Unnecessary surgery

Ferreres, Alberto R.
doi:10.1016/j.cireng.2023.11.003
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;It is simply unscientific to allege or believe that doctors do not&#44; under existing circumstances&#44; perform unnecessary operations and manufacture and prolong lucrative illnesses&#46;&#8221;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">GB Shaw</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#8220;The Doctor&#8217;s Dilemma&#58; Preface on Doctors&#8221;&#44; 1909</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Editorial Sudamericana&#44; Buenos Aires&#44; 1956&#44; p 10</p></span></p><p id="par0005" class="elsevierStylePara elsevierViewall">The proliferation of surgical procedures with debatable outcomes without the full consent of patients&#44; the growing number of legal proceedings for alleged malpractice based on weak surgical indications&#44; and the rise in health care costs have brought to the foreground the implications and consequences of unnecessary surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the topic seems to be current&#44; in 1894&#44; William Stokes&#44; former President of the Royal College of Surgeons of Ireland&#44; highlighted concepts of Ethics in Surgery regarding operations that were not very appropriate for the management of oncological pathologies and provided questionable results&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In 1908&#44; Ernest Groves&#44; a British surgeon&#44; promoted the registration of surgical interventions in order to know the number of procedures performed and their results&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Meanwhile&#44; in the USA&#44; Wetherill stimulated hospital efficiency&#44; the dissemination of Ethics&#44; and the exclusion of the inept and incompetent from clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> All of these concepts were summarized by Ernest Codman&#44; who emphasized the importance of setting standards as well as the reporting of results&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In 1922&#44; Haggard published an editorial article titled &#8220;The Unnecessary Operation&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The threat posed by unnecessary surgery was also addressed by Paul Hawley&#44; Executive Director of the American College of Surgeons&#44; when he stated that&#44; &#8220;the public would be shocked if it knew the amount of unnecessary surgery performed&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> A very recent article in the <span class="elsevierStyleItalic">New York Times</span> has once again focused on this significant problem&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and likewise another article published in <span class="elsevierStyleItalic">Forbes</span> magazine&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">For many&#44; it is a poorly defined entity&#44; but Leape and Pauly contributed to its conceptualization&#46; Surgery that is useless and ineffective is considered unnecessary surgery&#46; The subjective perspective of patients does not allow for its quantification or evaluation&#46; An unnecessary surgery is one that either does not benefit the patient or provides such minimal benefits that are far outweighed by the costs in terms of risk&#44; morbidity&#44; disability and pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Unnecessary surgery is not evaluated by its results or potential postoperative complications but must instead be analyzed from its evidence-based indication and after an informed decision by the patient&#44; who gives consent&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The interest in this topic is based on the fact that it represents a break in the ethical principles of the patient-surgeon relationship&#44; in which self-interest takes precedence over altruism&#46; Bevan highlighted that the two most serious problems facing Surgery are unnecessary surgeries and procedures performed by incompetent surgeons&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Unnecessary surgery is not evaluated based on results&#44; as complications are inherent to any surgical procedure and considering that the global postoperative complication rate can reach 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Crile made a distinction between appropriate and inappropriate procedures&#44; the latter being classified as&#58; a&#41; operations inappropriate for the disease&#59; b&#41; operations inappropriate for a given patient&#59; and c&#41; operations appropriate for the disease and the patient&#44; but performed by a surgeon who has not been adequately trained&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In 1974&#44; McCarthy presented before the US Congress the results of the First Second Opinion Program&#44; reporting 17&#46;6&#37; of indications for surgery had not been endorsed or confirmed&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Extrapolating his findings to the entire US population&#44; it could be estimated that there were&#44; at that time&#44; about 2&#46;4 million unnecessary operations performed annually&#44; resulting in an approximate cost of &#36;3&#46;9 billion and some 11&#44;900 deaths&#46; The Study on Surgical Services for the United States &#40;SOSSUS&#41; defined 6 categories of interventions&#44; which <span class="elsevierStyleItalic">a priori</span> and with no prior analysis&#44; could be considered unnecessary<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Operations in which pathological tissues are not removed</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Operations with a questionable surgical indication</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Operations to relieve tolerable or non-disabling symptoms</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Operations for asymptomatic or non-threatening disorders</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Operations considered obsolete&#44; discredited or outdated</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">f&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Operations with little or no justification based on symptoms and&#47;or complementary studies</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">This report clarifies that each category requires precise and rigorous evaluation of each case under study before judging the degree of need for the intervention&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The literature has shown evidence of this type of practice and has also demonstrated great variation in the rates of certain surgical procedures at the regional&#44; national and international levels&#46; For instance&#44; several clinical trials have shown that spinal fusion surgery for lower back pain has not achieved optimal long-term results compared to less invasive therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Knee arthroscopy is a very common operation and does not always achieve the desired results&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and the same holds true for arthroscopic partial meniscectomy&#46; The Fidelity study&#44; after comparing the results of arthroscopic partial meniscectomy versus placebo surgery&#44; found no relevant benefits over 12 months of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Similar conclusions were reported by Marsh in Canada&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Video-assisted colonoscopies performed in patients outside the recommended age range or at shorter intervals than indicated has been reported in 17&#37;&#8211;25&#46;7&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The Ischemia study&#44; with the support of the National Heart&#44; Lung and Blood Institute of the USA&#44; demonstrated that invasive treatment does not reduce 4-year mortality in coronary heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Between 2007 and 2015&#44; the proportion of implantable cardioverter-defibrillators that did not meet the Medicare National Coverage &#40;MNC&#41; criteria was 25&#46;8&#37;&#44; which then dropped by more than 15&#37; after the intervention of the US Department of Justice&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Flum and Koepsell called attention to the incidence of negative appendectomies&#44; defined as the non-incidental excision of a normal cecal appendix&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The management of localized prostate cancer has also been subject to critical analysis&#44; as noted in a study by the US Veterans Administration&#44; with an unjustified increase in radical surgeries&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The rates of use and the eventual overuse or over-indication of certain procedures should be a wake-up call for detailed analysis of the underlying circumstances&#46; One example is the high variation in the performance of cesarean sections&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> The existence of cases with unnecessary surgery should stimulate the development of clinical consensus and evidence-based surgery in order to ultimately reduce useless surgeries to a minimum&#46; Several reasons may justify performing unnecessary procedures&#44; including uncertainty&#44; social factors&#44; responding to pressure from patients to undergo procedures with doubtful results&#44; use and customs&#44; which in part may explain the differences in usage rates and remuneration systems&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Payment per service can also encourage this practice in the same way as the overuse of surgical procedures&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Basically&#44; unnecessary surgery arises from three recognized causes&#58; ignorance&#44; incorrect judgment&#44; or dishonesty &#40;which would encompass incompetence&#44; indifference&#44; or immorality&#41;&#46; From these three&#44; the ethical and medico-legal implications of a procedure that is not supported or justified by scientific evidence clearly emerge&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Monitoring&#44; supervision and auditing systems should be promoting within medical institutions at a general level&#46; Professional associations must advocate for transparent policies and therapeutic decisions based on scientific evidence as well as good clinical practice guidelines&#44; which should be adjusted for each hospital setting&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this manner&#44; medical associations should promote the ethics of competence in the style proposed by Arnau de Vilanova &#40;1238&#8211;1311&#41; and Richard Cabot &#40;1868&#8211;1939&#41;&#44; while likewise remembering the proposals by Engelbert Dunphy in his presidential speech upon assuming leadership of the American College of Surgeons in 1963&#58; &#8220;Surgeons have a collective responsibility to seek benefits for humanity&#46; The autonomy of the individual surgeon is conditional&#44; since society agrees with surgeons that they will act for the benefit of humanity&#46; Hence the importance of a central authority that ensures compliance with professional standards&#44; which represent the core of Ethics in Surgery&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Sources of funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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