Monday, November 13, 2017

Useless general surgical interventions that should no longer be done

England’s National Health Service (NHS) could save €153 million [$178 million USD] per year by scrapping 71 low-value general surgery practices says a recently published paper in the British Journal of Surgery.

The authors, from Imperial College London, extensively reviewed the literature and Choosing Wisely recommendations from a number of countries.

I agree with many of the 71 including performing a cholecystectomy during the first admission for a patient with symptomatic gallstones instead of waiting for another admission (saving more than €54 million) and not repairing minimally symptomatic inguinal hernias, which they estimate would save over €32 million.

The Telegraph reported, “The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’” This probably wouldn’t fly here in the US, because—like guns—too many robots are already in the hands of users.

Some low-cost but high-frequency interventions I agree should be dumped include use of mechanical bowel preparation before surgery, single-dose antibiotics for hernia surgery, and not using a drain after elective laparoscopic cholecystectomy which very few surgeons in the US do.

I was happy to see that they did not endorse the use of antibiotics instead of surgery for treating appendicitis.

But I was not happy with some of their other suggestions.

Their recommendation to save €4.3 million by eliminating CT scans for the diagnosis of appendicitis saving is misguided. They claim the percentage of negative appendectomies after CT diagnosis is similar to that seen with clinical judgment or ultrasound, but they apparently overlooked a study from the Netherlands which found quite the opposite.

It compared a sample of appendectomy patients from both countries. Only 32.8% of UK patients had preoperative imaging vs. 99.5% of patients in the Netherlands, and the rate of removing a normal appendix was 20.6% in the UK and 3.2% in the Netherlands. The latter figure is what most recently published studies of CT scanning for diagnosing appendicitis have found.

Ultrasound may not be available in all hospitals 24 hours per day, and its accuracy depends on the skill of the operator. Ultrasound is accurate when an inflamed appendix is found. An ultrasound that does not identify the appendix must be followed with another imaging study—usually a CT scan—which adds to the cost. As radiologist Saurabh Jha and I discussed in a 2016 blog post, the fear of radiation-induced cancer from CT scans may be overstated.

The Imperial College authors also recommended doing away with the use of facemasks in the operating room which would save a mere €173,000 per year. Citing a 2014 Cochrane review, they said, “There is a lack of substantial evidence to support claims that facemasks protect either patient or surgeon from infectious contamination.”

That review involved only three studies of questionable quality because of faulty randomization, bias, short or unknown duration of follow-up, and lack of criteria for defining surgical site infections.

The Cochrane authors concluded “From the limited results it is unclear whether the wearing of surgical face masks by members of the surgical team has any impact on surgical wound infection rates for patients undergoing clean surgery.”

No evidence exists that wearing a facemask protects the OR staff, but I was always glad I wore one especially when a resident [of course] cut a vessel and blood squirted in my face.

CORRECTION on 11/13/17: At the suggestion of radiology fellow @JosephMullineux, the first sentence of the last paragraph about ultrasound was amended by eliminating a phrase that implied a normal ultrasound was not useful in ruling out appendicitis.
2 minutes ago

17 comments:

artiger said...

I was unable to view the whole article, so humor me if you would please. Is the use of drains after elective lap cholecystectomy a common practice in the UK? Also, the abstract mentioned routine endoscopy for CT confirmed diverticulitis. That means well after the acute episode, right? As for single dose antibiotics preop for hernias, well, you know there are those quality measures.

gretchen kromer's blog said...

Because of accidents like the one you experienced, most dentists wear masks these days. Health care workers don't need unnecessary exposure to HIV, hepatitis, and who knows what else?

Skeptical Scalpel said...

Good point. My dental hygienist and dentist wear masks when near my mouth.

Skeptical Scalpel said...

Artiger, I can only guess that placing a drain after elective cholecystectomy, which we stopped doing in the US about 40 years ago, is still being done in England.

I also assume that colonoscopy after a diagnosis of sigmoid diverticulitis is not done for 4-6 weeks.

Ah, yes. Prophylactic antibiotics. Got to follow the rules.

Korhomme said...

Artiger, Skepto: I never used a drain for a lap chole, and I don't know anyone here who routinely does. I stopped using drains for open choles well over 30 years ago, though I'm aware that others in N Ireland didn't.

Skeptical Scalpel said...

I hope we hear from some UK surgeons on this point.

William Reichert said...

There is a lot of lower hanging fruit to pick than this.
I had a heart echo for palpitations and the tech scanned my GB which reveled stones. I was asymptomatic. When I left the the procedure and walked back to my office a surgeon stopped me and asked when I wanted to schedule my cholecystectomy .
A patient was recovering nicely from a PE and the pulmonary consultant came by and ordered an IVC filter to prevent recurrence.
A friend of mine went for an annual physical, feeling well.
The exam and "a bunch of" lab tests were normal and the doc ordered a liver, spleen and kidney ultrasound to "see how they were doing" .

Skeptical Scalpel said...

William, I enjoyed the stories. Thanks.

Kor, after thinking about it, I remember I stopped draining elective cholecystectomies in 1978.

artiger said...

Reichert, that sounds like a HIPAA violation on the part of the surgeon, and maybe someone in the radiology department.

Speaking of useless measures, I've just been asked to consult on an almost 100 year old patient with abdominal distension. The volume depletion, potassium of 7.1, sodium of 129, ongoing pneumonia, diabetes, and plain advanced age could perhaps explain this?

Anonymous said...

Hi all,

from the few UK hospitals I have worked in there is no routine use of drains in true elective cholecystectomies.

Regarding diverticular disease the general recommendation is sigmoidoscopy in the UK and that happens more than 6 weeks after the initial presentation. This, we are told, is to allow for the inflammation to settle and reduce the risk of perforation but also acquire better images.

Skeptical Scalpel said...

Artiger, we have all had those types of consults. And they are supposedly the "cognitive" doctors.

Anon, my 24-hour unscientific Twitter poll directed at UK surgeons confirms your observation. 75% of the 87 respondents said they almost never drain elective cholecystectomies

lp said...

The NHS budget is 124B and they are talking about all these changes to potentially save 153M?? Lol. I would still recommend lap chole for anyone with symptoms. And I think studies have shown that most symptomatic inguinal hernias eventually get fixed.

Blacksails said...

The modern data supports combined mechanical/antibiotic bowel prep...

artiger said...

Agreed, Blacksails, but was the study referring to the prep for all abdominal surgeries, or just colorectal procedures?

Skeptical Scalpel said...

Blacksails and Artiger, the paper was referring to mechanical bowel preparation for all types of surgery including colon and rectal. One of their references is from the 2016 National Institute for Health and Care Excellence (NICE) guidelines [] which state in section 1.2.8 "Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection."

The other is from a 2011 Cochrane review [https://www.ncbi.nlm.nih.gov/pubmed/21901677] which states “Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas.”

Blacksails, if you have references to the contrary, please let us know.

artiger said...

Scalpel, I did notice this:

https://www.doximity.com/doc_news/v2/entries/1900917

but it seems like I've seen conflicting evidence on this matter.

Skeptical Scalpel said...

artiger, I am not a big fan of NSQIP studies. They are all retrospective and do not include all patients who might have had colorectal surgery for example.

Cochrane reviews usually look at all relevant randomized trials.

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