The keys to deciding on surgery

“He’s not having surgery – too old. The doctors decided it’s not worthwhile.” How often do we hear such statements? And how do the various parties arrive at this conclusion?

We’re living longer, and more of us are living healthier lifestyles, so how do we assess when surgery is considered beneficial and when it becomes too great a risk?

The key concerns are frailty and the stress of anaesthesia.

Dr Juliana Kok, an anaesthetist and lecturer at the University of Melbourne, says stresses on the body during and after surgery mobilise our defences. “Surgery results in an increased secretion of hormones that promote the breakdown of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery,” she wrote in The Conversation.

These hormonal changes also have an effect on the sympathetic nervous system, which causes a rise in heart rate and blood pressure.

“The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impede the oxygen supply to the vital organs such as the heart and the brain,” she says.

But frailty is the big issue, according to Dr Kok.

Frailty relates to a decline in body function which means we are less able to cope with acute and everyday stress.

“In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure,” she says. “The organ systems near the threshold of failure are then unable to ‘bounce back’ from an external or internal stressor.”

Dr Kok explains that the Clinical Frailty Scale evaluates a person’s level of frailty on a scale of one to nine, with one being very fit. She says studies have shown frailty is associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk.

Couple the Frailty Scale with a study comparing surgery with sham or placebo surgery and the decision-making gets more complicated.

This review found certain surgeries were no better than placebo in just over half of the studies. And in studies where surgery was better than placebo, the difference was generally small.

Study authors Professors Ian Harris and Paul Myles wrote: “As an example, two studies compared placebo surgery to keyhole surgery (arthroscopy) of the knee in patients with degenerative conditions (arthritis, meniscus tears and catching and clicking). Both studies showed no important difference in surgery outcomes between the two groups.

“We don’t always need to compare surgery with a sham. Sometimes comparing surgery with non-surgical treatment (like physiotherapy or medications) is more appropriate.

“One study looked at all orthopaedic surgical procedures performed on more than 9000 patients in three hospitals over three years. Only half the procedures were compared with non-operative treatment. And of that half, about half were no better than not operating.”

The professors concluded in an article in The Conversation that there were two problems in surgery – an evidence gap (in which there’s a lack of high quality evidence) and an evidence-practice gap (where there’s high quality evidence that a procedure doesn’t work, yet is still performed).

They warned that doctors should not perform surgical procedures and taxpayers should not have to cover their cost until there was high quality evidence they worked.

The moral of the story? Do your own research and gather informed opinion.

Have you had surgery that resulted in more problems post-procedure? How did you go about making the decision to proceed with surgery?

Related articles:
Could you be denied surgery?
Elderly at risk after surgery
Make sure you need that surgery

Disclaimer: This article contains general information about health issues and is not advice. For health advice, consult your medical practitioner.

Written by Janelle Ward

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