Sizing Up Surgery

By Carol Lewis
From the FDA Consumer Magazine November-December 1998



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.�

“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:

chest x-ray–shortness of breath, chest pain, cough, fever without other
source, abnormal sounds

electrocardiogram (EKG)–chest pain, palpitations, arrhythmia, murmur,
distant heart sound

urinalysis–frequency, hesitancy, discharge, side pain, kidney disease,
diabetes, use of drugs known to cause kidney disease

white blood count–fever, suspicion of infection, use of drugs known to
affect white blood cell counts

platelet count–blood loss, easy bruising, alcoholism, use of drugs
known to affect platelet count

glucose–excessive sweating with tremor or anxiety, muscle weakness,
diabetes, pancreatitis, cystic fibrosis, altered mental status,
alcoholism

potassium–vomiting, diarrhea, congestive heart failure, kidney failure,
muscle weakness, tissue damage, hypertension, diabetes, use of drugs
known to affect potassium levels

sodium–vomiting, diarrhea, excessive sweating, thirst or fluid intake,
pulmonary disease, central nervous system disease, congestive heart
failure, cirrhosis.

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.

‘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.

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.