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Avoiding unnecessary surgery in irritable bowel syndrome
  1. George F Longstreth
  1. Correspondence to:
    D. G F Longstreth
    Kaiser Permanente Medical Center, 4647 Zion Avenue, San Diego, CA 92120, USA; george.f.longstreth{at}kp.org

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Protecting patients with IBS from the risks and costs of unnecessary surgery

Surgery has no role in treating irritable bowel syndrome (IBS), the prototypic functional bowel disorder.1 Nevertheless, since Ryle2 reported a high appendectomy rate in such patients nearly 80 years ago, descriptive case series, population-based studies and comparisons of patients with IBS with subjects without IBS and patients with inflammatory bowel disease3–8 have shown that patients with IBS are predisposed to surgery. In two large groups of patients with IBS, cholecystectomy and hysterectomy, which are mainly elective procedures, were increased threefold and twofold, respectively, and the primarily emergency operation, appendectomy, was also increased twofold.5,7 Other abdominopelvic operations, especially colon resection, are also increased,7 as is back surgery.5 Much of this increased surgery must be unnecessary, and high surgical rates have been reported from the UK, Western Europe, Scandinavia, North America, Latin America and South Africa. The association of IBS with normal appendiceal pathology after urgent appendectomy, as reported by investigators from Taiwan in this issue,9 (see page 655) further emphasises the worldwide importance of avoiding unnecessary surgery in IBS.

How much surgery is unnecessary on patients with IBS and the reasons for this problem are difficult to ascertain from studies that are retrospective and lack information on surgical pathology. Furthermore, unlike appendicitis, gallstones and uterine pathology are often asymptomatic and are not life threatening, so their documentation does not necessarily mean that surgery was needed. If hysterectomy is performed for dysfunctional uterine bleeding and chronic pelvic pain (CPP), consistent elimination of bleeding with variable pain relief complicates assessment of the overall benefit. Nevertheless, the available data identify preoperative misdiagnosis of the aetiology of pain as a major reason for increased abdominopelvic surgery in patients with IBS. The prospective study by …

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