Needless Surgery

Reprinted from Consumer Reports on Health (March 1998)
© 1998 Consumers Union*

Two decades ago, the number of tonsillectomies plummeted from about one million per year to 250,000, after studies showed that in most cases the tonsils didn't need to be removed. While ear, nose, and throat specialists cut back on tonsillectomies, they started performing more myringotomies, or insertion of tiny tubes to prevent recurrent car infection, usually in children. The number of myringotomies has risen nearly 250 percent in recent years, making the procedure the sixth most common operation in the U.S. But a recent large study concluded that well over half of all myringotomies are done for equivocal or inappropriate reasons.

Myringotomy is just one of many overused surgical procedures. While the trend toward managed-care insurance has reined in certain excesses, some plans are considerably less restrictive than others, and many surgeons have learned how to work the system and get their operations approved. There are various reasons for excess surgery: the allure of new technology, failure to follow the scientific evidence, the desire for profits, or pressure from patients demanding the latest cure. This report tells where you're most likely to face unnecessary surgery -- and how to avoid it.

Cataract Removal

In 1993, the Agency for Health Care Policy and Research warned that many operations to remove a cataract, or clouded lens of the eye, are not necessary. In those cases, the clouding had probably reduced visual acuity, but not enough to bother the patient. Despite the warning, the number of cataract operations has continued to rise -- an increase that far outpaces the rise in the older population.

The best objective indicator that you might benefit from the surgery is having a cataract that reduces your visual acuity to 20/150 even with glasses. But subjective factors are more important: If the cataract does not hamper your daily activities, you don't need surgery, regardless of what any test shows.

If you suspect you have cataracts, you may want to avoid having your initial evaluation performed by an ophthalmologist whose practice consists mainly of cataract surgery -- one who works in a special cataract clinic, for example. Some evidence suggests that such doctors perform a greater proportion of cataract surgeries on minimally impaired eyes than other eye doctors do.

Low-Back Surgery

Between 1983 and 1994, the number of operations for low-back pain rose from some 190,000 to 335,000 per year. While that rise has now leveled off -- possibly due in part to a warning from the Agency for Health Care Policy and Research -- many of those operations are still unnecessary.  (Mainly because HMOs require their managed physicians to wait at least 3 months before surgery—and by then most of the patients have self healed—jk)

The most common cause of low-back pain is a minor problem such as muscle strain, which almost always clears up within a month or so. Surgery or any other test or treatment beyond light exercise or painkillers is rarely justified in the first month. Even pain caused by a herniated disk -- the most common cause of persistent low-back pain -- resolves on its own within a year in some 60 percent of cases.  (Herniated discs are common.  They are present in both people without and with back pain.  This poor correlation to pain means that it can be removed when it is not the cause of pain.  The difficulty in treatment is that diagnosis is uncertain—jk.)  Pain from stenosis, or narrowing of the spinal canal, typically does not resolve, but patients often learn to control or live with the discomfort. Overall, surgery relieves low-back pain in 85 to 90 percent of cases. But the relief is sometimes temporary. And by the end of four years, people who have simply waited experience no more back pain, on average, than those who have undergone surgery.

In general, consider surgery for back pain only in the following circumstances: The pain has lasted for at least a month; other treatments, such as physical therapy and medication, have failed; and magnetic resonance imaging (MRI) shows a spinal abnormality pressing on a relevant nerve.

Gallbladder Removal

A decade ago, surgeons developed a new way to remove a gallbladder that has formed painful stones. That technique, called laparoscopy, uses miniature instruments and a lighted tube equipped with a video camera, all inserted through tiny abdominal incisions. Laparoscopy has almost completely replaced traditional "open" gallbladder surgery, since the new approach causes less postoperative pain and permits quicker recovery. But since the advent of laparoscopy, the number of gallbladder operations has risen 40 percent. And a study of some 54,000 gallbladder surgeries in Pennsylvania found that the number of procedures done in patients with minimal or no symptoms has risen more than 50 percent. Apparently, the advantages of the new technique have convinced some doctors to try preventing severe attacks before they occur.

Some 10 percent of Americans have gallstones, and most of those people never develop significant symptoms. While laparoscopy is generally less traumatic than the old approach, it's still major surgery with major potential risks. In fact, accidental severing of the bile duct, which can cause permanent liver damage, occurs in 1 to 2 percent of laparoscopies -- three times more often than in open surgery.

Avoid gallbladder surgery unless you've had at least one severe attack or several less painful attacks in the upper right part of the abdomen, or if you develop jaundice or pancreatic inflammation -- and tests confirm that stones are the real culprit. Surgery should not be done to treat vague symptoms such as flatulence or bloating, which many people -- and some doctors -- mistakenly attribute to gallstones. If you do need surgery, look for an experienced surgeon who has done at least 30 of the operations.

Hysterectomy

One of every three women has her uterus removed. A few years ago, the RAND Corporation, a nonprofit research group, found questionable justification for at least 2 5 percent of those hysterectomies and no justification at all for at least another 16 percent. Little has changed since then. (Thus, 41% of the operations shouldn’t have been done when they were.  Consequently many of the women would otherwise never had been operated upon--jk)

Hysterectomy creates scar tissue that can eventually cause intestinal obstruction. Loss of the uterus -- and of the cervix, which is often removed as well -- can reduce sexual pleasure. Further, surgeons remove the ovaries in roughly half of all hysterectomies. The ovaries are a woman's main source of the female hormone estrogen and of male androgens. After removal of a premenopausal woman's ovaries, the loss of estrogen triggers premature menopausal symptoms and clearly increases the risk of coronary disease and osteoporosis. After removal of any woman's ovaries, the loss of androgens may compound the reduction of sexual pleasure by reducing sexual desire.  (In women the loss of androgen secretion causes a decrease in sexual hair, but not for many years.  Testosterone replacement in androgen-deficient women will improve their libido, energy, muscle mass and strength, and bone mineral density.  Chapter 59 of Goodman & Gilman’s classic Pharmacology Textbook—jk.)

The conditions that most often lead to hysterectomy include fibroids, or benign uterine tumors; endometriosis, or abnormal proliferation of the uterine lining; uterine prolapse, or displacement of the uterus down into the vagina; and dysfunctional uterine

bleeding, or profuse or irregular menstruation. There are treatments for each of those conditions that can often make surgery unnecessary: anti-estrogen therapy for fibroids (or just waiting for menopause, when estrogen levels naturally dwindle), drugs for endometriosis; insertion of a removable device for prolapse; and hormone therapy or elimination of the uterine lining for dysfunctional bleeding.

If you do need a hysterectomy, you generally should not have your ovaries removed unless you have ovarian or cervical cancer. (However, a hysterectomy candidate whose mother or sister had ovarian cancer may want to discuss the option of preventive removal of the ovaries with her doctor and possibly with a genetics specialist.) Further, find out whether you're a candidate for a "supracervical" or a vaginal hysterectomy; the supracervical approach preserves the cervix, and both approaches are less invasive than the traditional open abdominal procedure.

Cesarean Section

The most common type of major surgery is an abdominal "C-section," performed in some 20 percent of births. That's down from a decade ago, but still well above the estimated 12 to 14 percent that are medically justified.  (40% MORE THAN IS JUSTIFIED—JK.)

Most cesarean sections are done because labor is progressing too slowly. But a number of less invasive approaches -- medication, deliberate rupture of the membranes surrounding the fetus, even massage or a warm shower -- may be enough to stimulate labor. Hospitals that adopt such steps have cut their rate of C-sections in half.

Doctors perform cesareans in about three-fourths of women who previously had the procedure. But 90% of those women could safely try for a vaginal delivery, and 75% of those who try would succeed. The rest simply switch to cesarean delivery when the vaginal attempt fails.

Continuous electronic monitoring of the fetal heartbeat, used in nearly three-fourths of all births, is actually part of the problem. It triples the chance of having a cesarean, by picking up worrisome signs that are often normal. Continuous monitoring does not protect the infant any better than intermittent electronic or even old-fashioned stethoscopic monitoring.

To avoid an unnecessary cesarean, find out what percentage of normal births, or births following a cesarean, your obstetrician delivers by cesarean. In general, look for rates below 15% for first deliveries, 25% for repeat deliveries. (However, those figures can be higher if the obstetrician treats many high-risk patients.) Ask about the doctor's willingness to try nonsurgical steps first. And consider delivery in a hospital by a certified nurse-midwife. The midwife has access to an obstetrician, who can perform a cesarean, if necessary. But deliveries managed by a nurse-midwife are far less likely to require the operation than those managed by an obstetrician and midwives' results are typically just as good.

Note that many obstetricians also routinely perform episiotomy -- cutting the skin and muscles in and around the lower vaginal wall -- to ease delivery and prevent skin or muscle tears. But that actually causes a larger number of serious tears than it prevents. So let your obstetrician know that you want to avoid episiotomy unless it's essential to speed delivery.

Surgery for Sleep Apnea

Snoring is usually caused by an intermittent obstruction at the back of the throat. In severe cases, called sleep apnea, airflow to the lungs is completely blocked for up to 90 seconds at a time. The resulting oxygen deprivation increases the risk of hypertension, coronary heart disease, and stroke.

Some throat surgeons and even dentists use a new laser technique to bum away the obstructing tissue in patients with possible sleep apnea. But the vast majority of apnea patients can be helped by steps such as trying not to sleep on their back, or by wearing a forced-air mask at night. If all else fails, conventional surgery -- including tissue removal and possibly jaw realignment -- can increase air intake and ease the apnea. But while laser surgery may reduce snoring, it does not significantly improve airflow or apnea.

If you're concerned about possible apnea, consult a sleep specialist. You'll get a definitive diagnosis, and you generally won't be pressured to undergo laser surgery for the condition. (For more on sleep apnea, see our May 1997 issue.)

Surgery for Jaw Pain

Millions of people suffer from muscle or joint pain in the jaw, often caused by tense muscles, clenching or grinding the teeth, or chewing too hard. Some dentists prematurely prescribe aggressive, costly treatments to realign the teeth or jaws, including braces, caps and crowns, deliberately grinding down the teeth, and jaw surgery.

But those steps, particularly surgery, are seldom necessary and often ineffective; they should be reserved for intractable cases where there's a clear-cut structural or mechanical problem. Instead, treatment for jaw pain should usually involve some or all of these strategies: analgesic drugs, moist heat or ice packs, physical therapy, exercise and relaxation techniques (to case stress), behavior-modification methods, and a plastic bite plate worn at night.

Summing Up

In general, avoid surgery unless the problem threatens your health or disrupts your activities, other treatments have failed, other causes have been ruled out, tests show that surgery should help, and there's little hope of spontaneous improvement. And get a second opinion if you have the slightest doubt about whether you need the procedure.

Before undergoing any operation, ask your doctor or the surgeon these questions:

• What will happen if I decline or postpone surgery? Will the disorder tend to worsen, stay the same, or possibly improve?
• Are there nonsurgical or less aggressive surgical alternatives? If so, how do the risks and efficacy compare with those of the contemplated operation?
• What are the chances of recurrence, failure, and complications of the surgery?

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