The mantra with which I grew up in medicine was that appendicitis is a surgical disease.  A recent review in the Journal of the American Medical Association (JAMA), however, documents medical studies that show broad spectrum antibiotics can be useful in a selected group of patients in the treatment of acute appendicitis.  Non-surgical intervention, therefore, can be considered in patients for whom surgery is very risky and/or for whom findings on a CT scan indicate uncomplicated pathology.  Deciding on a non-surgical approach requires, however, careful consideration of outcomes, as well as patient desires.  Studies show that recurrence of appendicitis within one year of using the antibiotice approach can range from 15 to 40 percent.  Antibiotic treatment is not a panacea, but can be useful in selected situations.

I was reminded of the more consevrive approach to medical problems with a recent study of laser therapy for symptoms from vaginal atrophy in older patients.  This intervention has become very common in postmenapausal women with recurrent vaginal infections and sexual dysfunction.  Good clinical research, somewhat tardy in the investigation of the usefulness of laser therapy, however, shows that the laser procedure has no advantage over vaginal estrogen cream.  Another cottage industry has been threatened with the new data.

These studies have called to mind many procedures in medicine that have fallen from common use because of good research that revealed their uselessness.  

Swan Song for the Swan-Ganz

The Swan-Ganz catheter is a prominent example.  The determination of the hydrational status of critically ill patients (do they need more IV fluids, or less?) can be very challenging.  In the 1970s, the two physicians after whom the device was named, developed the balloon flotation catheter that could fairly easily be inserted into the lungs through the right side of the heart.  For arcane physiological reasons that are not important for the purposes of this article, accurate assessment of a patient’s fluid status, which is critical to the care of very ill patients, became much easier.  

The use of the Swan-Ganz became a routine standard of care in the 1980’s up to the turn of the century.  Investigators then began to ask the question of whether this elegant tool actually improved patient outcomes. The answer was negative–in fact there was a non-statistically significant trend toward harm.  The routine use of this procedure, which is still useful in selected situations, fell out of favor with these studies.  But not before billions of dollars were spent on the discredited intervention. 

Another Beguiling Procedure Proven Useless 

A similar fate befell the Extracranial-Intrcracnial Arterial Bypass procedure in common use by neurosurgeons and vascular surgeons in the 70’s and first part of the 80’s.  This technique bypassed the normal cerebral circulation, in much the same way that heart surgeons establish circulation around diseased arteries in the heart.  Studies were finally done, and, even though the procedure definitely improved circulation, the clinically relevant question was negative: it did not reduce mortality and strokes, large or small.

Breast Cancer: Progress Through Restraint

Another famous example of restraint in medical care involves the surgical treatment of breast cancer.  The Halsted procedure, established in the late 1800’s, was the surgical standard of care up until the 1970’s.  It involved radical surgery, with removal of the breast and the axillary lymph nodes (lymph nodes in the armpit), and later, the pectoral muscle overlying the affected breast.  This often resulted in morbidity such as intractable swelling of the arm on the affected side, not to mention the adverse cosmetic consequences.  Now breast surgery is much less mutilating, and along with improved staging and diagnostic techniques, it is associated with mortality outcomes equal to or greater than those with the Halsted procedure.

Bad News/ Good News

I am often disturbed by the mindless embrace of new technologies in healthcare that slip into the medical armamentarium before they are proven to actually help patients.  On the other hand, I am proud when medicine finally finds the wherewithal to critically examine the efficacy of interventions that have come into common use without adequate study.  Sometimes, less is more.