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, 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.

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. Some tumors may be hard to diagnose, and a second or even a third opinion might be needed. Though these hard to diagnose tumors are rare, doctors need additional resources to confirm or dispute their findings and recommendations, such as through tumor registries, which are available 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 should talk to their doctors about what tests they need to have before surgery.

'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.

Questions to Ask Your Doctor Before You Have Surgery

The US Agency for Health Care Policy and Research (AHCPR) 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.

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.