Medicine: Second Opinions on the Bypass

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The study raises questions about other surgical efforts to increase the flow of blood to the brain in patients with a high risk of stroke. In an editorial accompanying the report, Dr. Fred Plum of Manhattan's New York Hospital cites a "Roto-Rooter" type of surgery called endarterectomy, in which the surgeon scrapes fatty material, or plaque, from a clogged carotid artery in the neck. This operation is far more common than the cerebral bypass (100,000 a year performed in the U.S., vs. about 3,000 bypasses), but, Plum observes, "there are sharp divisions of opinion about whether [it] offers an advantage for any but a very small number of patients." He also suggests that it is time for insurance companies and Medicare to re-evaluate their policy of covering bypass surgery, which costs an average of $15,000 per patient, including hospitalization.

About 400,000 Americans are afflicted by stroke each year. It is a leading cause of adult disability and the nation's third biggest killer, after heart disease and cancer. Other than surgery, treatment usually consists of preventive measures to control such risk factors as high blood pressure, high cholesterol levels in the blood, smoking and diabetes. In addition, doctors often recommend daily doses of aspirin to help prevent the formation of blood clots, which may become lodged in clogged vessels. The use of these measures, and particularly improved medical treatment of hypertension, are thought to be responsible for a 58% decline in deaths from stroke in the U.S. during the past quarter-century.

Despite the new study, some doctors believe that cerebral bypass surgery can still play a role in the treatment of stroke. "I agree that this is probably an operation that was done too often," says Surgeon John Little of the Cleveland Clinic Foundation, "but what are you going to do for the patients who are not helped by other medical treatment?" Little insists that the bypass procedure has been refined since the study began. Says he: "There is still a subgroup of patients who need this operation." Dr. Murray Goldstein, director of NINCDS, allows for this possibility, but, he cautions, "if you do the surgery, the responsibility is yours. The study results are crisp and clear. It's now up to those surgeons who believe in the benefits to demonstrate them." --By Claudia Wallis. Reported by Christine Gorman/New York