Would you buy an airplane ticket if the pilot refused to check his instrument panel before taking off?

You’d probably would run for the woods, choose another airline or decide it’s safer to go by train. But a recent study shows that some surgeons are not following proven surgical guidelines for a potentially fatal operation. What’s needed? A big dose of pilot discipline.

A study done at the University of Alberta reviewed carotid endarterectomies done in four western provinces. This study revealed that one in 10 of these procedures should not have been performed, and 47% were done for dubious reasons. The conclusion? Surgeons needed ‘cockpit management’.

Endarterectomy is a common operation performed to prevent stroke in patients who have partial blockage of carotid arteries. These arteries, situated along both sides of the neck, carry oxygenated blood to the brain. A sudden blockage triggers a devastating stroke.

Patients with partially blocked carotids often suffer from transient ischemic attacks (TIAs), mini-strokes. They complain of blindness and numbness lasting only a few seconds. Unfortunately, TIAs are often the prelude to a major stroke and there’s no better case for practicing prevention.

The surgical treatment is similar to a plumber’s approach to a blocked drain. But, rather than inserting a snake to remove the obstruction, surgeons use delicate instruments to scrape and suck out atherosclerotic plaque. It’s a tedious and potentially dangerous task. During the operation a portion of plaque may break loose, travel to the brain and cause a stroke, the very thing the operation was meant to avoid.

It’s a tragedy if a patient suffers a stroke when there’s valid reason for the surgery. But if it happens when surgery is unjustified, it’s a catastrophe impossible to measure.

So why are questionable endarterectomies being done?

Dr. Henry Barnett, professor emeritus at the University of Western Ontario, is a world authority on carotid endarterectomy.

He says guidelines for this surgery have been extensively researched and are crystal clear about when and when not to use the operation. And that some surgeons are not following the guidelines.

For example, the operation should not be done if the carotid artery is only 50% blocked. And great care should be taken if patients have no symptoms such as TIAs. In these cases the risk of surgery is greater than the risk of the disease.

This report reminded me of one of my Harvard professors who reminded us that, “It’s impossible to make a patient feel any better if he or she has no symptoms!”

The study also revealed that the risk of questionable surgery depends on where you live. Surgeons in Saskatchewan received the most accolades as 78% of the operations adhered to the strict guidelines. Surgeons in British Columbia followed the specifications in only 46% of cases.

For surgeons, this finding is like getting caught with a hand in the cookie jar, an embarrassing experience. But the result of this study, reporting potential problems has been good for patients.

Dr. Max Findlay, a neurosurgeon at the University of Alberta Hospital, reports that due to this criticism the rate of inappropriate endarterectomies has fallen from 18% to zero in Edmonton!

But should this surgery ever be proposed for patients who do not suffer from TIAs? If blockage is extensive even without symptoms, it could be the lull before the storm, and the risk of stroke greater than the risk of surgery.

The transcranial Doppler is now being used to determine which patients need surgery. If this procedure detects the presence of micro emboli (tiny blood clots) in the brain, it’s believed these patients would also benefit from the operation.

It’s always good to remember that surgery of any kind is a risky affair.

Harvey Cushing, Harvard’s famous neurosurgeon, once remarked, “There is no such thing as minor surgery, but there are a lot of minor surgeons.”

I’m sure he would agree that strict ‘cockpit management’ by surgeons would go a long way to removing part of the risk of this surgery.

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