date: 11/30/2005
12 surgeries you may be better off without
Before you have these invasive procedures, check out safer alternatives.
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Bloodletting. Lobotomy. Routine tonsillectomy. Medical history is littered with once-popular procedures that subsequently proved ineffective or dangerous. In the late 1990s, for example, more than a half-million Americans a year underwent knee “debridement and lavage,”designed to ease knee osteoarthritis by shaving rough joint surfaces and flushing out debris. But then researchers tested the surgery by performing the real operation on one group of volunteers and a sham operation—complete with sedation and superficial incisions—on another. One year later, the authentically treated knees were worse than the others; after two years there was no difference between them. Researchers at the nonprofit Rand Corporation have identified numerous operations, ranging from hysterectomy to heart procedures, that appear to be done more often than medically justified. Such overuse typically arises when surgeons:
  • Don’t keep up with the research and either perform discredited operations or do proven procedures in inappropriate patients.
  • Embrace cutting-edge approaches before their safety and efficacy are proved.
  • Recommend an unproven procedure without describing the other treatment options.
How to know if you need surgery

In general, avoid surgery unless the problem threatens your health or disrupts your activities, less aggressive treatments have failed, other causes have been ruled out, tests show that surgery would help, and there's little hope of spontaneous recovery. And get a second opinion if you have the slightest doubt about whether you need the procedure. Before undergoing any operation, ask your doctor or the surgeon these questions:
  • What will happen if I decline or postpone surgery? Will the disorder tend to worsen, stay the same, or possibly improve?
  • Are there nonsurgical or less-aggressive surgical alternatives? If so, how do the risks and efficacy compare with those of the contemplated operation?
  • What are the chances of recurrence, failure, and complications of the surgery?

Here are a dozen invasive procedures that may be overperformed, plus the safer or more effective alternatives you should at least consider.
Too many heart procedures
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Stable angina
Heart attack
Heart failure
Stroke prevention
Stroke, emergency care
What tests are available?
Learn more about diagnostic tests and procedures for heart problems

Tests for stable angina
Tests for a heart attack
Tests to check your carotid arteries

Blockage of the arteries feeding the heart can lead to a heart attack. But procedures to detect or treat such blockage may be overused. One such procedure is angiography, in which cardiologists inject dye into the coronary arteries to make them visible on an X-ray. The test can lead physicians to find clinically insignificant obstructions, which they may then treat aggressively.

Such treatment often involves angioplasty, in which cardiologists snake a tiny balloon up into a narrowed coronary artery and then inflate it to crush the blockage; then they insert a cylinder called a stent to prop the vessel open. But in 1995 researchers determined that nearly one-third of those procedures were performed when medication and lifestyle changes alone would suffice or, less often, when bypass surgery was the better choice. Today many experts worry that the rate of inappropriate angioplasty use is even higher.

One reason for that overuse is excessive enthusiasm for drug-coated stents, an innovation that reduces the risk of reclogging of the arteries. “Unfortunately, the extensive use of such stents is far ahead of the data that can be cited to support them,”says Eric Topol, M.D., who is chairman of the cardiology department at the Cleveland Clinic and conducted the 1995 research on angioplasty overuse.

Here’s a guide to when angiography and angioplasty are worth undergoing:

Angiography. The American College of Cardiology recommends generally limiting angiography to people who have angina, or heart-related chest pain, as well as abnormal results on a cardiac stress test; that’s a simpler, safer, less-expensive procedure that measures the heart’s function while it’s stressed by exercise or medication. But a substantial number of doctors ignore that guideline and skip the stress test before angiography. Others substitute a newer preliminary test that detects calcium in the arteries; some even order that test when there’s no angina. But while the test, called electron-beam computed tomography, may provide some information about overall coronary risk, it reveals little if anything about heart function or circulation.

Recommendation. Agree to angiography without a stress test only if you have heart-related chest pain and one of the following conditions, which make that preliminary test excessively risky: unstable angina (heart pain that strikes when you’re resting or gets progressively worse), aortic stenosis (narrowing of the heart’s main valve), or congestive heart failure (inadequate pumping). And don’t undergo the calcium test to determine the need for angiography.

Angioplasty. This procedure, along with stenting, has been proved to protect the heart or prolong life only in people highly susceptible to heart attack; in everyone else, it appears only to ease angina. Further, the procedure has risks, including, in 2 to 6 percent of patients, heart attack, stroke, or death. And the long-term safety and efficacy of drug-coated stents remain unknown.

Recommendation. Consider angioplasty plus stenting only if you have a history of heart attack or unstable angina, or if tests show significant (more than 70 percent) blockage, and lifestyle changes plus drugs haven’t relieved angina adequately. If you have blockage in multiple arteries or the main artery, or diabetes plus angina, ask your doctor whether bypass surgery would better relieve your symptoms and prolong your life.
Women’s choice
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Endometriosis
Fibroids
Heavy periods
Ovarian cancer
When should I consider hysterectomy?
Learn more about the risks and benefits

Hysterectomy for endometriosis
Hysterectomy for fibroids
Hysterectomy for heavy periods

Two of the most frequently performed major operations in the U.S. are exclusively for women: hysterectomy, or surgical removal of the uterus and often the ovaries, and cesarean section. In both cases research suggests that most physicians fail to follow treatment guidelines from the American College of Obstetricians and Gynecologists (ACOG). More than 700,000 women a year are also subjected to episiotomy, a less invasive but even more dubious procedure in which physicians make a short incision to widen the vaginal opening during childbirth.

Cesarean section. Most C-sections are done because labor is progressing too slowly. But several less-invasive approaches—medication, deliberate rupture of the membranes around the fetus, even a shoulder or foot massage or a warm shower—may be enough to stimulate labor. Physicians also perform cesareans in the vast majority of women who’ve already had one. But ACOG says that most of those women could safely try for a vaginal delivery, which would succeed about 70 percent of the time; if it doesn’t, the doctor could simply switch to cesarean delivery.

Recommendation. Ask what percentage of normal deliveries as well as births following a prior cesarean the physician delivers by C-section. Ideally, look for rates below 15 percent in women who haven’t had the procedure and about 60 percent in those who have. (Those rates can be higher if the physician treats many high-risk patients.) Ask about the doctor’s willingness to try nonsurgical steps first. Alternatively, consider delivery in a hospital by a certified nurse-midwife, if available. Deliveries by those practitioners tend to require C-sections less often than those done by obstetricians, with equally good results overall. And nurse-midwives have access to an obstetrician, who can perform a cesarean if needed.

Episiotomy. Many physicians routinely perform episiotomy during childbirth, claiming that the procedure accelerates delivery and prevents skin and muscle tears as well as subsequent incontinence. While episiotomy may sometimes slightly shorten labor, it’s necessary only if the baby appears to be in distress or the mother is overly exhausted or in excessive pain. And several studies now show that the procedure actually increases the risk of serious tears and incontinence.

Recommendation. Pregnant women should ask their physician or midwife to avoid episiotomy unless it’s clearly necessary. You may be able to lower your risk of a vaginal tear during childbirth by practicing Kegel exercises—relaxation and contraction of the pelvic muscles—before delivery and by having a doctor, midwife, or nurse massage and apply warm compresses to the region around the vagina during childbirth. (For more on Kegel exercises, go to National Kidney and Urologic Diseases Information Clearinghouse)

Hysterectomy. Common gynecological problems such as pelvic pain and heavy or irregular bleeding are often treated by removing the uterus, especially in women who don’t want children. But hysterectomy poses risks beyond the usual surgical hazards, including scar tissue that can lead to intestinal obstruction and, when the cervix is removed, reduced sexual pleasure. Removing the ovaries triggers premature menopause, which can adversely affect the heart, bones, genitals, and libido.

Moreover, the conditions that most often cause pelvic pain or abnormal bleeding—fibroids, or benign tumors; endometriosis, or growth of uterinelike tissue on abdominal or pelvic organs; and hormonal imbalances—can all be treated less aggressively. For example, either taking antiestrogen therapy or, if prompt treatment isn’t required, just waiting until estrogen levels drop after menopause will shrink fibroids. Or surgeons can remove just the fibroids rather than the entire uterus. The hormones in birth-control pills can often control irregular, lengthy, or heavy periods. If medical treatment fails, endometrial ablation—minimally invasive surgery to destroy the uterine lining—can reduce or stop the bleeding.

Recommendation. Hysterectomy is clearly warranted to treat uterine cancer, extremely large fibroids, or severe endometriosis. In other cases, expect simpler, less-invasive treatment. If hysterectomy is warranted, don’t agree to removal of the ovaries unless they’re diseased or there’s a high risk of ovarian cancer. And ask about having the hysterectomy via a “supracervical”or vaginal approach: Both methods avoid the need for a larger, abdominal incision, and the supracervical route preserves the cervix.
For males only
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Enlarged prostate
Prostate cancer
What do I need to know?
Learn the facts, see the evidence, and discuss your options with your doctor

TURP
Prostatectomy

Studies suggest that prostate problems—including cancer and benign enlargement—are often treated by invasive procedures without adequate discussion of the alternatives. But the best approach for both may sometimes be no treatment or watchful waiting.

When completely informed about alternative prostate treatments, men tend to choose less-aggressive options. But male patients have no say about another extremely common and medically unnecessary procedure: circumcision.

Circumcision. Some evidence suggests that circumcision in males may protect against urinary-tract infections in infants and, in adults, penile cancer and transmission of a virus linked to cervical cancer. However, the infections and penile cancer are rare, and the evidence linking circumcision with that cancer and disease transmission is weak and inconsistent. Moreover, good hygiene at least probably cuts the risk of all three problems. And circumcision itself poses slight risks, including bleeding and wound infection after the procedure. Overall, the American Academy of Pediatrics says there’s no clear medical justification for male circumcisions.

Recommendation. Deciding whether to circumcise a male infant depends entirely on the parents’personal and religious beliefs.

Enlarged-prostate procedures. Doctors often use one of several procedures to treat the urinary problems caused by benign prostate enlargement. In the standard treatment, transurethral resection of the prostate (TURP), a flexible, lighted instrument is inserted into the penis and up to the portion of the urethra, or urine-bearing tube, that’s surrounded by the prostate; then the urologist scrapes away some of the constricting prostate tissue. While very effective, TURP causes infertility and retrograde (dry) ejaculation—propulsion of semen backward into the bladder—in most men and serious bleeding or other complications in roughly 10 percent.

Increasingly, doctors are turning to somewhat simpler alternatives, which use lasers, electricity, or microwaves to destroy prostate tissue. Those may be much less likely to cause infertility and dry ejaculation, but they pose a somewhat higher risk of complications. And their long-term effectiveness is uncertain.

However, all of those treatments for prostate enlargement are usually unnecessary. Roughly 30 percent of men eventually get better on their own. Many others obtain adequate relief from the nonsurgical steps described below.

Recommendations. Before resorting to any invasive treatment for benign enlargement, see whether symptoms improve with time, ask your doctor whether any drugs you take may be aggravating the problem, and try the following steps: Ejaculate regularly and, to reduce nighttime waking, limit evening intake of fluids, particularly alcohol and coffee. In addition, consider trying the herb saw palmetto (320 milligrams a day), which may ease mild symptoms. Or ask your doctor for a more-effective prescription drug, notably finasteride (Proscar), to shrink the gland or an alpha-blocker such as terazosin (Hytrin) or tamsulosin (Flomax) to relax the muscles around the urethra and improve emptying of the bladder.

Prostatectomy. Removal of the prostate gland is the most common treatment for prostate cancer; such surgery appears to reduce the chance of recurrence slightly better than radiation therapy, the main alternative. But even with the best methods, surgeons, and surgical candidates, the operation causes impotence in roughly 30 percent of men and incontinence in 15 percent. The overall complication rates are at least as high as, probably higher than, those of radiation.

Recommendation. Men with prostate cancer whose overall health suggests they will live no more than 10 years, whether or not the malignancy spreads, should consider watchful waiting since treatment is unlikely to extend their life. Healthier men could also consider that approach if their biopsy suggests a very slow-growing tumor. Surgery generally makes the most sense for men with the longest life expectancy and the least surgical risk. Those whose age or poor health makes surgery excessively risky or who simply want to avoid a major operation should consider radiation. However, the risks and benefits of all treatments remain uncertain, so it’s essential to discuss the options thoroughly with your doctor.
Other overdone procedures
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Back pain
Heartburn/GERD
Weight loss/Obesity
Impacted wisdom teeth
What do I need to know?
Learn the facts, see the evidence, and discuss your options with your doctor

Surgery for back pain
Surgery for heartburn
Surgery for weight loss
Surgery for impacted wisdom teeth

Surgery for back pain. Since the 1980s, operations for low-back pain have increased from about 190,000 to more than 300,000 per year. Many of those operations are probably unnecessary. The most common cause of low-back pain is a minor problem such as a muscle strain, which almost always clears up within a month or so. Even pain from a herniated disk, the most frequent cause of persistent discomfort, resolves spontaneously within six weeks in some 90 percent of cases, since the protruding portion that’s pressing on a nerve tends to shrink. Further, the benefits of surgery appear to be temporary in most cases. By the end of four years, people who simply waited typically experienced no more back pain than those who had the operation, according to the only long-term study we could find.

Recommendation. In general, consider surgery for back pain only in these circumstances: The pain has lasted for at least six weeks; other treatments, such as physical therapy, pain relievers, and spinal steroid injections have failed; and magnetic resonance imaging (MRI) shows a spinal abnormality that’s clearly related to the symptoms. For acute pain, applying cold packs for the first few days and then switching to warm compresses may help. Try to stay active, which appears to speed recovery. Strengthening your stomach and back muscles can help prevent recurrence.

Surgical weight loss. The number of people undergoing surgery to lose weight quadrupled from 1998 to 2002, according to government figures released in 2005. Such surgery, which either shrinks the stomach or reroutes food around it, is one of the few techniques that appears to cause substantial long-term weight loss in severely obese individuals. But the operations are highly invasive, causing death in 1 of every 200 to 300 patients, and causing potentially dangerous complications, such as bleeding and malnutrition, in many more. Researchers worry that some patients are now having the procedures without seriously trying to eat less and exercise more. Some patients may have even deliberately gained weight in order to meet insurance requirements for such surgery.

Recommendation. Weight-loss surgery should be a last resort for people who are extremely overweight, have weight-related problems such as diabetes or sleep apnea, and have diligently tried to shed pounds in other ways.

Cutting out heartburn. Surgeons have long believed they could control heartburn—caused by stomach acid backing up into the esophagus, the tube linking the throat to the stomach—by surgically tightening a sphincter muscle that normally blocks such backup. But the procedure, called fundoplication, was rarely done because the standard, large-incision approach is relatively traumatic and because drugs can often control heartburn. But two factors have contributed to what some sources call a 30- to 40-fold increase in the number of fundoplications since the late 1990s: the development of a laparoscopic (minimally invasive) approach, done through several small incisions; and the hope that the procedure might decrease the risk of esophageal cancer, which may be caused by severe heartburn.

But studies in the past few years have failed to show that the procedure lowers cancer risk. It’s unclear how often the surgery lastingly relieves heartburn or if it’s any better than proton-pump-inhibitors such as omeprazole (Prilosec, Prilosec OTC). And other drugs such as H2-blockers (Axid, Zantac) as well as various lifestyle changes adequately control symptoms in most cases. And while laparoscopic fundoplication is less traumatic and possibly somewhat safer than the older approach, it still requires a one- to three-day hospital stay and a two- to three-week recovery, and poses certain risks, such as abdominal bloating and persistent difficulty swallowing.

Recommendation. Consider fundoplication only if lifestyle changes plus medication don’t control the problem or cause intolerable side effects and tests show high esophageal acid levels caused mainly by a defective sphincter. Effective lifestyle steps include eliminating heartburn triggers, such as coffee, tea, alcohol, fatty foods, and cigarettes; avoiding large meals; eating slowly; and not lying down afterward. If you get nighttime attacks, try sleeping on your left side (which positions the esophagus at an upward angle), elevating the head of your bed on 4- to 6-inch blocks, or using a wedge-shaped support under your mattress.

Wisdom-tooth extraction. The four wisdom teeth in the back of the mouth, which usually emerge between age 17 and 25, can get impacted, or lodged so firmly in the jawbone that they can’t break through the gum. Many dentists believe that routinely removing impacted wisdoms can prevent future problems, such as damage to or misalignment of other teeth. But there’s little if any evidence to justify that concern. Moreover, the procedure causes not only postoperative pain and swelling but also, in about 1 percent of patients, nerve damage that permanently numbs the tongue or lip.

Recommendation. Get a second opinion if your dentist advises removing an impacted wisdom tooth that isn’t causing any trouble.


CITATIONS
Moseley JB, et al. “A controlled trial of arthroscopic surgery for osteoarthritis of the knee,”The New England Journal of Medicine,July 11, 2002, pp. 81-8.

ACOG Practice Bulletin. “Vaginal birth after previous cesarean delivery,”Obstetrics and Gynecology, July 2004, pp. 203-12.

Weber H. “Lumbar disc herniation. A controlled, prospective study with ten years of observation,”Spine, March 1983, pp. 131-40.

Tran T, et al. “Fundoplication and the risk of esophageal cancer in gastroesophageal reflux disease: A Veterans Affairs cohort study,”American Journal of Gastroenterology, May 2005, pp. 1002-8.
Shaheen NJ. “Does fundoplication change the risk of esophageal cancer in the setting of GERD?”American Journal of Gastroenterology, May 2005, pp. 1009-11.
Spechler SJ, et al. “Long term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial,”Journal of the American Medical Association, May 9, 2001, pp. 2331-8.
Kahrilas PJ. “Surgical therapy for reflux disease,”Journal of the American Medical Association, May 9, 2001, pp. 2376-8.

OTHER SOURCES
Youssef R, et al. “Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery,”British Journal of Gynecology, July 2005, pp. 941-5.

Maggard MA, et al. “Meta-Analysis: Surgical treatment of obesity,”Annals of Internal Medicine, April 5, 2005, pp. 547-59.

TL, et al. “National trends in utilization and outcomes of bariatric surgery,”Surgical Endoscopy, May 2005, pp. 616-20.

Broder MS, et al. “The appropriateness of recommendations for hysterectomy,”Obstetrics and Gynecology, February 2000, pp. 199-205.

Task Force on Cesarean Delivery Rates. “Evaluation of Cesarean Delivery,”American College of Obstetricians and Gynecologists, Washington, D.C., 2000. 

American Academy of Pediatrics Task Force on Circumcision. “Circumcision policy statement,”Pediatrics, March 1999, pp. 686-93.

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