Sizing Up Surgery

Thousands of Americans face surgery each year, often with fear and doubts about whether the right step is being taken. And not knowing what's involved may mean putting yourself through as much grief as the procedure intends to do away with. Whether you are undergoing surgery for the first time or the tenth, understanding why you need it, the risks involved, available alternative treatments, and the aftereffects will help you make the right decisions and deal effectively with the outcome.

The Value of a Second Opinion -- Is Surgery Necessary?

The practice of medicine is not an exact science and, consequently, physicians do not always agree. This does not mean they are incompetent or unconcerned about their patients' well-being. It simply means there can be differences of opinion about the best way to treat a medical condition. A second opinion is a time-honored practice in the medical profession that public health authorities believe better enables people to weigh the benefits and risks of surgery against possible alternatives to surgery.

In the case of a middle-aged patient with gallstones, for example, Betsy Ballard, M.D., a surgeon in Silver Spring, MD, explains that the initial recommendation for surgery might be made based on the premise that someone that age would not be satisfied with spending remaining years on the strict diet needed to manage the disease. There also might be the danger of a recurrence or complications, such as pancreatitis, if the dietary restrictions did not successfully treat the disease. A second opinion, however, might reveal that the patient for whom surgery poses a risk or who refuses surgery would be a candidate for medicines or other procedures that can dissolve gallstones. In either case, a second opinion helps the patient make an informed decision about the best treatment for his or her condition.

Arno Albert Roscher, M.D., a clinical professor of pathology who specializes in diagnosing cancer at the Granada Hills Community Hospital in California, says that, like patients, health professionals often find it necessary to seek additional viewpoints as well. For example, some forms of cancer pose controversy for even the most skilled professionals in the field.

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"A certified pathologist can generally identify 85 percent of regular tumors," Roscher says, "but if there is a glandular difference, tumors are difficult to diagnose and often require second and sometimes third opinions." He adds that even with the small number of unrecognizable tissue growths, specialists need the availability of additional resources to confirm or dispute their findings and recommendations, such as through the California Tumor Tissue Registry, a network of qualified professionals that was created for such specialized second opinions.

There are, however, instances when emergency surgery is necessary in order to sustain life, such as when the diagnosis of acute appendicitis is firmly made. In this case, surgery must be done quickly and efficiently, and would not warrant a second opinion.

Routine Tests

The practice of ordering routine laboratory tests before admission for surgery is commonplace in most hospitals. Many doctors believe that urinalysis, chest x-rays, or complete blood counts, for example, can identify potential problems that might complicate the surgery if not detected and treated early. Some tests commonly performed before surgery and the symptoms that prompt doctors to order them are:

Patients facing surgery need to discuss with their doctors the necessity of having certain tests performed prior to surgery, says Mary Pat Couig, R.N., Associate Director for Nursing Affairs at the Food and Drug Administration.

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'Going Under'

Anesthesia is the art and science of relieving pain and keeping patients safe and stable during surgery. But for patients already nervous about their impending surgery, the idea of being unconscious may not be a comforting thought, especially if it's coupled with the fear of not regaining consciousness.

According to L. Melvin Elting, former Chief of Surgery at Riverdell Hospital in New Jersey, and Seymour Isenberg of the Kansas City College of Osteopathy and Surgery, authors of The Consumer's Guide to Successful Surgery, although many people associate anesthesia with regular sleeping, slumber is only a side effect. If you were to go to sleep and surgery began, you'd wake up in a hurry. While sleep involves a dousing of the highest brain recognition centers derived from the senses, it would take only a mild stimulus to peak them to alarm.

The unconsciousness or "deep sleep" required for surgery is another matter. The deep sleep that is required for loss of sensation of pain occurs in stages, beginning with a gradual dozing off to an eventual drifting into paralysis so that the nerve responses are dampened. Unconsciousness must then be maintained during surgery so that patients are not aware of their surroundings and do not experience pain.

Problems traditionally associated with anesthesia such as drug hangover, nausea, and awareness have been lessened over the years by better drugs, improved monitoring, and specialized training.

Waking to a Nightmare

Although it is rare, some patients have reported "awareness" or experiencing sensations while under anesthesia. Those patients say they recall hearing snatches of conversations, being aware of movement, and feeling pain. But whether this awareness really occurs or is just the subconscious mind playing tricks that come back to haunt the conscious mind has been subject to a lot of debate in the medical community. According to Elting and Isenberg, when the anesthesia is weak, or the depth of unconsciousness is purposely held shallow, the subconscious may provide its own interpretations of what is happening and those interpretations may not necessarily be accurate.

But whether or not awareness is real, anesthesiologists are always on the lookout for indications of "light" anesthesia, such as sweating or involuntary twitching. In these cases, says Brenda Hayden, R.N., an interdisciplinary scientist with FDA's Center for Devices and Radiological Health, the anesthesiologist would increase the anesthesia to put the patient in a deeper state of unconsciousness.

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Hospital Infections

According to the national Centers for Disease Control and Prevention, approximately 2 million people a year contract infections during a hospital stay, and nearly 90,000 die as the result. Urinary tract infections, surgical wound infections, pneumonia, and bloodstream infections annually are the most common hospital-acquired infections. Of those, pneumonia and bloodstream infections cause the most deaths (about 34,000 and 25,000 respectively; infections from surgical wounds cause about 11,000 deaths, and urinary tract infections 9,000). Those numbers would be far greater, CDC says, without infection-control programs that have been required for hospital accreditation since 1976. In fact, according to a recent CDC survey of 265 hospitals nationwide, without these programs, there would have been 50 to 70 percent more infections and deaths.

Hand washing is the single most important procedure for preventing hospital-acquired infections, according to CDC. Patients and their families should ask their health-care workers to follow good hand washing practices, and bring it to their attention when they do not. In addition, health-care professionals need to follow CDC guidelines and recommendations on the use of intravenous lines and other medical devices, and the proper use and administration of antibiotics.

Patients should alert their physicians or nurses who are providing them care, or hospital administrators, if they have concerns about their health-care workers' practices. All states have licensing and oversight bodies in their state health departments that respond to concerns and complaints brought by patients.

Patients should always provide their doctors with a complete health history, including:

  • other medications (some drugs may increase the risk for infection)
  • infections
  • recent exposure to people or animals who might have infectious diseases
  • travel to areas with high rates of infectious diseases.

If you become more ill after arriving home from a hospital stay and develop unexpected symptoms such as pain, chills, fever, discharge, or increased inflammation of a surgical wound, you should alert your doctor.

What's New in the Operating Room?

The following is a list of some of the latest advances available in surgical patient care:

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Bispectral Index (BIS)

The BIS monitoring system was first cleared by FDA in October 1996 to monitor the state of the brain in the intensive-care unit, the operating room, and for clinical research. The system, which includes an enhanced electroencephalogram (EEG) monitor, analyzes a patient's brain wave pattern and converts it into a "depth of sedation" number between 0 (indicating no brain activity) and 100 (fully awake).

It's a popular belief that anesthesiologists use the device to reduce or prevent "awareness" during surgery. But FDA's Center for Devices and Radiological Health says the device has not been approved or labeled for monitoring to reduce awareness. It is intended only to monitor the state of the brain.

Scopolamine Patch

FDA initially approved the scopolamine patch, distributed under the brand name Transderm Scop by Novartis Consumer Health in New Jersey and manufactured by ALZA Corporation of Palo Alto, CA, in December 1979 as a prescription drug to prevent nausea and vomiting associated with motion sickness. Following the manufacturer's removal of the product from the marketplace in 1994 due to manufacturing problems, FDA approved the drug again on Oct. 27, 1997, for the additional indication of preventing nausea and vomiting during or after surgery.

The small, Band-Aid-like patch is placed behind the ear the night before surgery, or an hour before a Caesarean section. The medication in the patch goes through the skin directly into the bloodstream. It is not to be worn for more than three days, and is intended for a single use only.

Remifentanil

Approved by FDA in July 1996, remifentanil, marketed as Ultiva and manufactured by Glaxo Wellcome of North Carolina, is an analgesic for inducing and maintaining general anesthesia for surgery. It safely breaks down in the bloodstream and body tissues within minutes. Unlike other drugs that must be metabolized or broken down by the liver and kidneys, remifentanil gets broken down by enzymes in the blood and muscles. This means that the drug has a half-life of three to six minutes in the body, compared to 90 minutes or more for other drugs. That, in turn, results in the patient waking up and having the breathing tube removed considerably sooner.

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Fibrin Sealants

A new class of blood-derived fibrin sealants, distributed by Baxter Healthcare Corporation, can stop oozing from small, sometimes inaccessible, blood vessels during surgery when conventional surgical techniques are not feasible. FDA approved the first of these sealants in May. The main active ingredient of fibrin sealants is fibrinogen, a protein from human blood that forms a clot when combined with thrombin -- another blood protein that helps blood clot. The sealants, which form a flexible material over the oozing blood vessel, can often control bleeding within five minutes.

Questions to Ask Your Doctor Before You Have Surgery

The Agency for Health Care Policy and Research recommends you ask your physician the following types of questions before having surgery. The answers to these questions will help you be informed and make the best decision about whether to have surgery, by whom, where, and when. Patients who are well-informed about their treatment, according to the agency, are usually more satisfied with the outcome and results.

1. Why Do I Need the Operation?

There are many reasons to have surgery. Some operations can relieve or prevent pain, others can reduce the symptom of a problem or improve some body function, and some surgeries are performed to diagnose a problem. Surgery can also save your life. When your surgeon tells you the purpose of the procedure, make certain you understand how the recommended operation fits in with the diagnosis of your medical condition.

2. Are There Alternatives to Surgery?

Sometimes surgery is not the only answer to a medical problem. Medicines or other nonsurgical treatments might help you just as well or more. Always ask your doctor or surgeon about other possible choices.

3. What Are the Benefits of Having the Operation?

Ask your surgeon what you will gain by having the operation. For example, hip replacement may mean that you can walk again with ease. Ask how long the benefits are likely to last. For some procedures, it is not unusual for the benefits to last for a short time only. There might be a need for a second operation at a later date. For other procedures, the benefits may last a lifetime. Be realistic. Some patients expect too much and are disappointed with the results.

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4. What Are the Risks of Having the Operation?

All surgery carries some risk. This is why you need to weigh the benefits of having the operation against the risk of complications or side effects. There is almost always some pain with surgery. Ask how much you can expect and what the health-care providers will do to reduce pain.

5. What If I Don't Have This Operation?

Based on what you learn about the benefits and risks of the operation, you might decide not to have it. But you must also decide what the likely outcome will be for the condition -- it could stay the same, continuing to cause pain, it could get worse, or it could clear up on its own -- if you choose not to have the surgery.

6. What Is Your Experience in Performing This Surgery?

One way to reduce the risks of surgery is to choose a surgeon who has been thoroughly trained in the procedure you are considering. Besides asking the surgeon directly, you can also ask your primary-care physician about the surgeon's qualifications.

7. What Kind of Anesthesia Will I Need?

Your surgeon can tell you whether the operation calls for local anesthesia (a numbing of only a part of the body for a short time), regional anesthesia (a numbing of a larger portion of the body for a few hours), or general anesthesia (a numbing of the entire body for the entire time of the surgery) and why this form of anesthesia is recommended for your procedure. Ask what the side effects and risks of having anesthesia are in your case. Be sure to mention any medical problems you have, including allergies, and any medications you have been taking, since they may affect your response to the anesthesia.

Hospital-Acquired Infections

Number of life-threatening infections acquired annually in hospitals and nursing facilities:

Urinary tract -- 566,000

Surgical wounds -- 293,000

Pneumonia -- 274,000

Bloodstream -- 236,000

Deaths from these infections:

Pneumonia -- 34,000

Bloodstream -- 25,000

Surgical wounds -- 11,000

Urinary tract -- 9,000

WebMD Public Information from the FDA

Sources

Source: Centers for Disease Control and Prevention

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