Tagged Surgery and Surgeons

Robotic Surgery for Prostate Cancer May Offer No Benefits Over Regular Surgery

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Robotic prostate surgery may be no more beneficial than a conventional operation, a randomized trial has found.

In robotic surgery, the doctor operates through quarter-inch incisions using tiny instruments and cameras guided by robot, giving the surgeon a clear view of the operating site and precise control of the tools. In conventional surgery, the doctor makes a larger incision and uses standard surgical equipment.

Several earlier observational studies had reached the same conclusion. For the current study, in The Lancet, researchers randomly assigned 163 men with localized prostate cancer to robotic surgery and 163 to conventional operations.

Three months after the operations, there was no difference between the two groups in urinary or sexual function, or in complications of surgery. The operations were equally effective in removing cancerous tissue.

Longer-term follow up is needed, but for now, “we recommend that patients choose a urologist with whom they have rapport and who is experienced with either open or robotic prostatectomy,” said the senior author, Dr. Robert A. Gardiner, a urologist at the Royal Brisbane and Women’s Hospital in Australia. “At this stage, we advise that the choice should be based on the person and not on the operative approach. A surgeon may have good clinical reasons for advocating one or the other approach, and the patient should be open to consider his or her advice.”

When Doctors Have Conflicts of Interest

My mother-in-law is an impressive woman.

At the age of 77, she still maintains a garden the size of my entire backyard, on the three acres of land she and my father-in-law, now 81, share in rural western Pennsylvania.

She does not tolerate stasis, and anytime my father-in-law collapses into his plaid armchair in front of the television, she appears on the scene within a minute or two, barks at him that there will be plenty of time to rest when they’re in the old age home, grabs the remote control, and turns the television off while simultaneously giving him another task to perform.

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Mikkael Sekeres, M.D.

Mikkael Sekeres, M.D.Credit

She has kept old age at bay through constant activity, sheer strength of will, and a splash of denial.

Her hip must have been bothering her for some time, then, before she let me and my wife in on her problem. At our insistence, she told one of her doctors, who sent her for X-rays and reviewed them with her, in his office, with my wife at her side.

“Ouch,” her doctor said, pointing at the image of her hip where her femur was scraping against the acetabulum of her pelvis, bone-on-bone. “That looks like it hurts.”

“Well, I do a few chores around the house in the morning and rest on the couch with a heating pad, and then I’m all right,” she told him.

My wife interjected. “Just so you understand, by ‘a few chores,’ she means that she plants five flats of flowers.”

Her doctor’s eyes widened. Recognizing that she is the type of person who would have to decide for herself when she was ready for surgery, he recommended she let the rest of us know when that time occurred. Earlier this summer, she decided it was time.

She met with the orthopedist who would perform her surgery, and the two quickly bonded. As it turned out, his wife is also a gardener, and like my father-in-law, he collects classic cars. He discussed the surgery he intended to perform, her likely recovery period, and then paused.

“Now, I have to tell you that the artificial hip I’m going to use is one that I had a hand in inventing, and although I will receive no royalties for implanting this hip in you, I do have a conflict of interest, and want to make sure you’re O.K. with that.”

I sit on our institution’s conflict of interest committee and this scenario, while not falling into the majority of doctor-patient interactions, is becoming increasingly common.

There are a number of different types of potential conflicts that can arise.

Like my mother-in-law’s surgeon, a doctor may invent a technology, or develop a drug, and receive payments every time that technology or drug is used – though, as my mother-in-law’s doctor told her, no royalties are received if the device is used at our institution. Still, you might wonder if his using that artificial hip influences other doctors who want to emulate him to use the same device, from which he would receive royalties.

Or, a doctor may provide advice to a company, for which she receives an honorarium, and conducts research (such as being an investigator on a clinical trial) using that company’s product. Will the payment she received influence her interpretation of the clinical trial results, in favor of the investigational drug? Or did she make the trial better because of the advice she provided?

What if, instead, the drug for which she provided advice is already commercially available. How much is her likelihood of prescribing this medication – what we call a conflict of commitment – influenced by her having been given an honorarium by the manufacturer for her advice about this or another drug made by the same company?

We know already that doctors are influenced in their prescribing patterns even by tchotchkes like pens or free lunches. One recent study of almost 280,000 physicians who received over 63,000 payments, most of which were in the form of free meals worth under $20, showed that these doctors were more likely to prescribe the blood pressure, cholesterol or antidepressant medication promoted as part of that meal than other medications in the same class of drugs. Are these incentives really enough to encroach on our sworn obligation to do what’s best for our patients, irrespective of outside influences? Perhaps, and that’s the reason many hospitals ban them.

In both scenarios the doctor should, at the very least, have to disclose the conflict to patients, either on a website, where patients could easily view it, or by informing them directly, as my mother-in-law’s doctor did to her.

More importantly, what do patients think of these conflicts? Back in the comfort of our family room, following her appointment, I asked my mother-in-law that very question.

“Oh, I was glad he told me.” I prodded her to go on, as she shifted in her chair, trying to get comfortable. “It made me trust him more. He must be an expert if he helped invent the hip. And of course I want him using the one he invented, he knows it better than anyone!”

It turns out, she’s not alone. In a study of over 600 surgical patients, about 80 percent felt it was both ethical and either did not influence, or actually benefited their health care, if their surgeons were consultants for surgical device companies.

It’s complicated. Certainly, the relationships doctors have with drug or device manufacturers drive innovation, and help make those products better for patients. But can we ever be sure these relationships aren’t influencing the purity of our practice of medicine, even a little?

Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic. Follow him on Twitter @MikkaelSekeres.

With Cataracts, My Own Private Light Show

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Tivoli Gardens amusement park in Copenhagen at night.

Tivoli Gardens amusement park in Copenhagen at night.Credit April O’Hare

Over the past three years I’ve been plagued by one of the common curses of aging: cataracts. During that time my vision gradually deteriorated, as the normally transparent natural lenses of my eyes became increasingly opaque, going from a gentle soft focus, to gauzy, then cloudy, and ultimately downright foggy. This was apparently the result of some unhappy combination of sun exposure, age, a number of potentially insidious environmental and dietary factors, and just plain genetic bad luck. (My mother and two of my brothers also suffered from this condition.)

Every patient experiences the development of cataracts a little differently. For me, the symptoms weren’t just the inevitable cloudiness and fogginess. They also included a problem with diminished depth perception, which I became aware of one evening when I went to pour my wife a glass of wine and ended up suavely splashing it across the adjacent tablecloth. Even more disturbing, for a period of half a year or so, I had occasional brief episodes of double vision. Naturally I feared these were serious neurological red flags, perhaps indicating small strokes — my father and one of my brothers had those — until my eye doctor reassured me that they were much more likely just another, if somewhat rarer and scarier, symptom of cataracts.

Along with these daylight deficits, I also experienced the phenomenon of night glare. On the road, the headlights of approaching vehicles struck me as painfully bright and disorienting, like some kind of blazing “Close Encounters” spacecraft streaking toward me out of the darkness. In addition, my night glare symptoms took the only slightly more benign form of halos appearing around light sources. If I looked up at, say, a full moon on a clear night I would see not just the old face of the man in the moon, but that familiar glowing visage wreathed by a ring of smaller spheres — half a dozen mini-moons sprouting around its circumference like the petals of a flower.

Likewise, if I directed my attention toward smaller light sources — say the windows of distant buildings across from my apartment — instead of registering as single bright points of light, each little window appeared as an arcade of stars, a shimmering necklace of gleaming beads. Thus my normally prosaic neighborhood cityscape of gray and beige high-rises became a jeweled fairyland, reminding me of the famous Tivoli Gardens in Copenhagen. (Actually, I’ve never been to that storied old amusement park, but the travel-poster images I’ve seen invariably show a radiant nighttime lightscape of sparkling fountains, shimmering ponds, rainbow rows of colored lanterns and, on summer nights, dazzling displays of fireworks.)

Of course, that magical panorama outside my window was ultimately more the result of pathology than pixie dust. And unfortunately, there’s no little pill you can pop that will miraculously make things clear up. So as time went by and my cataracts gradually “ripened” — my ophthalmologist’s charming expression for getting worse — my only option became surgery.

Not surprisingly, the very thought of anyone wielding sharp, shiny objects anywhere near my eyes induced a case of the major willies.

Modern cataract-removal surgery, though, turned out to be hardly the nightmare assault I’d feared. The operation involves removing the diseased natural lens and replacing it with a synthetic one, much as hip replacement surgery consists of removing an arthritic or damaged hip and inserting a metal and plastic version in its place. Certainly it’s a delicate procedure, but not one that requires flashy recent advances like prosthetic robot arms that move in response to mere thought. In fact, cataract surgery is among the most commonly performed operations in the country. The procedure for each eye took less than an hour, during which I remained awake but comfortably sedated. I was aware of lights, sounds and occasional gentle pressure, but it was all virtually painless. And the results have been remarkable.

The new world that floated into focus on an ocean of post-surgical eyedrops over the next few days has been strikingly — sometimes even alarmingly — clear, crisp and bright. And for the first time in years I find myself able to effortlessly read a book (including footnotes), peruse restaurant menus in low light and make out the fine print on medicine bottles. I can decipher distant road signs and foreign film subtitles, recognize faces from afar, and even distinguish the expressions on those faces.

The only downside has been that when I now scan the neighborhood outside my window at night, my private Tivoli is nowhere in sight. The curtain has descended on that alluring light show. Not that I’m complaining.

The benefits far outweigh this small deprivation. In the world I navigate these days, the colors are richer, the outlines sharper. For a change I’m looking forward to really enjoying a vacation with the prospect of doing some sight-seeing and actually being able to see the sights. Right now, in fact, I’m thinking of Europe, perhaps, say, Denmark, maybe Copenhagen, which I’ve been told at this time of year can be … wonderful.

Richard Liebmann-Smith is a writer and editor based in New York who, thankfully, can now read again.

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Your Face Is Beautiful — Do You Want It to Change?

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Credit Juliette Borda

One of my daughters was born with a cleft lip. The repair, done when she was an infant, left its mark: Her face isn’t significantly different from the faces around her, but it is different. She knows it, but at 10, she cares a lot more about whether she can outpitch her younger brother than about how she looks in her baseball cap.

But now she needs orthodontic surgery, and there may be a benefit to doing cosmetic facial surgery at the same time. That means tackling a difficult subject — her looks.

How do you ask a child if she would like to change her appearance, without suggesting that something about her needs to change?

I would like to think that I’m raising a child who has absorbed all my lessons about how little our outer appearance matters compared to who we really are, but in reality, I’m raising a girl who has not yet reached her teens, in a world where magazines tell 9-year-olds what bathing suits are best for their body types. Research suggests that girls’ self-esteem plummets at around age 12 and doesn’t start heading upward again until they enter their 20s. In other words, a few short years from now, she’s likely to care about her appearance a whole lot more than she does now. But other research (and common sense) also tells us that how much emphasis our mothers put on our appearance, whether it’s our weight or our faces or anything else, affects how we feel about ourselves.

Our particular challenge might be a little unusual, but the conversation isn’t. Any parent who has talked to a child about doing something to alter the self he or she presents to the world has tried to walk that fine line between proposing a change (braces, acne medication, a healthier diet, straightened hair) and seeming to demand it — and any adult who still hears a parent’s voice judging him or her not thin enough, pretty enough, good enough knows how easy it is to get this one wrong.

“Girls tell themselves these stories about their appearance,” said Catherine Steiner-Adair, a clinical psychologist, the creator of “Full of Ourselves: A Wellness Program to Advance Girl Power, Health, and Leadership,” a program for middle-school girls and the author of “The Big Disconnect: Protecting Childhood and Family Relationships in the Digital Age.” Parents’ words and actions become a part of those stories.

“My mother wasn’t happy with her nose, so I would hear about my nose constantly,” said Jen Lancaster, a novelist and author of the memoirs “Such a Pretty Fat” and “Bitter Is the New Black.” “To this day, I can’t look in the mirror without trying to figure out, ‘Do I need to contour my nose differently today? How does my nose look today?’ This is not a conversation I should ever have with myself, because my nose is fine.”

Too often, Ms. Adair sees parents drawing conclusions from their own experience. A parent who struggled with weight worries that the weight gain many children experience as preteens may become the precursor to a life of teasing and dieting rather than just puberty.

“I tell parents, ‘it sounds like this might be more your issue than hers,’” Ms. Adair said.

The same can happen for parents who want to turn glasses into contacts, straighten or highlight a young teenager’s hair, get braces over with early or worry about girls and boys who want to wear hairstyles or clothing in a way that contradicts our vision of their gender identity. We hear the mocking voices of our own childhood.

Nancy Redd, a former Miss Virginia and the author of “Body Drama: Real Girls, Real Bodies, Real Issues, Real Answers,” says that even when a procedure seems most easily justified, if it’s purely cosmetic, parents like me should think hard before we suggest it.

“We are so arbitrary about what is attractive and what is a disfigurement,” Ms. Redd said. “Mole above the lip? Awesome. On the chin or nose or eyelid? Gross. Wide space between your two front teeth on a low-income woman in rural America? Gross. On a European supermodel? Fabulous.”

Perception, she points out, is everything.

My daughter’s nose, and her scar, and her whole face, are fine, awesome, fabulous. Some experts say it’s better not to talk about weight or appearance at all. I wish it were that simple. I’d love to take the easy way out while getting to declare it the high road. But my daughter may want to look different, and don’t think she’ll thank me for my reticence if it means a second operation when one might have been enough.

When appearance and health overlap, parents who want to talk about a child’s looks just need to be very matter-of-fact, advises Ms. Adair.

“She may not be talking about it because she’s not worried about it, or she may not want you to worry about it,” she said. She suggested that to start the conversation with my own daughter, I could remind her of times when she’s asked about her scar. Ask her if she still thinks about it, and tell her that during her surgery, “the doctors can change that if you want,” she suggested.

Parents can be similarly direct but neutral about other issues, like acne. Saying, “I see you’re getting some pimples” is a better way to preface a visit to the dermatologist than saying, “your skin looks terrible.”

When I suggested to my daughter that orthodontic surgery might give her the opportunity to make other changes, she was interested. And she had thought about her appearance, but not in the way I’d expected. After gently broaching the topic of her childhood surgery, I asked her if she wanted to change the asymmetry of her lips. She shook her head.

Instead, she asked about the symmetry of her nose, which is affected by the pull of the scar. I had never thought about that. I still suspect her upper lip will be on her list when she’s older, but knowing it was her nose she wanted to talk about guided me in asking doctors about timing and combining surgeries.

But even though she wanted answers, the consultation took us both aback. Hearing her face so bluntly discussed was upsetting for my daughter and we interrupted the doctors repeatedly, and finally steered them away from the topic. (We revisited it later, with her out of earshot.) In hindsight we should have talked to the doctor privately first. As Ms. Adair reminded me, it’s fine for parents to tell doctors: “Please do not use language that will echo in her head for years.”

In the end, my daughter’s doctors didn’t want to do anything more than remove a tooth and look around. As for her nose, they said that reconstructions done too early, while a child’s face is still growing, may have to be redone later. She didn’t seem disappointed.

For now, we’ve decided to wait and see if any additional operations are essential before we broach the topic of cosmetic surgery again. We will make health decisions for her, but we will let her decide whether she wants to undergo an optional cosmetic procedure.

And we won’t dwell on it. I don’t want my daughter’s face to look any different, and I never will. But if she does, I want what she wants — and then, I want to go back to talking about baseball.

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After Cataract Surgery, Hoping to Toss the Glasses

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How the World Looks With Cataracts

This video shows what it is like to see the world when you have cataracts.

By CLINIC COMPARE on Publish Date May 4, 2016.

Two years ago, Anne Collins of Arlington, Va., who has been wearing glasses since fifth grade, noticed she had trouble reading the overhead street signs while driving. Cataracts, the clouding of the natural lenses that occur with age, were taking their toll.

She decided it was time for cataract surgery.

Mrs. Collins, now 61, chose to have her lenses replaced with two different intraocular lenses – one for seeing far and the other for seeing near — in a procedure known as monovision cataract surgery.

“I thought it was a miracle,” Mrs. Collins said after the surgery was completed. “It was like I was back in second grade and didn’t have any problems with my eyes.” Still, her vision isn’t perfect. Mrs. Collins still needs glasses to read the newspaper, but she can see her cellphone just fine.

By age 80, more than half of all Americans either have a cataract or will have had cataract surgery, according to the National Eye Institute. The average age for the surgery is the early 70s.

Cataracts typically develop in both eyes, and each eye is done as a separate procedure, usually one to eight weeks apart. Patients most commonly have their clouded lenses replaced with artificial monofocal lenses that enable them to see things far away. Most will still need glasses for reading and other close-up tasks.

With monovision surgery, the patient’s dominant eye receives a replacement lens for distance vision. In a subsequent operation, the less dominant eye receives a lens for close vision. Once surgery on both eyes is completed, the brain adjusts the input from each eye and patients typically can see both far and near. Some people can stop wearing glasses altogether, although many, like Mrs. Collins, still need them for certain tasks.

But monovison takes some getting used to. The ideal candidates may be people who already have tried a monovision approach with contact lenses for 15 or 20 years, before they even have developed cataracts, said Dr. Alan Sugar, a professor of ophthalmology at the University of Michigan. “People who have worn contact lenses in their 40s, with one contact for near vision and one for distance, are good candidates,” he said.

Others may be able to give monovision a trial run. The cataract surgeon replaces the first eye with a lens that corrects for distance vision and then, if the cataract in the second eye hasn’t progressed too far, can let the patient use a contact lens for near vision in the second eye, Dr. Sugar said. If the patient is comfortable with the trial monovision, the surgeon can then implant a lens for near vision in the second eye.

Experts caution that monovision surgery is not for everyone. “Many patients get misled by asking how their friends like monovision,” said Dr. David F. Chang, a clinical professor of ophthalmology at the University of California, San Francisco, and past president of the American Society of Cataract and Refractive Surgery. “Some individuals hate what another individual loves.”

After any cataract surgery, including monovision surgery, patients may also experience what doctors call “dysphotopsia,” or visual disturbances like seeing glare, halos, streaks or shadows. Moderate to severe problems occur in less than 5 percent of patients, said Dr. Tal Raviv, an associate clinical professor of ophthalmology at the New York Eye & Ear Infirmary of Mount Sinai Icahn School of Medicine. Symptoms often improve during the first three months after surgery without treatment, he said, though in a small number of cases one or both lenses may need to be replaced.

In addition, some patients who get monovision surgery will need a separate pair of glasses that focus both eyes for distance vision for driving at night. “Night driving is more difficult if both eyes are not optimally focused at distance,” Dr. Chang said.

Another option in cataract surgery for those hoping to get rid of the glasses altogether is the use of multifocal lenses, which focus each eye for both near and far viewing, something like the progressive lenses in eyeglasses. In one study of around 200 patients who had either multifocal or monovision cataract surgery, just over 70 percent of the multifocal group could forgo glasses altogether, compared to just over 25 percent of the monovision group.

But patients who undergo multifocal surgery are more likely to have side effects like glare and halos, according to Dr. Mark Wilkins, the lead author of the study and a consultant ophthalmologist and head of clinical services at Moorfields Eye Hospital in London. In his study, six of 94 patients in the multifocal group had to have second surgeries to get replacement lenses, versus none in the monovision group.

Typically, Medicare covers regular cataract surgery and implantation of standard monofocal lenses but does not pay for multifocal lenses, so insurance reimbursements may be limited.

The key to deciding which type of cataract surgery is right for you is to understand your eyes and goals. “Talk about the pros and cons” of each type of cataract surgery, Dr. Wilkins said. “There’s no other way really.”

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No Regrets After Double Mastectomy, but Questions Remain

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Vivien Foldes is one of a growing number of women with breast cancer who are having a double mastectomy.

Vivien Foldes is one of a growing number of women with breast cancer who are having a double mastectomy.Credit Uli Seit for The New York Times

Vivien Foldes says she does not regret having her breasts removed five years ago after she was found to have an early-stage cancer.

But there are things Ms. Foldes, a 58-year-old accountant from Woodmere, N.Y., wishes she had known when she chose a double mastectomy, like the fact that the process of reconstruction would drag on for five months and leave her forever unable to sleep on her stomach. Or that it would leave her with no sensation “from the front all the way to the back in the entire bra area,” she said. “Nothing. Zero. Zip.”

Ms. Foldes says there are days that she asks herself, “Should I have done it?” But, she said, her mother had two types of cancer, and she wanted to be proactive: “I didn’t want to be waiting for the other shoe to drop.”

Ms. Foldes is one of a growing number of women opting to have both breasts removed after a diagnosis of breast cancer, even though doctors say the operation does not improve the chances of survival. Now a new study, based on surveys of thousands of women, suggests women who have double mastectomies also do not benefit from a big improvement in quality of life, either. The study was published online in the Journal of Clinical Oncology earlier this month

“Quite a few studies have shown that in patients who don’t have a genetic mutation that increases breast cancer risk, the benefit from removing the healthy breast — purely from a cancer perspective — is zero to tiny at best,” said Dr. E. Shelley Hwang, the chief of breast surgery at Duke Cancer Institute, who led the study.

What she wanted to find out was, “If it doesn’t extend longevity, does it at least improve their quality of life?”

Dr. Hwang concluded that the benefits were marginal. “I don’t want to sound terribly negative; some women had very good results and are happy they made the decision,” she said. But, she added, “You’re not better off, you’re not happier, you don’t feel better about yourself sexually by having the healthy breast removed.”

The number of women opting to remove the cancerous breast and the healthy breast – a procedure known as contralateral prophylactic mastectomy or C.P.M. — has surged in recent years. In 2011, about 11 percent of women who were having a mastectomy for cancer chose C.P.M., compared with less than 2 percent in 1998.

Many breast cancer doctors are concerned by the trend, which they expect to increase. Women with early-stage breast cancer have the same odds of survival whether they have a lumpectomy or a mastectomy, and research suggests the risk of a cancer in the contralateral breast is low. But patients say they want to eliminate even the most negligible risk of a recurrence or cancer in their healthy breast.

“Nine times out of 10, the women are the ones who decide,” Dr. Hwang said. “They have cancer, they never want to deal with it again, they just want both breasts off, and they can’t rest until the other breast is done.”

But Dr. Hwang says she has seen the downside of double mastectomies. Surgical complications can occur during reconstruction, which is often a protracted process, and many women have unrealistic expectations about what the new breasts will look and feel like after reconstruction.

Surgery usually leaves the patient with no sensation in the breast area, and the extensive operations can also result in chronic pain.

“One patient said she couldn’t feel hugs anymore when she snuggled up to her kids,” Dr. Hwang said. “That really affected me.”

Many women are influenced by family history. Valerie Garguilo, 54, of Bellport, N.Y., watched her sister die in 2008 after a seven-year bout with breast cancer that was treated with a lumpectomy followed by two recurrences and two more lumpectomies, and then metastasis to her bones and brain. When Ms. Garguilo was found to have a stage-zero cancer herself four years ago, she opted for a double mastectomy, even though she tested negative for harmful genetic mutations.

“I wanted to do whatever I could to cut my chances of a recurrence; I wasn’t going to keep going in for lumpectomies,” she said.

Some women say they do not believe studies that report no difference in survival rates. “I feel like a lumpectomy can’t possibly get everything out,” said Maria Sawicki, 67, of Massapequa, N.Y., who needed a mastectomy on her affected breast but removed her other breast as well. “The littlest thing can be missed.”

For the study, 3,977 volunteers who had had mastectomies — including 1,598 who had had both breasts removed — completed an extensive survey, called BREAST-Q. The survey measured physical well-being, which asks about neck, arm and upper back pain, mobility and the ability to lift the arms; psychosocial well-being, which focuses on body image and confidence in social settings; sexual well-being, including sexual confidence and feelings of attractiveness and comfort level during sex; and breast satisfaction. The last question asks whether bras and clothes fit well, whether the breasts are symmetrical and whether one is comfortable with one’s appearance, clothed and unclothed.

After adjusting for differences between the groups, the researchers found that women who had had double mastectomies had slightly higher scores on psychosocial well-being and breast satisfaction — the differences were only about a point higher on a scale of 100. But scores on the other domains of physical and sexual well-being did not differ from those of women who did not have double mastectomies.

The most important factor in a woman’s overall well-being, the new study found, was whether she had had reconstructive surgery. Most women who had had such surgery reported substantially higher quality of life scores, whether they had single or double mastectomies.

“That’s a much more powerful intervention to improve quality of life than a contralateral prophylactic mastectomy,” Dr. Hwang said.

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A New View of Appendicitis

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Credit Paul Rogers

Gwen Deely’s story is an example of how not to deal with a health crisis when traveling abroad. She realizes she’s lucky to be alive.

Ms. Deely, a 66-year-old living in Manhattan, was on an overnight flight from New York to Venice in October when she developed what she thought was food poisoning, perhaps from the tuna sandwich she had eaten at home that day. She weathered the night armed with more than a dozen airsickness bags and figured it would pass.

But it didn’t, and she spent the entire week in Venice in bed staring at the ceiling in the Airbnb apartment she and her partner had rented. She attributed her low-grade fever and chills to the flu shot she had received just before the trip.

“I would have had to take a boat to get to a doctor, and I couldn’t even stand up,” she said. Her decision not to go to a hospital that was a water taxi ride away was reinforced by a reluctance to seek medical help where she didn’t speak the language. “Had I been in a hotel, I would have asked to see a doctor who spoke English,” she said.

Ms. Deely somehow managed to fly home as scheduled, trying not to act sick on the plane, and went from the airport to the emergency room, where blood tests and a CT scan revealed a ruptured appendix.

Riddled with infection, she spent five days in a hospital on intravenous antibiotics, followed by months of antibiotic treatment and abdominal drainage at home. Finally, in mid-February, she was healthy enough for her ailing appendix to be removed with laparoscopic surgery, involving several tiny incisions in the abdomen.

A ruptured appendix is a life-threatening condition. Blindsided by atypical flulike symptoms rather than the stabbing abdominal pain one usually associates with a ruptured appendix, Ms. Deely failed to realize how close she came to dying. She now knows better than to try to “tough it out” when unexplained, debilitating symptoms occur.

Appendicitis, after all, is very treatable, and surgery is no longer the only option. Patients are now increasingly being offered a trial of antibiotics instead of being rushed into surgery to remove an inflamed appendix (the suffix “-itis” in appendicitis means inflamed). Without treatment, an inflamed appendix can rupture in two to three days after symptoms develop and can spill dangerous microorganisms throughout the abdomen. Thus, it is important to see a doctor as soon as possible.

Symptoms of appendicitis vary, and fewer than half of patients have them all. They often start with abdominal bloating and pain around the navel, which then moves to the lower right side of the abdomen and becomes sharp and continuous. The abdomen is likely to be tender to the touch, and a cough, sneeze, sudden movement or deep breath can intensify the pain. Mild fever, nausea and vomiting, diarrhea or constipation may occur.

Such symptoms are a clear warning that requires prompt medical attention. However, a third to a half of people with appendicitis do not have these typical symptoms, making cases like Ms. Deely’s especially challenging.

The appendix is a finger-shaped pouch attached to the large intestine (colon), usually on the lower right side of the abdomen. Long considered a vestigial organ with no known function, many people, young and old, have theirs removed in the course of another operation.

However, there are now indications that the appendix serves as a repository of healthy bacteria that can replenish the gut after an extreme attack of diarrhea. People who have had appendectomies, for example, are more likely to experience recurrent infections with the bacterium Clostridium difficile, a debilitating intestinal infection that causes severe, difficult-to-treat diarrhea.

Appendicitis occurs most often in children and young adults, and more often in men than women, but the risk of rupture is highest in older adults. The estimated lifetime chance of developing appendicitis ranges from 7 percent to 14 percent.

Acute appendicitis is the nation’s most common surgical emergency. It is most often performed laparoscopically, which is associated with faster recovery, less pain and lower risk of infection than an open operation. Some 300,000 people in the United States undergo an appendectomy each year, but sometimes, the appendix turns out not to have been inflamed, meaning the operation was not necessary.

The results of several recent studies suggest that patients with uncomplicated appendicitis should not be rushed into surgery and instead should be offered the option of a trial of antibiotics.

In a controlled study among 540 adult patients, 72.7 percent of 257 patients randomly assigned to take antibiotics in lieu of an operation did not require subsequent surgery a year later, and those who did need surgery had no bad effects from the delay.

In another nonrandomized study of 3,236 patients who were not operated on initially, the nonsurgical treatment failed to cure the appendicitis in 5.9 percent of cases, and the inflammation recurred in 4.4 percent.

Some patients may choose an operation so they won’t have to worry about developing another attack of appendicitis, but if they aren’t told they have a choice, they can hardly make one.

Writing in JAMA last month, Dr. Dana A. Telem, a surgeon at Stony Brook University Medical Center, noted that “the notion of nonoperative treatment of appendicitis has not been well-received by the majority of the surgical community.” This is hardly surprising, because doctors, like many of us, are creatures of habit, and surgeons who don’t operate miss out on a hefty fee.

But Dr. Telem pointed out that under the Affordable Care Act, it may soon become necessary for physicians to inform patients of nonsurgical options, which may include “watch and wait,” as some cases of appendicitis disappear without any treatment, and there may be nothing wrong with the appendix in others.

“Surgeons would be well served to take a leadership role in proactively developing decision aids to inform patients about the benefits and risks for both nonoperative antibiotic treatment and surgical treatment of appendicitis,” Dr. Telem said. She added, however, that the information should include the fact that data on the long-term outcome of nonsurgical treatment is currently lacking.

Also lacking is a large controlled trial in which patients with uncomplicated appendicitis are randomly assigned to antibiotic or surgical treatment and followed for perhaps five or more years. Such a study could define exactly which patients do best with nonoperative therapy and which require immediate surgery.

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Choose a Thyroid Surgeon Who Does Dozens of Operations a Year

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For surgeons who do thyroid operations, practice makes perfect.

Thyroidectomy, the removal of the thyroid gland, is a common operation, performed more than 130,000 times a year in the United States, but doing it right is difficult.

Researchers, writing in the Annals of Surgery, studied 16,954 patients, about half of whom underwent thyroidectomy for cancer and half for benign conditions.

After adjusting for age, sex, diagnosis and other factors, they found that the risk of complications went down as the number of operations the surgeon performed went up. There was an 87 percent risk of complications for surgeons who did one operation a year; 68 percent for two to five; 42 percent for six to 10; 22 percent for 11 to 15; and 10 percent for 16 to 20. Only 3 percent of patients of surgeons who did 21 to 25 operations a year had complications; those who did more had a similar rate of complications.

Patients of high-volume surgeons had fewer complications not only with the thyroid gland itself, but also less bleeding and wound infection, and fewer respiratory problems. They also spent less time in the hospital after surgery.

The senior author, Dr. Julie A. Sosa, the chief of endocrine surgery at Duke, said that a patient has to be his own advocate. “If you can only ask only one question,” she said, “the most important is: ‘Who are the surgeons who do more than 25 thyroidectomies a year?’ ”