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Office Surgery: Is It Safe?

Study suggests, yes, for most procedures

TUESDAY, May 22 , 2001 (HealthDayNews) -- Some doctors have been accused of practicing a swashbuckling brand of surgery in their offices, taking dangerous liberties with patients' lives by performing procedures more appropriate in the hospital.

But with pressure mounting on states to crack down on medical errors, a new study suggests that patients who undergo minor surgery in a doctor's office aren't at any particular risk.

The study, which looked at Florida doctors working on their own and in small surgical centers, found that operations that rely on local anesthesia are generally quite safe. However, the study shows that general anesthesia, especially when combined with liposuction, can be deadly and may well be better left to fully outfitted hospitals.

"The worries about office procedures are greatly exaggerated," says Dr. Brett Coldiron, the Cincinnati dermatologist who conducted the study. It appears as a letter in this week's issue of the Journal of the American Medical Association. "I personally think they should ban general anesthesia in the office, but if you have a fully equipped anesthesiologist anywhere, you've got any capability that you need."

Coldiron, who is also a clinical professor of dermatology at the University of Cincinnati, examined the fallout of a 2000 Florida law requiring doctors to report to the state any deaths, brain or spinal injuries, procedures performed on the wrong patient, and other serious blunders that occur in their offices. Reports of deaths resulting from outpatient surgery, largely from liposuction to remove fat, prompted a temporary, emergency moratorium on procedures involving deep or general anesthesia.

In addition to Florida, at least four other states -- California, Texas, Rhode Island and New Jersey -- have passed some form of law addressing office surgeries, according to the American College of Surgeons.

Coldiron reviewed the Florida case reports collected between February 2000 to February 2001. Of 55 initial reports, 31 involved procedures resulting in major complications or deaths, and these were performed by 28 physicians. (Since his letter was published, Coldiron has posted another 20 or so reports on his Web site but has yet to fully analyze them.)

Six patients died, one from a fatal allergy to an imaging contrast chemical. All of the remaining five had received general anesthesia, Coldiron says, and three had undergone liposuction. Indeed, liposuction under general anesthesia was linked to eight complications, more than any other single operation.

When incidents did occur, everything from blood clots to snagged instruments, they were things that could just as easily have happened in a hospital, Coldiron says. "There were no examples of something that went on in the office that wouldn't have gone on in the hospital."

Far from being "renegade physicians," as some critics have suggested, all but one of the 28 doctors who reported deaths or serious complications were board certified, Coldiron says. And almost all had hospital admitting privileges. "Dermatologists aren't performing neurosurgery in their garages."

Nor were doctors without training in anesthesia giving the sedating drugs. "Anesthesiologists were claiming that people were doing their own anesthesiology, but that's not the case," he says.

What's more, he says, the fact that a surgical center or office was accredited by an oversight group didn't immunize it from the risk of complications. "Having an accredited office is not a guarantee that you won't have an incident," says Coldiron, who adds that such an endorsement might encourage physicians to be more aggressive.

The debate over the safety of in-office surgery has profound economic implications, Coldiron says, since a trip to the hospital for the same procedures can cost two to three times as much as an in-patient operation. "You'd hate to see someone die because they can't afford their colonoscopy in the hospital."

Dr. Dean Johnston, president of the Florida Society of Plastic Surgeons, disagrees that either liposuction alone or general anesthesia are too dangerous for the doctor's office. However, Johnston says, evidence suggests that the combination of "tummy tuck" surgery with the fat removal procedure, regardless of the manner of anesthesia, can be deadly.

"When you combine [the two] there's an increased risk of death, and my personal opinion is that they should never be done together," says Johnston, who notes that two of the deaths cited in the journal letter involved tummy tucks, one of which was paired with liposuction.

While Johnston commends Florida for "taking the bull by the horns" with patient safety issues, he says the state went too far in its statute by failing to protect the confidentiality of doctors who report adverse reactions.

Linda Peterson, who oversees ambulatory and laboratory programs at the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, Ill., says her group is in favor of state efforts to monitor office surgery. "I'm in full support of any type of reporting process that improves patient safety," she says.

As a result of the Florida law and brief moratorium, the Joint Commission this year introduced a new accreditation program for office-based surgeons practicing in groups of four or less, Peterson says. The review doesn't assess an individual doctor's skills, but it does rate offices for factors like infection protection, proper emergency equipment and adequately trained staff. So far, at least 16 physicians have signed on to the program, she says.

What To Do

For more on patient safety, try the Joint Commission on Accreditation of Healthcare Organizations. You can also visit the American Society of Plastic Surgeons.

Or you may want to take a look at previous HealthDay stories on medical errors.

SOURCES: Interviews with Brett Coldiron, M.D., clinical assistant professor of dermatology, University of Cincinnati; Linda Peterson, executive director, ambulatory and laboratory programs, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill., and Dean Johnston, M.D., president of the Florida Society of Plastic Surgeons, Jacksonville; Journal of the American Medical Association, May 23, 2001
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