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Unnecessary abdominal and back surgery in irritable bowel syndrome: time to stem the flood now?

2004; Elsevier BV; Volume: 126; Issue: 7 Linguagem: Inglês

10.1053/j.gastro.2004.04.029

1528-0012

Nicholas J. Talley,

Music Therapy and Health

Irritable bowel syndrome (IBS) is a remarkably prevalent and important condition; it affects at least 1 in 20 Americans (and, depending on some estimates, as many as 1 in 5), causes chronic symptoms that can seriously impair quality of life, and remains a treatment challenge in practice.1American College of Gastroenterology Functional Gastrointestinal Disorders Task ForceEvidence-based position statement on the management of irritable bowel syndrome in North America.Am J Gastroenterol. 2002; 97: S1-S5PubMed Google Scholar, 2Halder S.L Locke III, G.R Talley N.J Fett S.L Zinsmeister A.R Melton III, L.J Impact of functional gastrointestinal disorders on health-related quality of life a population-based case-control study.Aliment Pharmacol Ther. 2004; 19: 233-242Crossref PubMed Scopus (170) Google Scholar, 3Saito Y.A Schoenfeld P Locke III, G.R The epidemiology of irritable bowel syndrome in North America a systematic review.Am J Gastroenterol. 2002; 97: 1910-1915PubMed Google Scholar Positive symptom criteria have been developed by the Rome Committees that, in the absence of alarm features, allow the positive identification of IBS without the need for any tests (arguably a major advance).4Cash B.D Schoenfeld P Chey W.D The utility of diagnostic tests in irritable bowel syndrome patients a systematic review.Am J Gastroenterol. 2002; 97: 2812-2819Crossref PubMed Google Scholar However, diffusion of this knowledge has been relatively sparse. Longstreth et al.5Longstreth G.F Burchette R.J Family practitioners’ attitudes and knowledge about irritable bowel syndrome effect of a trial of physician education.Fam Pract. 2003; 20: 70-74Crossref Scopus (47) Google Scholar, for example, have reported that, among a group of 35 family practitioners in a large health maintenance organization, IBS was ranked among the 5 chronic, painful syndromes as the highest in difficulty in satisfying patients. Worryingly, the majority could not identify the Rome symptom criteria. Similar data have been reported in other countries and practice settings.6Bijkerk C.J de Wit N.J Stalman W.A Knottnerus J.A Hoes A.W Muris J.W Irritable bowel syndrome in primary care the patients’ and doctors’ views on symptoms, etiology and management.Can J Gastroenterol. 2003; 17: 363-368PubMed Google Scholar Hence, the potential for misdiagnosis and medical misadventure, including unnecessary tests or procedures, in IBS remains high. In this month’s Gastroenterology, Longstreth and Yao7Longstreth G.F Yao J.F Irritable bowel syndrome and surgery a multivariable analysis.Gastroenterology. 2004; 126: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar examined an enormous health maintenance organization dataset, composed of more than 89,000 patients, to determine whether a physician diagnosis of IBS is associated with excess abdominal surgery rates. They went to great efforts to adjust for several potential confounders and included nongastrointestinal surgery data (coronary artery bypass) as a type of control. The results were striking. Among those with an IBS diagnosis, they were 3 times as likely to undergo cholecystectomy, twice as likely to have an appendectomy or hysterectomy, and 50% more likely to have back surgery. On the other hand, IBS was not associated with excess peptic ulcer or cardiac surgery in this sample; it seems unlikely that ulcer symptoms or complications or coronary artery disease symptoms would be confused with IBS. There was good agreement between the data collected by questionnaire and available record data on IBS diagnosis and surgery in one small validation sample that was examined. Of interest, fibromyalgia and psychologic distress were also independent predictors of increased surgery, but did not account for the link between IBS and surgery.7Longstreth G.F Yao J.F Irritable bowel syndrome and surgery a multivariable analysis.Gastroenterology. 2004; 126: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar Few other studies have addressed this important issue of excess surgery but they generally support these results.8Hasler W.L Schoenfeld P Systematic review abdominal and pelvic surgery in patients with irritable bowel syndrome.Aliment Pharmacol Ther. 2003; 17: 997-1005Crossref PubMed Scopus (67) Google Scholar Hungin et al.9Hungin A.P Whorwell P.J Tack J Mearin F The prevalence, patterns and impact of irritable bowel syndrome an international survey of 40,000 subjects.Aliment Pharmacol Ther. 2003; 17: 643-650Crossref PubMed Scopus (624) Google Scholar reported the findings from a telephone marketing survey across Europe. Among 41,984 subjects, those with symptoms of IBS reported excess rates of appendectomy (17% compared with 11% in non-IBS), but this was not observed for cholecystectomy or hysterectomy.9Hungin A.P Whorwell P.J Tack J Mearin F The prevalence, patterns and impact of irritable bowel syndrome an international survey of 40,000 subjects.Aliment Pharmacol Ther. 2003; 17: 643-650Crossref PubMed Scopus (624) Google Scholar However, whether selection bias accounts for these results is unclear. Kennedy and Jones10Kennedy T.M Jones R.H Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population.Br J Surg. 2000; 87: 1658-1663Crossref PubMed Scopus (82) Google Scholar reported a 2-fold increased odds of cholecystectomy in IBS, with an estimated excess of 16 cholecystectomies per 1000 middle-aged women in an adult population from the United Kingdom. Similarly, there was an excess of 57 hysterectomies per 1000 women in another report from the same population.11Kennedy T.M Jones R.H The epidemiology of hysterectomy and irritable bowel syndrome in a UK population.Int J Clin Pract. 2000; 54: 647-650PubMed Google Scholar Walker et al.12Walker E.A Gelfand A.N Gelfand M.D Green C Katon W.J Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome.J Psychosom Obstet Gynaecol. 1996; 17: 39-46Crossref PubMed Scopus (104) Google Scholar observed that 35% of patients with IBS recruited from a gastrointestinal outpatient clinic had chronic pelvic pain compared with 14% of those with inflammatory bowel disease. Even more disturbingly, hysterectomies had been performed in 71% of those with IBS and pelvic pain, which was significantly higher than the rates in the remainder without pelvic pain (41%) and in controls with inflammatory bowel disease (14%).12Walker E.A Gelfand A.N Gelfand M.D Green C Katon W.J Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome.J Psychosom Obstet Gynaecol. 1996; 17: 39-46Crossref PubMed Scopus (104) Google Scholar Similar results were seen in a retrospective chart review from South Africa.13Burns D.G The risk of abdominal surgery in irritable bowel syndrome.S Afr Med J. 1986; 70 (abstr): 91PubMed Google Scholar Although important, there are some important limitations in the study by Longstreth and Yao,7Longstreth G.F Yao J.F Irritable bowel syndrome and surgery a multivariable analysis.Gastroenterology. 2004; 126: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar which the authors acknowledge. Misclassification of IBS remains a possible issue, with underreporting of the condition being most likely. Diagnosis was based on physician labeling (and patients recalling this event) rather than standard symptom criteria. The dates of surgery and dates of IBS diagnosis were not collected, so whether IBS preceded or followed surgery is not clear for each condition in which excess odds were observed. It is also unknown how often cholecystectomy was performed for cholelithiasis. Indeed, whether the incidence of gallstones or endometriosis is increased in IBS, which explains the excess surgery rates, is unknown. Moreover, symptoms of IBS are known to fluctuate widely,1American College of Gastroenterology Functional Gastrointestinal Disorders Task ForceEvidence-based position statement on the management of irritable bowel syndrome in North America.Am J Gastroenterol. 2002; 97: S1-S5PubMed Google Scholar, 3Saito Y.A Schoenfeld P Locke III, G.R The epidemiology of irritable bowel syndrome in North America a systematic review.Am J Gastroenterol. 2002; 97: 1910-1915PubMed Google Scholar and whether patients with IBS would have or could have been recognized before surgery remains unclear. In addition, some surgeons believe IBS-like symptoms are relieved by surgery, but adequate data are lacking. Johnson14Johnson C.D Arris & Gale lecture. Regulation and responses of gallbladder muscle activity in health and disease.Ann R Coll Surg Engl. 2003; 85: 297-305Crossref PubMed Scopus (6) Google Scholar has stated that IBS appeared to be present in two-fifths of patients before cholecystectomy; just one-third of these patients had persistent IBS symptoms 1 year after surgery. How often this really occurs and for how long needs to be documented in controlled studies. Finally, those presenting for health examinations do not necessarily represent the general population and skeptics might conclude that selection bias could account, in part, for the observations of excess surgery because these patients might be more obsessed with their health. However, the rates of excess surgery in IBS generally concur with other population-based investigations,8Hasler W.L Schoenfeld P Systematic review abdominal and pelvic surgery in patients with irritable bowel syndrome.Aliment Pharmacol Ther. 2003; 17: 997-1005Crossref PubMed Scopus (67) Google Scholar, 10Kennedy T.M Jones R.H Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population.Br J Surg. 2000; 87: 1658-1663Crossref PubMed Scopus (82) Google Scholar, 11Kennedy T.M Jones R.H The epidemiology of hysterectomy and irritable bowel syndrome in a UK population.Int J Clin Pract. 2000; 54: 647-650PubMed Google Scholar so this bias seems unlikely to be major. Therefore, a key question remains: is there a cause and effect association between IBS and excessive abdominal surgery? In other words, does a misdiagnosis of IBS lead to excessive unnecessary surgery, and, if so, what are the personal and public health consequences? Unfortunately, the lack of prospective data on the temporal relationship between IBS and surgery in the present study remains a major limitation. To further weigh the evidence, is it necessary to consider if there could be alternative explanations for the apparent link between IBS and abdominal or pelvic surgery, aside from misdiagnosis? There is limited but fascinating evidence that gynecologic surgery itself may precipitate the onset of IBS. Heaton et al.15Heaton K.W Parker D Cripps H Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy—a population based study.Gut. 1993; 34: 1108-1111Crossref PubMed Scopus (62) Google Scholar reported more symptoms of constipation in community subjects after hysterectomy, but IBS was not assessed. Prior et al.16Prior A Stanley K.M Smith A.R Read N.W Relation between hysterectomy and the irritable bowel a prospective study.Gut. 1992; 33: 814-817Crossref PubMed Scopus (72) Google Scholar prospectively followed up 205 consecutive patients undergoing hysterectomy in a hospital in the United Kingdom; after hysterectomy, 10% with no preoperative IBS complaints experienced IBS symptoms more than once a week. The reasons surgery might do this remain obscure. Antibiotic use has been implicated in a case-control study. Among 421 subjects attending a general practice health-screening clinic, 48 subjects had symptoms of IBS but there was nearly a 4-fold increased risk with a history of antibiotic use (adjusted odds ratio, 3.70; 95% confidence interval, 1.80–7.60).17Mendall M.A Kumar D Antibiotic use, childhood affluence and irritable bowel syndrome (IBS).Eur J Gastroenterol Hepatol. 1998; 10: 59-62Crossref PubMed Scopus (122) Google Scholar Alterations in colonic and small bowel flora might account for symptoms in this setting, with some studies of IBS showing a higher number of facultative organisms and a low number of lactobacilli and bifidobacteria.18Madden J.A Hunter J.O A review of the role of the gut microflora in irritable bowel syndrome and the effects of probiotics.Br J Nutr. 2002; 88: S67-S72Crossref PubMed Google Scholar However, the importance of this is still speculative and, further, nonabsorbable antibiotics may actually improve symptoms in IBS.19Pimentel M Chow E.J Lin H.C Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome a double-blind, randomized, placebo-controlled study.Am J Gastroenterol. 2003; 98: 412-419PubMed Google Scholar The stress of surgery is another possibility. Surgery might precipitate new-onset anxiety or depression or might alter physiology via stimulating increased release of corticotrophin releasing factor (CRF), therefore precipitating IBS in predisposed patients.20Monnikes H Tebbe J.J Hildebrandt M Arck P Osmanoglou E Rose M Klapp B Wiedenmann B Heymann-Monnikes I Role of stress in functional gastrointestinal disorders. Evidence for stress-induced alterations in gastrointestinal motility and sensitivity.Dig Dis. 2001; 19: 201-211Crossref PubMed Scopus (224) Google Scholar Khastgir et al.,21Khastgir G Studd J.W Catalan J The psychological outcome of hysterectomy.Gynecol Endocrinol. 2000; 14: 132-141Crossref PubMed Scopus (32) Google Scholar in a systematic review, reported that the majority of retrospective studies described an adverse psychologic outcome after hysterectomy, but the prospective studies showed that the incidence of depressed mood was actually higher before hysterectomy and often improved after surgery. Other limited data fail to suggest that surgery precipitates IBS postcholecystectomy. Heaton et al.15Heaton K.W Parker D Cripps H Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy—a population based study.Gut. 1993; 34: 1108-1111Crossref PubMed Scopus (62) Google Scholar examined self-reported bowel function by using the validated and objective Bristol stool form scale in female patients from a United Kingdom community who had undergone gallbladder ultrasonography. Postsurgical cases were more likely to report urgency but not changes in stool form compared with controls with gallstones.15Heaton K.W Parker D Cripps H Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy—a population based study.Gut. 1993; 34: 1108-1111Crossref PubMed Scopus (62) Google Scholar In a prospective study of laparoscopic cholecystectomy in 106 adults from the United Kingdom, bowel frequency increased on average by 1 movement per week and fewer subjects felt that they became constipated 2 to 6 months later, but the study showed no consistent change in stool frequency, stool form, or defecatory symptoms.22Hearing S.D Thomas L.A Heaton K.W Hunt L Effect of cholecystectomy on bowel function a prospective, controlled study.Gut. 1999; 45: 889-894Crossref PubMed Scopus (40) Google Scholar New-onset diarrhea and IBS postcholecystectomy therefore seem to be relatively uncommon events, suggesting IBS must have been present before the surgery. However, acute life event stress may lead to increased acute presentations with abdominal pain in IBS, promoting additional misdiagnoses. Creed23Creed F Life events and appendectomy.Lancet. 1981; 1: 1381-1385Abstract PubMed Scopus (71) Google Scholar recorded life events for the year preceding appendectomy in 119 young adults. In 53%, appendicitis was confirmed histologically but, in the rest, the appendix was not acutely inflamed.23Creed F Life events and appendectomy.Lancet. 1981; 1: 1381-1385Abstract PubMed Scopus (71) Google Scholar Both groups had experienced significantly more life events that carried a degree of threat to the individual compared with a community control group. A follow-up study showed that the number of people experiencing threatening events fell to the expected level postoperatively, although depression was associated with continued abdominal pain.23Creed F Life events and appendectomy.Lancet. 1981; 1: 1381-1385Abstract PubMed Scopus (71) Google Scholar Whether these findings are relevant to those with IBS is uncertain. Excess surgery rates in IBS have unknown health consequences. There is good epidemiologic evidence that appendectomy protects against ulcerative colitis.24Rutgeerts P D’Haens G Hiele M Geboes K Vantrappen G Appendectomy protects against ulcerative colitis.Gastroenterology. 1994; 106: 1251-1253Abstract PubMed Google Scholar, 25Russel M.G Dorant E Brummer R.J van de Kruijs M.A Muris J.W Bergers J.M Goedhard J Stockbrugger R.W South Limburg Inflammatory Bowel Disease Study GroupAppendectomy and the risk of developing ulcerative colitis or Crohn’s disease results of a large case-control study.Gastroenterology. 1997; 113: 377-382Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Any protection may depend on whether or not the appendix is acutely inflamed. Patients who underwent appendectomy for appendicitis and mesenteric lymphadenitis had a lower risk of ulcerative colitis, but patients who underwent appendectomy for nonspecific abdominal pain had the same risk of ulcerative colitis as controls.26Andersson R.E Olaison G Tysk C Ekbom A Appendectomy and protection against ulcerative colitis.N Engl J Med. 2001; 344: 808-814Crossref PubMed Scopus (336) Google Scholar Any impact of appendectomy on the risk of postinfectious IBS or its prognosis, also arguably a mild form of inflammatory bowel disease at least in some cases,27Gwee K.A Collins S.M Read N.W Rajnakova A Deng Y Graham J.C McKendrick M.W Moochhala S.M Increased rectal mucosal expression of interleukin 1beta in recently acquired post-infectious irritable bowel syndrome.Gut. 2003; 52: 523-526Crossref PubMed Scopus (367) Google Scholar, 28Talley N.J Spiller R Irritable bowel syndrome a little understood organic bowel disease?.Lancet. 2002; 360: 555-564Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar is unknown. A key issue not resolved by Longstreth and Yao7Longstreth G.F Yao J.F Irritable bowel syndrome and surgery a multivariable analysis.Gastroenterology. 2004; 126: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar is whether subgroups of IBS may have differing risks of symptomatic cholelithiasis and hence cholecystectomy. For example, constipation is associated with an increased risk of cholelithiasis.29Heaton K.W Review article epidemiology of gall-bladder disease—role of intestinal transit.Aliment Pharmacol Ther. 2000; 14: 9-13Crossref PubMed Scopus (20) Google Scholar Heaton29Heaton K.W Review article epidemiology of gall-bladder disease—role of intestinal transit.Aliment Pharmacol Ther. 2000; 14: 9-13Crossref PubMed Scopus (20) Google Scholar has reviewed evidence for the hypothesis that biliary deoxycholic acid can be raised and lowered by slowing down and speeding up colonic transit. Slow transit has been associated with cholelithiasis in epidemiologic studies of no-obese women in the United Kingdom, and high biliary deoxycholic acid levels and laxative use were also associated with recurrence of gallstones, supporting the link to slow gut transit.29Heaton K.W Review article epidemiology of gall-bladder disease—role of intestinal transit.Aliment Pharmacol Ther. 2000; 14: 9-13Crossref PubMed Scopus (20) Google Scholar, 30Veysey M.J Thomas L.A Mallet A.I Jenkins P.J Besser G.M Wass J.A Murphy G.M Dowling R.H Prolonged large bowel transit increases serum deoxycholic acid a risk factor for octreotide induced gallstones.Gut. 1999; 44: 675-681Crossref PubMed Scopus (62) Google Scholar, 31Veysey M.J Thomas L.A Mallet A.I Jenkins P.J Besser G.M Murphy G.M Dowling R.H Colonic transit influences deoxycholic acid kinetics.Gastroenterology. 2001; 121: 812-822Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 32Azzaroli F Mazzella G Mazzeo C Simoni P Festi D Colecchia A Montagnani M Martino C Villanova N Roda A Roda E Sluggish small bowel motility is involved in determining increased biliary deoxycholic acid in cholesterol gallstone patients.Am J Gastroenterol. 1999; 94: 2453-2459Crossref PubMed Scopus (27) Google Scholar Kamath et al.33Kamath P.S Gaisano H.Y Phillips S.F Miller L.J Charboneau J.W Brown M.L Zinsmeister A.R Abnormal gallbladder motility in irritable bowel syndrome evidence for target-organ defect.Am J Physiol. 1991; 260: G815-G819PubMed Google Scholar showed that, during infusions of cholecystokinin octapeptide, the gallbladders of patients with IBS responded abnormally (as measured by ultrasonography), suggesting gallbladder dysfunction in IBS could predispose one to gallstones. Others have reported no alterations of gallbladder motor function in IBS34Misra S.P Dwivedi M Mital M Misra V Gallbladder dynamics in patients with irritable bowel syndrome and essential dyspepsia.J Clin Gastroenterol. 1991; 13: 65-68Crossref PubMed Scopus (12) Google Scholar and any risk has not been adequately quantified. Traditionally, IBS has been considered to be a condition with no associated mortality despite the considerable morbidity in many of those seeking care.1American College of Gastroenterology Functional Gastrointestinal Disorders Task ForceEvidence-based position statement on the management of irritable bowel syndrome in North America.Am J Gastroenterol. 2002; 97: S1-S5PubMed Google Scholar, 28Talley N.J Spiller R Irritable bowel syndrome a little understood organic bowel disease?.Lancet. 2002; 360: 555-564Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar For example, Owens et al.,35Owens D.M Nelson D.K Talley N.J The irritable bowel syndrome long-term prognosis and the physician-patient interaction.Ann Intern Med. 1995; 122: 107-112Crossref PubMed Scopus (288) Google Scholar in the longest follow-up, reported outcomes in 112 consecutive Olmsted County, Minnesota, residents. They were first diagnosed with IBS at the Mayo Clinic during the period from 1961 to 1963, and were followed up for a median of 29 years.35Owens D.M Nelson D.K Talley N.J The irritable bowel syndrome long-term prognosis and the physician-patient interaction.Ann Intern Med. 1995; 122: 107-112Crossref PubMed Scopus (288) Google Scholar Organic gastrointestinal disease occurred in 10 patients a median of 15 years after diagnosis of IBS, and survival in patients with IBS did not differ from expected survival (with a median survival of more than 30 years after initial diagnosis). However, the number followed up was relatively small and certainly underpowered to detect even moderate increases in mortality. Other prognostic studies in IBS have also been relatively small in size.1American College of Gastroenterology Functional Gastrointestinal Disorders Task ForceEvidence-based position statement on the management of irritable bowel syndrome in North America.Am J Gastroenterol. 2002; 97: S1-S5PubMed Google Scholar, 28Talley N.J Spiller R Irritable bowel syndrome a little understood organic bowel disease?.Lancet. 2002; 360: 555-564Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar If there is excess surgery being undertaken in IBS, does this mean that mortality in IBS could be unnecessarily increased? The answer is likely to be yes if the excess surgeries are largely the result of misdiagnosis. The mortality of elective cholecystectomy has been estimated to be around 1 in 1000 overall, but it is age related.36MacFadyen Jr, B.V Vecchio R Ricardo A.E Mathis C.R Bile duct injury after laparoscopic cholecystectomy. The United States experience.Surg Endosc. 1998; 12: 315-321Crossref PubMed Scopus (281) Google Scholar, 37Glasgow R.E Mulvihill S.J Surgical management of gallstone disease and postoperative complications.in: Feldman M Friedman L.S Sleiserger M.H Sleiserger and Fordtran’s gastrointestinal and liver disease. 7th ed. Saunders, Philadelphia2002: 1091-1105Google Scholar We can assume conservatively that the annual prevalence of IBS in the United States is 10%, meaning that, of the United States population of 291,500,000 in 2003, approximately 29,000,000 Americans currently have the condition. Let us assume that approximately one-third of these people seek treatment, so approximately 9,600,000 will enter the health care system for IBS. Based on the data from Longstreth and Lao,7Longstreth G.F Yao J.F Irritable bowel syndrome and surgery a multivariable analysis.Gastroenterology. 2004; 126: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar we can estimate the number currently with IBS who in their lifetime will undergo unnecessary cholecystectomy is approximately 8% (assuming the remaining third undergoing the procedure have an acceptable indication), or 768,000 procedures nationwide, of whom approximately 770 will die directly because of the surgery and, conservatively, approximately 38,000 (5%) will suffer morbidity because of other surgical complications. However, any excess mortality will be confounded by age, and it is unknown if the increased surgery observed in IBS shortens life expectancy. Prospective data on the indications and outcomes of surgery in IBS is now needed; such research should focus on the presenting complaints rather than only on the final diagnosis. However, based on the available data, it seems reasonable to surmise unnecessary surgery is a major problem in people with IBS. A concerted effort by professional societies such as the American Gastroenterological Association and the American College of Gastroenterology seems justified to educate not only surgeons about IBS but also those physicians who refer their patients with unexplained abdominal pain to them. Better education of house staff about the recognition of IBS could also be helpful in the long-term. This will not be easy to do and to achieve long-term benefits. In one study of family physicians, a single education class improved knowledge only for the short-term; the knowledge gained was diminished at 3 months and did not alter perceived diagnostic difficulties with treating IBS.5Longstreth G.F Burchette R.J Family practitioners’ attitudes and knowledge about irritable bowel syndrome effect of a trial of physician education.Fam Pract. 2003; 20: 70-74Crossref Scopus (47) Google Scholar Guidelines might help but, alone, will also almost certainly be insufficient, as they have been in other areas.38Talley N.J Helicobacter pylori management how to improve the therapeutic confusion in practice.Can J Gastroenterol. 2003; 17: 21B-24BPubMed Google Scholar Hippocrates (465–370 bc) wrote, “Practice two things in your dealings with disease: either help or do not harm the patient.”39Huth E.J Murray T.J Medicine in quotations. Views of Health and Disease through the ages. American College of Physicians, Philadelphia, PA2000Google Scholar Whether the excess surgery in IBS is cause or effect, unnecessary surgery must be avoided and the gastroenterology community should take responsibility for actions to protect the public.