutional review board, that
is. So far, at least, it has. Early MRI pictures of related procedures
have shown impressive growth of regenerative tissue. And there's even
better news: By using the patient's own stem cells, the surgical team
avoids the ethical debate over using embryonic tissue for research purposes. See BroadPoints.com. --
The
Appendix
It's
useful after all!
By
SETH BORENSTEIN
"I'll
bet eventually we'll find the same sort of
thing with the tonsils and the male foreskin."
WASHINGTON October 8 – Some scientists think they have figured
out the real job of the troublesome and seemingly useless appendix:
It produces and protects good germs for your gut.
That's the theory from surgeons and immunologists at Duke University
Medical School, published online in a scientific journal this week.
For generations the appendix has been dismissed as superfluous.
Doctors figured it had no function. Surgeons removed them routinely.
People live fine without them.
And when infected the appendix can turn deadly. It gets inflamed
quickly and some people die if it isn't removed in time. Two years
ago, 321,000 Americans were hospitalized with appendicitis, according
to the Centers for Disease Control and Prevention.
The function of the appendix seems related to the massive amount
of bacteria populating the human digestive system, according to
the study in the Journal of Theoretical Biology. There are more
bacteria than human cells in the typical body. Most of it is good
and helps digest food.
But sometimes the flora of bacteria in the intestines die or are
purged. Diseases such as cholera or amoebic dysentery would clear
the gut of useful bacteria. The appendix's job is to reboot the
digestive system in that case.
The appendix "acts as a good safe house for bacteria,"
said Duke surgery professor Bill Parker, a study co-author. The
location of the appendix -- just below the normal one-way flow of
food and germs in the large intestine in a sort of gut cul-de-sac
-- helps support the theory, he said.
Also, the worm-shaped organ outgrowth acts like a bacteria factory,
cultivating the good germs, Parker said.
That use is not needed in a modern industrialized society, Parker
said. If a person's gut flora dies, they can usually repopulate
it easily with germs they pick up from other people, he said. But
before dense populations in modern times and during epidemics of
cholera that affected a whole region, it wasn't as easy to grow
back that bacteria and the appendix came in handy.
In less developed countries, where the appendix may be still useful,
the rate of appendicitis is lower than in the U.S., other studies
have shown, Parker said.
The appendix, which is about two to four inches long, may be another
case of an overly hygienic society triggering an overreaction by
the body's immune system, he said.
Even though the appendix seems to have a function, people should
still have them removed when they are inflamed because it could
turn deadly, Parker said. About 300 to 400 Americans die of appendicitis
each year, according to the CDC.
Five scientists not connected with the research said that the Duke
theory makes sense and raises interesting questions.
The idea "seems by far the most likely" explanation for
the function of the appendix, said Brandeis University biochemistry
professor Douglas Theobald. "It makes evolutionary sense."
The theory led Gary Huffnagle, a University of Michigan internal
medicine and microbiology professor, to wonder about the value of
another body part that is often yanked: "I'll bet eventually
we'll find the same sort of thing with the tonsils." --
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