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Doctor's Consultation  by Dr. Iain Corness


Surgical risks

Last year I received an email from a farang who was worried about his 17 year old daughter wishing to have the shape of her nose altered (known as a ‘rhinoplasty’).

I replied and (in part) wrote “Yes, there are always inherent risks with all surgical/anesthetic interventions, but honestly the risk in this case is so small as to be almost negligible.  On a practical note, I agree with the decision to delay until she is 18 and can assume some responsibility for going ahead.  Pick a certified cosmetic surgeon working out of an accredited hospital.”

This month I received another email, with him writing, “It gives me no pleasure to tell you that (my daughter’s) friend has been having serious problems with the nose augmentation requiring several doctor visits and long trips from Si Sa Ket (to the clinic).  A second implant surgery to place ear cartilage has been necessary.  I want to reaffirm to you that ‘...almost negligible’ DOES happen; and as you say, NO surgery is totally safe.  Far too many folks, Thai and Farang alike, believe with today's technology surgery is foolproof.  They need a pharmaceutical dose of your wisdom that living life with a bit of a pixie (na-lak) nose shape (one that I personally prefer) isn’t worth ANY small risk of unnecessary cosmetic surgery.”

In my reply, first off, I am not going to get involved in criticizing either the surgeon or the clinic, neither of which I know.  I will also emphasize that I did suggest “a certified cosmetic surgeon working out of an accredited hospital.”  It does not sound as if this was the case here, but I repeat, I am not pointing any fingers in a case where I am not at all appraised of all details.

To give an idea of the chances of unsatisfactory outcomes, I have studied the results in my hospital, and also delved into other resources.  It pleases me to report that our incidence of problems, for all our cosmetic procedures is very much less than one percent.  For rhinoplasty, the figures for ‘real’ problems is even less.  For the anesthetic risk, Dr David Wilkinson of the Association of Anesthetists of Great Britain and Ireland states, “Anesthesia is now very safe, with mortality of less than 1 in 250,000 directly related to anesthesia.”

However, do take heed of the fact that it can take two to four months for all swelling to go down after the surgery.  In some cases, it can take up to a year before the patient knows exactly what their nose is going to look like.  Some people become upset with the look of their post-operative nose in these first months, as crookedness and bumps may show up during the healing process.  Most western surgeons recommend against going through any other procedures, such as revisions, for at least nine months after having nose job.  This does not seem to have been the case in the situation you mentioned, and incidentally, my advice has always been one year.

You are quite correct, of course, when you write that adverse events DO happen; and as you say, NO surgery is totally safe.  However, all of life has inherent risks.  Using a pedestrian crossing in Thailand being a prime example.  It is up to the individual to understand the risks, and then decide for or against.  With cosmetic surgery, which can be a life-changing event, the patient has to weigh up the risk versus the (hoped for) outcome.  It is extremely important that the patient has realistic expectations of the final result, and to have that degree of maturity is, in my view, beyond the ken of a teenager.

It is also my belief that all prospective candidates for the cosmetic surgeon’s knife should have a psychological assessment before any surgery is carried out.  That may sound hard, but unreal expectations are a much greater source of “problems” post surgery, than any problems related to the surgery itself.

However, all of us have a degree of vanity.  Have you ever looked in the mirror and pulled at your cheeks to see what you would look like after a face lift?  I am sure you have!

A miracle for Mrs Gonzales

Mrs. Gonzales was your typical Gibraltarian Mumma.  Around 20 stone in weight, give or take the odd kilogram or six.  These Gibraltarians, descended from the mainland Spanish, were all very similar.  Obese and not particularly stoic, tending towards the histrionic when under stress.  “Oy, Oy, Oy, me dwelle mucho!” (I am in much pain) was regularly heard in the Casualty department before the diagnosis of blisters from new shoes and the medically applied Band-Aid handed out.  Mrs. Gonzales was one of these.

She presented at outpatients with a history of alternating diarrhoea and constipation for some months and now she noticed that there were some hard lumps in her stomach.  Some?  She had lots.  My boss, Mr. Toomey, was one of the last of the British colonial surgeons and I asked him to see her.

Mr. Toomey confirmed the presence of the lumps with his experienced hand, and told me the diagnosis.  Mrs. Gonzales would have disseminated cancer and would be inoperable; however, we would open her up to confirm the diagnosis, but that would be as far as the operation would go, he said.  Open and close.

On the Tuesday, Mrs. Gonzales was prepped and a large abdomen awaited us.  Mr. Toomey made a mid-line incision and we did not have to go further.  Large grey/white lumps, firmly adherent to everything, greeted us.  We did not count how many.  It was pointless.  It was, just as Mr. Toomey predicted, simply everywhere.  We had opened, and we closed.

Mrs. Gonzales was returned to the ward after being sewn up and the gravity of the situation was later explained to her.  We could not help.  There were limits to medical science, expertise and knowledge (and there still is), but we would make her last remaining weeks as comfortable as possible, while she came to terms with her personal God (Gibraltar, like Spain was predominantly Roman Catholic).

Mrs. Gonzales reacted to the bad news with none of the expected wailing and gnashing of teeth, but by telling us that she would be getting better and she would be going home for Xmas.  “In a wooden box,” I thought to myself.

The post-operative phase was not uneventful.  The cancer tissue came through the wound and we now had an abdominal ulcer that was never going to heal.  Daily dressings and wound cleaning was all that could be done, she was, after all, terminal.

It did not stop there.  The cancer then eroded through the bowel, so now there was a direct passage for the faecal matter to get to the outside.  It was quite horrible.  The smell was so bad we had to put her in a private room, as the other patients in the ward began to complain.  And yet, all the time, Mrs. Gonzales said she would be going home for Xmas.  I did not change my opinion.  It would be on a pine box.

However, after three months, the seemingly impossible occurred.  Her inoperable multiple cancerous lumps had disappeared, along with the abdominal discharge.  It had healed over!  When I told Mr. Toomey, he also did not believe me, but after examination had to agree that clinically there was no cancer evident, and the abdomen was clear.

Mrs. Gonzales did indeed go home for Xmas, waddling proudly out of the hospital to the waiting taxi.  She thanked us all for what we had done, but I felt embarrassed.  We doctors had done nothing to get her over her cancer problem.  The nursing staff had done far more than we had, but the final outcome was all down to Mrs. Gonzales’ personal faith.  Her personal ‘Higher Physician’ was obviously not ready for her, even though we had mentally consigned her to crossing the River Styx.

(Footnote: In this day and age, with medical technology so much more refined, there are many more procedures we could use to evaluate Mrs. Gonzales’ condition such as CT scans, Magnetic Resonance Imaging (MRI) and even colonoscopy.  However, these would not have changed the outcome, they are merely diagnostic tools, and not definitive treatment, and would not replace the practised surgeon’s hand on the abdomen, which was about all we had on the rock of Gibraltar in 1967.)

Why an MRI?

MRI (magnetic resonance imaging) is one of the battery of radiological diagnostic examinations that can be done.  The procedure is similar to an X-Ray, in the fact that the end result shows the internal structures of the body with a test that produces very clear pictures - but without the use of X-rays.  MRI uses a large magnet, radio waves, and a computer to produce these images.

Some folk are a little apprehensive about these expensive tests, but the risks to the average person are negligible.  The MRI uses magnetic fields, rather than radio-active imaging.  However, the magnetic field is very strong.  Walk into the examination room and the MRI can wipe the details from the magnetic strip encoding on your credit card, stop your watch and even pull the stethoscope from the doctor’s pocket!

MRI is also different from X-Rays in what it can pick up.  The MRI can detect tumors, infection, and other types of tissue disease or damage.  It can also help diagnose conditions that affect blood flow.  Tissues and organs that contain water provide the most detailed MRI pictures, while bones and other hard materials in the body do not show up well on MRI pictures, as opposed to X-Rays which do show bone well but not soft tissue.  For these reasons, MRI is most useful for detecting conditions that increase the amount of fluid in a tissue, such as an infection, tumors, and internal bleeding.  In some cases a contrast material may be used during the MRI scan to enhance the images of certain structures.  The contrast material may help evaluate blood flow, detect some types of tumors, and locate areas of inflammation.

People who have had heart surgery and people with the following medical devices can be safely examined with MRI: surgical clips or sutures, artificial joints, staples, cardiac valve replacements (except the Starr-Edwards metallic ball/cage), disconnected medication pumps, vena cava filters or brain shunt tubes for hydrocephalus.

However, some conditions may make an MRI examination inadvisable.  Tell your doctor if you have any of the following conditions: heart pacemaker, cerebral aneurysm clip (metal clip on a blood vessel in the brain), pregnancy during the first three months (we are just being super cautious here), implanted insulin pump (for treatment of diabetes), narcotics pump (for pain medication), or implanted nerve stimulators (“TENS”) for back pain, metal in the eye or eye socket, cochlear (ear) implant for hearing impairment, or implanted spine stabilization rods.

I think most people are familiar with the standard X-Ray procedure, stand there, breathe in, hold it, now breathe out routine, but MRIs are a little different.  These are done with you lying there and inserted into the MRI scanner, which is like a tunnel.  Those people who are claustrophobic can have a little problem here, as the MRI “tunnel” is very tight.  When I had my own MRI done I noticed that my nose was close to the top of the tunnel and both elbows were brushing the sides, and I am considered a reasonably slim individual.  I have to say that although not claustrophobic, I do not particularly like being in enclosed spaces, and found that the best way to endure the MRI was to pretend I was lying relaxing in a field.

During the procedure, which can take up to an hour, you can hear the operator talking to you, and he or she can hear your reply, but you still will feel rather isolated in your magnetic tunnel.  You can also hear (and feel) muffled thumps and groans that come from the tube, which can be somewhat unsettling.

In some cases a contrast material may be used during the MRI scan to enhance the images of certain structures which may help evaluate blood flow, detect some types of tumors, and locate areas of inflammation.  The contrast material is injected via a vein, and the MRI operator will advise you when this is being injected.  You may feel a warmth or even tingling feeling as this is happening, but this is not worrisome.

The radiologist then reviews the pictures produced and will advise you of the outcome.  I hope it will be good news!

“Natural” remedies and EBM? Are they good for you?

I was fortunate enough to have dinner with a retired ENT professor the other night.  As all doctors do after being introduced, we began exploring each other’s opinions on various aspects of medicine, and I was delighted to hear he was an advocate of EBM, as I am.

Regular readers of this column will know that I have mentioned the acronym EBM many times.  This stands for “Evidence Based Medicine” and is a key factor in modern medicine.  It just means we test until we have the evidence that any drug or treatment really does work.  This all takes time, as the evidence cannot just hang on one person who got better.  It requires huge series, across the globe (and even then we get a few wrong).

However, as patients, or sufferers of any complaint, we want that “cure” right now!  Consequently, with all medical conditions where we cannot give the patient the “wonder pill” there is then a tendency for them to try something else, anything else, hoping for the relief that conventional medicine has not promised or delivered.  For the musculo-skeletal conditions, for example, the “alternatives” are multiple, from magnets to mussels from New Zealand.  But do they really work?

The problem with the non-pharmaceutical mainline pills and potions industry is in unbiased scientific testing.  The tablets that Roche, Parke-Davis, Bayer and all that lot produce are rigorously and vigorously (viagorously?) tested.  Not only do the drug companies have to show that their pills actually work, but they also have to show what side effects they can produce and whether or not they interact with other pills and potions to make explosive mixtures.  The “alternative” pill and potion manufacturers do not have the same degree of scientific scrutiny.

There are those who will claim that because the remedies come from plants, that the ingredients are then “natural” and therefore OK for us humans.  This is pseudo-scientific nonsense.  Extracts of plants and herbs are chemicals - and some chemicals can kill, that is why wild animals can die after eating the wrong plants.  So can you!

So let us look at a few of the alternative treatments and analyze just whether they are indeed efficacious.  Willow Bark is one that is used for arthritis, because it was imagined that since the tree grew in damp environments, and arthritis was thought to be caused by “damp” then treatment with the bark was “logical”.  The herbalists got the right answer, however, no matter how wrong the reasons!  Willow Bark does have an effect because it contains salicylates - more commonly known these days as aspirin!  Other “natural” sources of aspirin include poplar tree bark, black cohosh (a North American plant), pansies, violets and meadowsweet.  Aspirin works!

Have you heard of Devil’s Claw?  This South African plant has been studied to see if it has any anti-inflammatory action in arthritis.  The small studies that have been done show no effect, but it is an analgesic (pain killer), so those people with arthritis do feel better when they take it.  In fact, demand is now outstripping supply - but they would do just as well with a strip of paracetamol tablets.  And cheaper too!

Another of the well touted treatments for arthritis is the green lipped mussel.  According to the pundits, this form of treatment has had numerous clinical trials, and unfortunately, the same number of clinical failures!  However, I believe they are quite nice steamed with garlic, ginger and shallots!

One other niggling problem with the “natural” therapies is that for musculo-skeletal problems, most of which are of a long standing chronic nature, even less scientific work has been done to see what happens when you take these medications for a protracted period of time.  Until long term safety has been ascertained, I would counsel caution, and beware mixing pharmaceutical drugs and over the counter “alternatives”!

Reactions to pharmaceutical items are still reasonably rare and well documented.  I cannot say the same for the “natural” remedies.

Finally, I was very amused to read of a health food shop being offered for sale.  The reason the owner was prepared to sell?  Ill health!