
Confessions of a Sydney surgeon: why your operation may not work - yetanotheracc
http://www.smh.com.au/nsw/confessions-of-a-sydney-surgeon-why-your-operation-may-not-work-20160302-gn95ya.html
======
analog31
_Appendectomy: The possibility of dying from a ruptured appendix is enough for
surgeons to recommend this procedure but several studies have shown that
antibiotics alone are also effective. The recurrence rate is higher with
antibiotics, but the surgical complications are lower._

I can think of a reason why the recurrence rate for appendectomy is lower than
for antibiotics. ;-)

~~~
sandworm101
Much probably turns on the progression of the disease at the point of
diagnosis. An infection only detected as an elevated white cell count in a
clinic, without any localized pain/swelling, may be treatable with
antibiotics. And that is probably safer than the knife. But an ER patient
howling in pain with an appendix swollen and about to burst is no candidate
for pills.

~~~
et2o
This is a pretty stupid example imo, it isn't really workable in practice. You
can die from a ruptured appendix and the surgery isn't terribly involved.
Whereas people come in constantly with elevated WBCs; it'd require a high
index of suspicion to treat for appendicitis with antibiotics in every
circumstance. You would probably end up doing more harm than good that way
because antibiotics are not benign drugs.

~~~
sandworm101
The WBC count would only be some evidence. I presume some sort of ultrasound
could localize the infection in the appendix.

I imagine there are some people for whom surgery isn't an option. I'm not sure
what that condition might be given the routine nature of the procedure, but
they might be out there.

~~~
et2o
I'm sorry, I shouldn't have called it stupid, that was needlessly
inflammatory.

Basically my point is that most people where you could diagnose appendicitis
from elevated WBCs followed by ultrasound will probably not be in the hospital
or clinic or ED in the first place. The reason this is a surgical emergency is
because the symptoms are of rapid onset. Thus, elevated WBCs are of limited
utility. Furthermore, because appendicitis is an emergency, ultrasound is not
the preferred imaging modality–CT scans are used instead, which are relatively
more expensive and expose patients to ionizing radiation.

You can choose to treat patients with antibiotics (and they've done studies),
but generally over 50% of patients managed initially with antibiotics will
ultimately require surgery anyway within 48 hours, and of the <50% that don't,
there is a relatively high recurrence rate that will ultimately also require
surgery. Given that appendectomy has a very low morbidity and mortality, this
is one of the surgeries that are harder to argue against in my opinion.

From my reading of Uptodate, experts in the field feel similarly; after
performing a cost/benefit analysis, initial management with antibiotics is
indicated only for patients who cannot undergo surgery.

------
sp332
There was a study where knee surgeons just made an incision in the skin and
told the patient the procedure was done. The result was about the same rate of
success, and a lot less risk of complications. I can't find a date on this
article but it's at least from 2010 if not older.
[http://abcnews.go.com/Health/story?id=116879&page=1](http://abcnews.go.com/Health/story?id=116879&page=1)

~~~
vitd
Isn't it unethical to lie to a patient? Isn't that grounds for a malpractice
suit?

~~~
felipemora
As part of a study? No. This is how studies are done. Give one set of people
the real medicine and another people the fake one and see what happens. They
are told before hand that they could receive the fake medicine/treatment and
they must agree to the study.

------
ryanmarsh
A couple of years ago I slipped (herniated) two lumbar disks. Both of the
surgeons I consulted begged me NOT to get surgery (one with tears in his
eyes). I'm ever so grateful that there are surgeons out there who will push
back. Contrast that with when I went to an orthopedic specialist about knee
pain from running. In less than two minutes of consultation he told me he
wanted to _snip_ my tight IT bands. My jaw was on the floor. I was nothing but
meat and a paycheck.

Thankfully acupuncture has given me back the ability to sit/run/lift/stand.
I'm so grateful I didn't get surgery in either case.

~~~
sosuke
Acupuncture, there has been so much FUD spread about alternative medicine that
I have no idea what to trust anymore. It isn't even covered by most insurance.

What is real, who to trust.

~~~
DanBC
You can look at sites like the Cochrane Collaboration or NICE.

Cochrane provide meta-analysis of various treatments. The meta review include
a good summary of the paper. Here's their list of stuff about acupuncture:
[http://www.cochrane.org/search/site/acupuncture](http://www.cochrane.org/search/site/acupuncture)

NICE reviews evidence of safety and efficacy to try to decide if the English
NHS should offer (and thus pay for) a treatment. Nice will sometimes say "do
this", sometimes they'll say "we don't have enough evidence to say either
way", and sometimes they'll say "do not do". If they recommend to not do
something it's because they have plenty of evidence of harm. Here's their list
of stuff about acupuncture (a lot of which is of the "do not do"
recommendation):
[http://www.nice.org.uk/search?q=acupucture](http://www.nice.org.uk/search?q=acupucture)

England is also introducing "personal health budgets" for people with long
term conditions. This is a small pot of money that the patient can spend
pretty much how they wish (not on debt, gambling, alcohol, tobacco, or
anything illegal) so long as they can persuade a panel. This could include
homeopathy or acupuncture. For example: Imagine a person who is frequently and
severely self-harming. (They attend emergency department every week, and
they're usually admitted from ED into hospital for surgery.) This person may
feel that a joining a 5-a-side soccer club and getting acupuncture would help
reduce either the frequency or severity of their self harm.
[http://www.nhs.uk/choiceintheNHS/Yourchoices/personal-
health...](http://www.nhs.uk/choiceintheNHS/Yourchoices/personal-health-
budgets/Pages/about-personal-health-budgets.aspx)
[https://www.england.nhs.uk/healthbudgets/](https://www.england.nhs.uk/healthbudgets/)

~~~
raverbashing
The NICE results are interesting:

"Do not use acupuncture to treat hyperbilirubinaemia", "Do not offer
acupuncture for treating lower urinary tract symptoms (LUTS) in men.",
"Acupuncture is not recommended for the management of otitis media with
effusion (OME)."

But it is an option for low back pain
[https://www.nice.org.uk/guidance/cg88/chapter/1-guidance](https://www.nice.org.uk/guidance/cg88/chapter/1-guidance)

------
fpoling
This is no limited to Australia. I know a person in Russia who consulted 3 or
4 surgeons regarding her foot problem. The advise was always to perform a
complex operation that would leave her with crutches for at least 3 months.

Finally somebody recommended another doctor. His advise was to make a hole in
shoe insole around problematic area and see how things go. Then 9 months later
she spent a month at sea and that mostly cured the problem.

------
jlg23
> "But the decision to operate should be based on the best science, not on the
> worst-case scenario. If the best evidence tells us that a procedure is not
> effective, or that the benefits are outweighed by the risks for some
> patients, then it should not be done."

As long as patients can sue their doctor, no sane doctor will do less than
what the patient wants if there is a remote chance the procedure is slightly
more effective. A simple but prominent example is the prescription of a
generic drug versus the "original". Science tells us that there is absolute no
difference. Now you tell the patient - the same patient who feels a very real,
"objective" decrease in pain when being injected a saline solution instead of
steroids.

And last but not least: the "best science" does not help us if doctors don't
know about it. And some treatments are so weird that a doctor won't even
consider it. Three anecdotes on that from my last 2 years:

1) British guy with pain in his knee. His doctor has been urging him to
operate for years now. But he works in Nigeria on a oil drilling project in a
good position and rather would prefer to wait the few years until he retires.
The local "joujou"-man told him to rub python fat into his knee. It works for
him! He told his doctor in the UK who dismissed that and told him that he
might get into trouble for repeatedly rejecting sound medical advice. Shortly
after I meet this guy in the Caribbean on his holiday, he tells me that story,
I am skeptical and do some googling: 5 Minutes later I find a scientific study
that proved that python fat is indeed a very good treatment for his condition.
He mailed that to his doctor who read it and now leaves him alone. Snake oil,
anyone?

2) Sahrawi ecologist with kidney stones but without the money to pay for the
medical procedure to have them removed. He turns to local folk medicine, for a
week he drinks a concoction that makes the stones break up and he can pass
them naturally pretty much without pain. His doctor in Rabat speaks of a
"miracle".

3) Business man in Casablanca was told by his doctor that he either needs
surgery on his knee or he should try the traditional desert treatment:
Undress, get buried in hot sand, 30 minutes later get into a tent, firmly
wrapped. Repeat for 3 days. When I met him he was on his way back from his 5th
treatment - he says he does it every 2 years and thereby has avoided surgery
for 10 years.

~~~
justinclift
As a data point, one of the problems with generics is the falsely made ones.

There have been (unfortunately) large pharma companies over the years who
manufacture generics, which are later found out to be not even close to
manufacturing the real thing, or whose manufacturing processes are extremely
unsafe.

Ranbaxy and GVK Biosciences are examples that spring to mind from not too long
ago. There may have been others since. :(

------
pasbesoin
A few personal experiences, and the stories of many family and friends, have
left me with the strong opinion that surgery is a very reluctant, last resort.

Not my worst experiences, but two similar injuries left me with very differing
experiences, as comparative examples. In the first one, the doctor wanted to
get me into (arthroscopic, fortunately) surgery right away, without even doing
an MRI. In the second, a different doctor said that, even if surgery were
eventually warranted/needed, the condition had left me too weak to be a good
surgical candidate. So, see a PT and work and strength-building, and see how I
tolerated it.

The first doctor racked up a big bill and produced no positive effect. The
second doctor saw me for one visit, got me to a good PT / rehab program, and
helped me make a full recovery.

Anecdote, sure. But, combined with some other singular, not positive
experiences: I'll go under the knife only when I have no other choice.

------
na85
What a lot of people seem to overlook is that, in the developed world, you
have a 1% chance of death every time you go under general anesthesia.

~~~
AznHisoka
citation? This to me sounds incredibly high.

~~~
pgrote
It is much lower.

[http://healthland.time.com/2011/08/04/under-the-knife-
study-...](http://healthland.time.com/2011/08/04/under-the-knife-study-shows-
rising-death-rates-from-general-anesthesia/)

"People have always been afraid of general anesthesia. Many fear they won’t
wake up from this “artificial sleep” — actually more of a coma, albeit drug-
induced and reversible. In the 1940s, for every one million patients operated
on under full anesthesia, 640 died. By the end of the 1980s, fatalities were
down to four per every million, thanks to modern safety standards and better
medical training. However, a recent article published in the Deutsches
Ärzteblatt, the German Medical Association’s official international science
journal, shows that after decades of decline, the worldwide death rate during
full anesthesia is back on the rise, to about seven patients in every million.
And the number of deaths within a year after a general anesthesia is
frighteningly high: one in 20. In the over-65 age group, it’s one in 10."

~~~
goldenkey
5% death rate within a year doesnt sound lower..sounds significantly worse.

~~~
ceejayoz
Death rate within a year is a really odd stat to couple with anesthesia. If
you die six months after an operation, it's probably not the sedation.

------
jensen123
Caldwell Esselstyn has proven that it's possible to cure heart disease such as
angina with a low-fat, plant-based diet. He's written a book about this 20
year study: Prevent and Reverse Heart Disease: The Revolutionary,
Scientifically Proven, Nutrition-Based Cure.

I find it interesting that most doctors are continuing to recommend things
like cardiac stenting. Maybe it's money? I wonder if they even mention diet to
their patients? Or is it the patients that are the problem - even if doctors
mention diet, do many patients continue to eat unhealthy?

~~~
chris_wot
I don't disagree that diet is important in reducing heart disease (and a lot
of other things besides) but I'd be very cautious before listening to someone
who claims he has a "revolutionary" cure.

In the case of Caldwell Esselstyn, a quick Google search took me to my
favourite skeptic blog: Science Based Medicine:

[https://www.sciencebasedmedicine.org/bill-clintons-
diet/](https://www.sciencebasedmedicine.org/bill-clintons-diet/)

Get about halfway down. I remain skeptical!

