Ginseng, yoga and surgery – a recipe for success?.

Patterns of usage of complementary and alternative medicine in general surgical patients

Use of complementary and alternative medicine (CAM) is becoming increasingly common. The purpose of this study was to determine the prevalence among general surgical patients, whether its use is related to disease type, and if postoperative patient-perceived problems and actual complications may be related to some CAM use.

Methods

One hundred fifty-one consecutive patients over a 3 month period were queried. Demographic information was obtained from the medical record pertaining to age, gender, race, marital status, treatment and postoperative complications. CAM practices were divided into three categories: body/structure, herbal medications/supplements, and mind/spirit. Data were analyzed for overall use of CAM and type of CAM. Relationships of CAM use to gender, age, race, and disease type, patient-perceived postoperative problems, and actual incidence of postoperative complications were determined.

Results

Sixty patients (40%) used some type of CAM: 17% body/structure interventions, 31% herbal medications, and 3% mind/spirit practices. Demographics of CAM use: 47% of Caucasians, compared to 29% of African-Americans; 44% of females, compared to 34% of males; 49% of patients less than or equal to 60 years old, compared to 32% of patients more than 60 years old; 48% of patients with a cancer diagnosis, compared to 31% of patients with a benign diagnosis. Thirty-three of CAM patients reported some type of postoperative problem, compared to 26% of non-CAM patients. Actual complication rates were 8% for CAM patients, compared to 11% for non-CAM patients.

Discussion

This study demonstrates that CAM use is common among general surgical patients. About 40% of patients used some type of CAM, with herbal medications being the most common (31%). This is consistent with other studies, which report the use of CAM by surgical patients in 5–60% range. Some of these practices, like the use of chiropractic, are relatively innocuous; while, others, such as acupuncture, may be beneficial. The most concerning group of CAM use is herbal medications because of their potential adverse surgical effects and drug interactions.

Several of the herbal medications used in this study are known to have adverse effects on anesthesia and surgery, while others are completely unknown. Echinacea, Ephedra, Ginkgo, garlic, St. John's Wort, Ginseng have all been shown to have potential adverse perioperative effects. Although generally considered safe, there has been one case of intraoperative bleeding associated with Saw Palmetto. Grapeseed extract has been shown to interfere with platelet function and, therefore, may increase the risk of operative bleeding. Other herbal medications may affect perioperative care because of their interactions with allopathic drugs. For example, Echinacea and Astragalus may offset the effects of corticosteroids. Ginseng, Ephedra, and St. John's Wort affect MAO inhibitors. Garlic, ginger, Ginkgo, and Ginseng affect warfarin effectiveness. Others mafy not directly affect perioperative care, but other aspects of patients' care. Flax seed oil, Black cohosh, and Ginkgo have estrogenic properties and may affect estrogen-receptor positive breast cancers. Substances with antioxidant properties, such as garlic, grapeseed extract, Ginkgo, and green tea, may affect cancer therapies that rely on oxygen radical production, like radiation therapy, anthracyclines, alkylating agents, and podophyllum agents. What is most troubling is that many of the products used are proprietary, and there exact herbal combinations and amounts are not to public knowledge. Therefore, there is no way to predict what perioperative effects these may have. In general, the magnitude of the risks posed by herbal medications is still unclear.

There appears to be populations of patients who are more likely to use CAM therapies. We found that younger patients, Caucasians, females (although not statistically significant), and patients with a cancer diagnosis were more likely to use CAM. Adusumilli et al. similarly found that younger patients, Caucasians, those with a college level or professional level education, and higher income levels were more likely to use CAM. Others have also documented a high prevalence of CAM usage among cancer patients. Therefore, although it would be prudent to inquire about CAM usage with all patients, surgeons should know which groups are more likely to use these treatments.

Because there may be a higher level of distrust of traditional allopathic medicine in CAM users, one of the hypotheses of this study is that they would perceive that they had more problems with surgery than non-CAM users. For example, in a study of breast cancer patients who refused standard treatment for breast cancer, several used CAM treatments as an alternative. Among the basic reasons these patients gave for refusing standard treatment included misunderstandings and distrust toward allopathic medicine and physicians. There are other reasons cited for the use of CAM, including the sense of “being in control.” Given how CAM users may feel about allopathic medicine, and especially surgery in which they are not in any type of control, one would suspect that they would perceive more adverse surgical consequences. Although one-third of CAM users felt that they had a postoperative problem, this was not statistically different than the one-quarter of non-CAM user. This appears to be the first study assessing patient-perceived postoperative outcomes of CAM users.

Despite a long list of potential perioperative complications and drug interaction that could have occurred, there was no difference in actual postoperative adverse events. This has two potential explanations. The first is that the sample size of this study was too small to detect a true difference. A larger sample may be better at detecting these differences. Secondly, although there is much literature on potential adverse events, we simply do not have good data on the occurrence rates of these events. We do not know what exactly is the increased risk documented by many studies. There are two reasons for this. Firstly, we do not know the denominator of the number of surgical patients who use CAM, particularly herbal preparations. Secondly, we do not know the numerator of the number of postoperative complications that can be definitively contributed to CAM use. Clearly, more studies are needed on these issues.

In summary, surgeons should seek out information from their patients with respect to CAM usage. Most authorities advise their patients that all herbal medicines and dietary supplements (especially megadose supplement) should be discontinued for at least 2–3 weeks prior to surgery. Despite the potential adverse events associated with CAM, there is very little in the surgical literature on actual adverse events. Nevertheless, surgeons should be cognizant of CAM usage by their patients, and be aware that some CAM practices may have potential adverse surgical and anesthetic effects.

Conclusions

Use of CAM is relatively common, with younger, Caucasian patients with malignancies being the most common users. However, there seems to be no difference in perceived postoperative problems, nor actual postoperative complications between CAM and non-CAM users.