Confessions of a Sydney surgeon: why your operation may not work
smh.com.auAppendectomy: 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. ;-)
I was with the article until this statement... Appendicitis is a medical emergency and suggesting you can just take antibiotics and it'll go away, or that antibiotics (a group of medicines with their own problems) are preferable to an established and very effective treatment feels irresponsible to me. Even if that's true, if you are experiencing appendicitis you NEED to talk to a doctor and you likely NEED to consider surgery.
Sorry but I trust a surgeon's opinion, especially one who is willing to step forward publicly and challenge the status quo at risk of their reputation, far more than some random internet user.
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.
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.
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.
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.
Yes, but the recurrence rate will be lower if you get an appendectomy.
lol! I just emailed the reporter.
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
Wouldn't they have to do a bit more, to induce pain, swelling, soreness and such, for the patient to think surgery on their knee had actually been performed?
Isn't it unethical to lie to a patient? Isn't that grounds for a malpractice suit?
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.
Not if they agreed to be part of a study. Otherwise, no one could use a placebo.
In a study, patients aren't lied to exactly; they're told their either going to receive a real treatment or a phony one, but they won't know which.
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.
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.
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
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
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... https://www.england.nhs.uk/healthbudgets/
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
Acupuncture is a very effective placebo (because you can really feel it working). There's a whole complex theory about points all over the body which affect ailments in different parts of the body, also based on personality type, but (of course!) none of it matters. Carefully poke someone with needles anywhere (and pretend there's some meaning behind the placement) and the effect is the same.
The big give-away that a treatment is just a convincing placebo is that it claims to help with everything.
> Carefully poke someone with needles anywhere (and pretend there's some meaning behind the placement) and the effect is the same.
Citation needed.
http://www.ncbi.nlm.nih.gov/pubmed/19250001
"Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials"
I tried accupuncture last, I should have tried it first. I love how western medicine calls any mechanism it doesn't understand "placebo" (reference to child comment) or "psychosomatic". Acupuncture worked for me after I exhausted everything western medicine had to offer (short of surgery). I had serious injuries (MRI showed this). I had verified radiating nerve pain, tests showed the nerves were innervated (activated) by these injuries to the spine. Acupuncture did what steroids, gabba blockers, physical therapy, et.al. could not.
Western medicine has some amazing things to offer for serious conditions. Its really silly how most other ailments are covered by crap in the drug store. I say crap because after my wife started treating the family with essential oils, and my acupuncturist's herbal remedies I'm sick less often and recover faster. I even avoided having to have my gallbladder removed. On fucking herbs ¯\_(ツ)_/¯ Do I know why all these organic compounds and odd treatments work? Does that mean they don't? Does it mean it's all psychosomatic? sigh Maybe, just maybe people in the east figured out a system for treating many ailments. Maybe western medicine needs to zoom out from the molecule and start looking at the whole patient.
You want a lesson in the limits of western medicine? Watch your child die slowly of cancer. Losing my daughter disabused me of any fantasies of cures just around the corner. Meanwhile top doctors kept saying "we've never seen this before". Western medicine doesn't have answers for half of what people think it does. This isn't CSI. Humble out. If some herbs and acupuncture can heal people then deal with it.
I'm so sorry you lost your daughter.
Well, the fun part about acupuncture is this that all the studies that 'disprove' acupuncture are disproving very specific things. Specifically, they show that 'traditional chinese acupencture' with the whole crap about chi and meridians and whatever are not significantly different from the control treatment.
The control treatment is typically use of acupuncture needles in areas not specifically specified by codified acupuncture standards (it is a thing... you can go to school for this stuff remember), or the use of sham needles, which still penetrate by like half a inch or something.
All most of the studies you will find that both arms (control and 'real' acupuncture) both show similar improvements in outcome. A valid (and I think the right one) conclusion to draw from these studies is that while the internal logic of acupuncture doesn't do anything, the mechanical action of poking needles into the body has non-trivial benefits.
If you can't get acupuncture covered by insurance, you can look into dry needling (its mechanically the same thing...). A quick google search tells me that some states will allow chiropractors and physiotherapists to perform dry needling and may fall under different insurance buckets.
edit: sorry, I forgot to add this in. obviously poking needles into muscles won't do anything for stuff that isn't rooted in muscles/other connective tissue. Won't do shit for your asthma or allergies for example...
Trust results. For some people the best medicine is guided by some change from within. I believe that as far as positive outcomes are concerned (ruling out helpful communities and other factors) the actual reason that placebos and that any organized system of belief work for some people is the same. They want to, and believe that they will, get better; thus they do, or at least they learn to cope. It's pretty much a psychological solution.
You can talk your way out of some problems; but not all problems. Some things require physical changes driven by external (alien to the self) forces.
Acupuncture does not need even to have an effect of placebo to be helpful.
One benefits from anything that at worst can bring very little harm if it keeps the person from a surgery with a small upside at best but that can potentially bring a lot of harm through post-operational complications.
I had a herniated disc - incredibly painful and it had terrible affects on my mood and my weight as well. I found that most of the effective treatments were ones that put me in a better mental state even if they had no effect on the pain. As someone else said; trust results!
The problem is that due to the placebo effect you will never know what is real or not. That said I would suspect that a lot of alternative medicines have therepeutic benefits. We just don't know why or how.
Don't trust it, try it. If it works for you, it works. If not, try somewhere else. I've tried ayurveda, which even doesn't use needles, just some weird hippie waving with hands above me, not even touching me, and nothing else has give me so much energy back in a period when my energy was really low. I've tried acupuncture then as well, and various other alternative techniques. Most of them were very relaxing, like a day in a spa, and a day later the effect was gone.
I've tried to analyse what the therapist did, but couldn't explain it. The only - off the chart - explanation is that everything is energy, and that we have energy outside our body boundaries that can influence our well being. I'm pretty down to earth. I've met enough people who worship these alternative methods, and I don't. But if it works, it works, and I will use it.
So maybe this is not promoting acupuncture, but I'm just saying that these alternative methods can do stuff to me - but maybe not to you - and modern medicine cannot explain it. Acupuncture may work like this in another situation and for other persons.
Then there is another big thing regarding acupuncture, and that is holism, which makes the acupuncturist look at the whole picture, all your problems, qualities, strenghts and weaknesses.
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.
> "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.
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. :(
You should put that third guy in touch with the first guy.
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.
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.
citation? This to me sounds incredibly high.
It is much lower.
http://healthland.time.com/2011/08/04/under-the-knife-study-...
"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."
And probably most of those are dead from their illness, complications here of, or some other illness. You can't tell me that there are even trace amounts of the drugs used in the body 1 month after general anesthesia, much less 12.
It is one of the most "technically true" facts I have ever seen.
5% death rate within a year doesnt sound lower..sounds significantly worse.
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.
Within a year? But how many is caused directly by anesthesia?
These numbers carry a very high selection bias. At age you generally operate people who are already sick and about to die anyways. I don't know if we even have data to correct them for that to calculate the "Death rate of healthy people after anaesthesia" vs. "Death rate of healthy people of the same age group."
It is absolutely way too high. Here's a paper that puts it at about 1 per 13,000: Lagasse (2002): http://student.purduecal.edu/~jbojczuk/Research/Anesthesia%2...
It's worth noting that their data contains zero observed deaths in ASA Physical Status I Patients, which are basically healthy adults.
I would assume things have either stayed the same or improved: Sevoflurane was just starting to be used around the time that the data were taken for that paper.
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?
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/
Get about halfway down. I remain skeptical!
My anecdotal inference is that they will recommend pills and surgery more often than diet and excercise, because most people want the quick fix solution and that it is very difficult to get someone to adhere to diets and excercise.
Again anecdotally, but consider the stories from people with diabetes who still won't eat well even when their foot was just amputated due to that behaviour.
An important part of a treatment is patient compliance. Even if a treatment is 100% effective, if the patient can't or won't comply then it is useless. A 100% Plant based diet would be difficult for most people. Also it would take quite a bit of time for the diet to be effective. A stent is an immediate solution.