Opinion: Benefits of Surgery Not Always Greater Than the Risks of Undergoing an Operation
In This Article
- It is important that surgeons know when they should operate but even more so, when they should not
- Marilyn Heng, MD, MPH, FRCSC, and colleagues performed meta-analyses, which included RCTs and observational studies, to compare the outcomes of surgical and nonsurgical options
- Their findings revealed that the benefits of surgery may not always outweigh the risks of undergoing an operation
It is important that surgeons know when they should operate, but even more so, when they should not. Surgeons should operate if the benefits of surgery exceed its risks, but surgeons often differ in how they perceive benefits and risks.
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Previous studies evaluated the risk of treatment on meniscal tears and found no difference between surgical and non-surgical treatment leading to much debate about the necessity of surgical treatment in the field of orthopedics.
To investigate this further, Marilyn Heng, MD, MPH, FRCSC, a surgeon in the Orthopaedic Trauma Center at Massachusetts General Hospital, Yassine Ochen, a PhD candidate at University Medical Centre Utrecht, Rolf H.H. Groenwold, MD, PhD, professor of Clinical Epidemiology at Leiden University Medical Centre and R. Marijn Houwert, MD, PhD, a trauma surgeon at the University Medical Centre Utrecht, performed two randomized controlled trials (RCTs) of surgery.
RCTs provide the highest level of evidence about medical treatment effects and are superior to observational studies of such effects. However, the study group struggled to perform RCTs because patients did not want to be randomized and surgeons were hesitant to randomly assign a surgical procedure. There were also low inclusion rates and a lack of funding that terminated one of the studies early.
Because of these difficulties, the study group performed meta-analyses, which included the RCTs and observational studies. The meta-analyses compared the outcomes of surgical and nonsurgical options. The study group analyzed midshaft clavicle fractures, proximal humeral fractures, flail chest or multiple rib fractures and acute Achilles tendon ruptures. It seemed that surgeons chose treatments based on their own preferences rather the characteristics of their patients.
Past meta-analyses only included only RCTs and revealed that in comparison to nonoperative treatments, operative treatments of acute Achilles tendon ruptures reduce the risk of re-rupture. However, surgery also significantly increases the risk of other complications like infection, deep vein thrombosis and sural nerve injury.
In this analysis, the study group found that re-rupture and complication rates are lower than expected with operation in comparison to data. There were few differences between treatment groups. Such findings show that the benefits of surgery may not always be greater than the risks of undergoing an operation.
Nonoperative treatment may be better than operative treatment with regards to acute Achilles tendon ruptures. Therefore, surgeons should advise patients about the risks and benefits of both surgical and nonsurgical treatments, and surgeons should know when it is and is not appropriate to operate.
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