Disadvantage of Bypass Surgery

Dr. SJS Randhawa MD; DNB; Noninvasive Cardiologist Randhawa Hospital, 12 Mall Road, Amritsar, India

You have chest pain on exertion, an abnormal ECG, and three blocked arteries on angiography. Every cardiologist you consult will advice “opening up” of the blockages and put in a stent to “keep it open”. If you happen to consult a cardiac surgeon the invariable advice is CABG (Bypass surgery) “to fix it once for all”. Doctors recommend immediate bypass surgery despite a lack of vigorous studies to support that strategy. Today I will present some current views against Bypass surgery.

The biggest argument against CABG is that it is a major, risky, life-threatening procedure. You can actually be dead trying to cure a disease which may not have killed you in the next 15 years. The surgeons may tell you that in the best centers in the world the surgical mortality is about 2% only. They overlook two factors. Your neighborhood heart center may not be “the best” in the world. Add to it the greed, lack of skill, lack of adequate post operative care, cutting corners to save more money, re using of disposables and the recipe for disaster is complete.

The biggest argument against CABG is that it is a major, risky, life-threatening procedure. You can actually be dead trying to cure a disease which may not have killed you in the next 15 years. The surgeons may tell you that in the best centers in the world the surgical mortality is about 2% only. They overlook two factors. Your neighborhood heart center may not be “the best” in the world. Add to it the greed, lack of skill, lack of adequate post operative care, cutting corners to save more money, re using of disposables and the recipe for disaster is complete.

What the surgeon will conveniently “forget” to tell you is that the 30 day post op mortality is 5% even in the “best centres”. A large study (STICH STUDY) comparing surgery with aggressive medical management found no difference in death rates after 5 years. Dr Eric J. Velazquez, a cardiologist at Duke University Medical Centre, Durham, N.C., and lead investigator of the Stich study said “In many cases, patients tested for coronary-artery disease "get put on an express train. By the time people realize it, they've had bypass surgery." Thank you sir, for putting it so frankly!

I quote from the STICH study “Open-heart surgery has an early risk of death, with nearly 5% of patients who underwent bypass surgery in the study dying within 30 days of surgery. The result was in line with surgical outcomes in both Europe and the U.S. for high-risk patients”.

Add to the above, the fact that up to 5% of Diabetics develop deep wound infection after surgery and in these patients the death rate could be as high as 30%. Also to be considered is further damage caused to an already poorly functioning kidney (due to old age, diabetes or hypertension), resulting in lifelong dialysis.

The most disturbing complication is Stroke or paralysis in 2-3% of the patients.Dr Frank M Sellke who is the vice chairman of American Heart Association says that after Bypass Surgery upto 20% of patients have some degree of mental impairment in the form of recognition, memory and higher functions. Tiny fragments of blood clots travel to the brain and block small arteries, reducing mental function. (BBS – Cognitive Study) 2006.

In an editorial in the New England Journal of Medicine accompanying the study, James Fang, a cardiologist at University Hospitals Case Medical Centre in Cleveland, said doctors "should be comfortable" generally that surgery isn't better than the best medical therapy for the kind of patients participating in the study.Get a surgeon to agree to that!

"You don't have a good therapy and a bad therapy, you have a choice," said Clyde Yancy, chief of cardiology at Northwestern University's Feinberg School of Medicine, who wasn't involved with the study. "It really is about choice and not about which is superior."

"If patients are informed, they will make different decisions based on their own background," experiences and perception of risk, said Raymond Gibbons, a cardiologist at the Mayo Clinic who wasn't involved in the study. "I don't think doctors should be making the judgment for them."

I have been saying all of this and more since the last 15 years, and now finally it is heartening to know that more and more doctors have the courage and evidence to spell it out. My own experience is that surgery should be the last resort after failure of Aggressive medical treatment (AMT).In the last 10 years the failure rate of AMT, hence recommendation for CABG at Randhawa hospital has been about 5%.In other words, if you do have CAD with triple vessel disease there is a 90 to 95% chance of avoiding bypass surgery.

And you know what the tragedy is ? Not even 10% of the patients in my country are on AMT. Can anyone guess the reason for that?

Someone in the Govt should read this.

Comments welcome.

Dr SJS Randhawa MD DNB