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To cut or not to cut.

To cut or not to cut

Contrary to the primary dictum of the Hippocratic oath, surgeons performing a particular type of surgery to prevent strokes may be doing more harm than good, according to Mark L. Dyken, a neurologist at Indiana University School of Medicine in Indianapolis.

Carotid endarterectomy, in which a clogged artery leading to the brain is surgically cleaned out, is "a clinical application looking for some good science," Dyken says. While it may prove worthwhile in the hands of experienced surgeons operating on carefully selected people experiencing strokelike symptoms, that has yet to be shown, he says.

Studies have found that 3 to 9 percent of people with signs of an impending stroke who are treated with drug therapy alone die of a stroke within a year. Using the National Hospital Discharge Survey, Dyken and Robert Pokras of the National Center for Health Statistics in Hyattsville, Md., found that nearly as many -- 2.8 percent -- of the people who get carotid endarterectomies die before being discharged from the hospital. And other studies have reported that anywhere from one to five times as many more surgery patients suffer surgery-related stroke or death after discharge. Based on these and other data, Dyken and Pokras calculate there were 3,808 to 11,560 strokes or deaths resulting from the 103,000 procedures done in 1984.

For this, the hospital bill was $309 millionf with doctors' fees the total is more like $500 million to $1 billion.

Recently extracranial-intracranial (EC/IC) bypass surgery, another procedure purported to protect against stroke, was shown in a carefully controlled prospective study to be of no value in reducing illness or death (SN: 11/16/85, p. 309).

Neurosurgeon James T. Robertson of the University of Tennessee in Memphis agrees with Dyken's figures, but says there has already been a heightened awareness among surgeons about the questionable value of the operation. Recently instituted training programs and more careful selection of patients have already resulted in fewer such operations being done and a lower complication rate, he says.

Both Dyken and Robertson agreed that a large multicenter evaluation similar to the EC/IC trial is needed to determine who may benefit from the operation.
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Title Annotation:research on value of carotid endarterectomy
Author:Silberner, Joanne
Publication:Science News
Date:Feb 8, 1986
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