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Law of diminishing returns: the laparoscope

The effects of medical progress are subtle and complex. A fascinating paper from Maryland shows just how complex.

The march of the laparoscope

Laparoscopic cholecystectomy has made dramatic inroads into conventional surgical practice, with many benefits. A large survey of discharge data from all 54 acute care hospitals in Maryland was carried out between 1985 and 1992 to identify open and laparoscopic cholecystectomies [1].

The annual rate increased from 1.7 per 1000 residents in 1987-9 to 2.2 per 1000 residents in 1992, an increase of 28%. Patients undergoing laparoscopic cholecystectomy were younger, less likely to have acute cholecystitis or a common-duct stone, and were more likely to be white and have private health insurance.

Operative mortality

Operative mortality of laparoscopic cholecystectomy was less than that for the open operation (odds ratio 0.22; 95% confidence interval 0.13 to 0.37). There was a decline in the overall cholecystectomy mortality rate from 0.84% in 1989 to 0.56% in 1992.

Swings and roundabouts

When a new medical or surgical advance is introduced, it may be used not simply for the population that received the old treatment, but for a new population. This may be because it is safer (as is the case for laparoscopic cholecystectomy), or because it is more acceptable to patients (as with MRI rather than myleography, for instance).

The authors' conclusions were striking. What they found was "although the adoption of laparoscopic cholecystectomy has been accompanied by a 33% decrease in overall operative mortality per procedure, the total number of cholecystectomy-related deaths has not fallen because of a 28% increase in the total rate of cholecystectomy."

The authors are duly cautious, and the paper is worth reading for its careful analysis of possible confounding factors. But one is left with the uneasy suspicion that the development of a new technology to solve an old problem has led to a new population being treated whose need for, and benefit from, treatment is not as clearly defined.

Bandolier does not like to appear Luddite. Laparoscopic cholecystectomy is clearly an important advance (though not all keyhole surgery has fulfilled its early promise), but the subtle change in threshold that takes place on introduction of a new technology is always a cause for concern.

  1. CA Steiner et al. Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. New England Journal of Medicine 1994 330: 403-8.

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