Having been surgically trained and surgically-minded, I’ve had expression ingrained in my psyche such as “a chance to cut is a chance to cure,” “when in doubt, cut it out” and “nothing can heal like cold, hard steel.” Indeed, as a surgeon, I see patients in my office and in the hospital with the specific question of whether or not surgery is indicated, what type of surgery and how urgently it needs to be performed.
But coming up to my 20-year anniversary as a full-time faculty member at an academic medical center, I’ve noticed my own sea change in recommendations. Yes, I have seen the beneficial outcomes of even the most minor of surgeries, as well as the literal life saving from major ones. I’ve also seen the disastrous consequences of delaying surgery or from holding off on surgery altogether. But I have also seen surgical disasters. Because as most surgeons know, there is more to surgery than simply “cutting it out.”
Perioperative morbidity is how we term it. What are the anesthetic risks, the risks of immediate and delayed postoperative complications? And the larger questions: Will this surgery really change the ultimate outcome of the patient’s prognosis? Quality of life? While there are countless research articles, data sets and population norms on who makes the best surgical candidate, some of these answers come simply with time and experience. And sometimes the better surgeon is the one who recommends against surgery.
My dear friend’s father is a perfect example of how choosing the surgeon who advised against surgery may be the best way to go.
Let’s set the scene: He is 85. In days gone by, this was considered too old for surgery. Well, there are plenty of folks well into their 90s undergoing hip fracture surgery, cancer surgery and hearing rehabilitation surgery without a hitch. But there’s so much more that makes this man a high-risk surgical candidate. He has a long history of cardiac disease, having suffered his first of several heart attacks in his forties, leading to valve disease and congestive heart failure. But he’s a lucky guy. He received a heart transplant more than 20 years ago. It’s still ticking. But a few years back, he sustained a spontaneous intracranial bleed, requiring an emergent craniotomy.
Lucky, he walked out of the hospital from that one. But when he fell at home a few months ago and continued to have severe pain, he went to his local hospital. X-rays and CT scans showed a fractured cervical spine — a high one — just below the skull. He was in pain but was walking, talking and eating. The surgeons recommended surgery. The risks of anesthetic induction alone were treacherous in this man — he could develop quadriplegia or require an emergency tracheotomy just from the risky intubation. We suggested a second opinion. A second surgeon agreed that surgery would be in order. It just didn’t sit right with my friend. So he went to his regional academic medical center. “No way,” they stated. “He is a high-risk surgical candidate, and this could heal with a cervical collar. Just give it some time.” And he did. He’s now collar-free, walking, talking and without pain or any symptoms. His fracture has healed. Would he have had the same or better outcome had surgery been performed? Indeed, it’s possible. But when seeing the big picture, sometimes the better surgeon is the one who doesn’t operate.
Nina Shapiro is a pediatric otolaryngologist. She is the author of Take a Deep Breath: Clear the Air for the Health of Your Child, can be reached on her self-titled site, Dr. Nina Shapiro, and can be reached on Twitter @drninashapiro.
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