AW: [HSF] The fallacy of surgical research

[Ani Anyanwu]

Carrel was not in recent times, same with Kocher before him. Forssman did not receive a Nobel prize for surgery (but for cardiac cathetherization). Murray in 1990  is the only surgeon to have been granted a Nobel in over 30 years - even it is regarded by some as a token Nobel as he did not make any scientific discovery in particular (was for discoveries concerning organ transplantation - Murray performed the first renal transplant).
 
Ani



> From: battr at medizin.uni-leipzig.de> To: OpenHeart-L at lists.hsforum.com> Subject: AW: [HSF] The fallacy of surgical research> Date: Thu, 2 Aug 2007 11:18:26 +0200> CC: > > Ani,> Science in an art and science discipline (surgery) is very complicate, near> the theory of caos. Tell the clinical academics to come to surgical> services and do science. They are not going to make it better than we> surgeons. > Of course, we are not as good in biostatistics as they are. And the most> important factor, the surgeon itself is never included in the studies!> > By the way, there are 2 Nobel Prize surgeons, Carrel and Forssmann (together> with Cournand).> > Roberto> > -----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu> Gesendet: Mittwoch, 1. August 2007 22:14> An: openheart-l at lists.hsforum.com> Betreff: RE: [HSF] The fallacy of surgical research> > The other issue the discussions on myocardial protection brings up is the> fallacy of surgical research and the poor understanding of research method> by surgeons. This is what prompted the Lancet editor many years ago to> describe surgical research as 'comic opera'. The reality is that few in> academics or research takes us surgeons seriously. Look at the> representation of surgeons in key research bodies, funding of surgical> research by NIH or similar bodies, surgical influence in research groups,> surgical publications in key journals, guidelines committees, involvement in> key epidemiological efforts etc. The only Nobel prize received by a surgeon> in the recent era wasn't even for surgical research. The problem is we as> surgeons believe too much in our individual selves and individual methods> that we become blinkered as to the requirements of the scientific method.> > Examples include> > - there is evidence that such and such an additive to cardioplegia is of> benefit (this evidence comes from isolated animal hearts, animal experiments> and at best clinical measures of surrogate markers - these do not mean the> additive is benefit in the human, indeed it could be worse)> > - it has worked well in my cases so it is okay (but as Dr Salerno and> Prasanna say the heart has great reserve - that nothing goes wrong does not> mean all is okay)> > - i have had no deaths (the patient came to you alive; why is it an> achievement that he remains alive after surgery? (unless the aim of surgery> was to save life))> > - Kirklin and Buckberg or Cleveland clinic demonstrated...(i.e. eminence> based medicine; but how many have ever read work of Kirklin or Buckberg? Do> they stand up to the requirements of scientific proof? Indeed did either> really show clinical benefit of the things we attribute to them? For example> the 'seminal' Cleveland clinic NEJM paper purpurtedly showing benefit of IMA> over SVG barely constitutes evidence of such)> > - There was no enzyme rise (has anyone cared to show any relationship> between enzyme rise and any outcome of interest after surgery? Does the> patient really care what his CK, troponin or coronary sinus lactate are? Why> do we look at outcomes of no relevance to the patient?)> > - Ventricular fibrillation means bad protection ( but has anyone shown so> scientifically? maybe fibrillation is intrinsic to some techniques and rare> with others and is a reflection of the technique rather than the degree of> protection; certainly a fibrillating heart in Salerno's beating heart> technique has different implications to an Arch done by Martin on DHCA)> > - The patient was extubated the next day (and so what? Several times you go> back to ask what happened to the patient 2 months later and you hear a> different story. This outcome is of no relevance at all unless aim of> surgery was to allow extubation in patient previously ventilator dependent)> > - My method of cold myocardial preservation works (but how do you know that> that is what is working? As Salerno says if you don't know the myocardial> temperature how do you know it is the hypothermia, and not some other> factor, that is in play?)> > - Since I changed I use less inotropes (but you decide what you use- could> you not be just biased towards the success of your change? Maybe you should> compare two methos objectively)> > - Multiple defibrillation harms the heart and leads to bad outcome (maybe> but could it be the condition requiring defibrillation that is resulting in> the bad outcome rather than the shock?)> > - I have done it this way for 10 years and never had problems (how do you> know? Have you actually measured the outcomes on all your patients? Kocher> said the same about his thyroidectomies and was shocked when he recalled his> patients and found the majority had myxedema)> > etc> The inability to critique within the scientific framework and a lack of> understanding of, or refusal to apply the research method, is a major> problem in surgery and is in part the reason why we are so diverse in> opinion and yet so opinionated and firm in our belief that what we do is> right (when yet examined there is often no evidence to support it). No> internist or scientist or epidemiologist would approve a drug based on any> of the criteria we list above yet we swear by what we do to the degree that> we suggest alternative approaches are inferior. > > Until we start thinking in a scientific and epidemiological manner, we as> surgeons will remain the laughing stock of academic medicine.> > Ani> > > Date: Thu, 2 Aug 2007 04:52:48 +1000> To: OpenHeart-L at lists.hsforum.com>> From: benjamin.bidstrup at bigpond.com> Subject: Re: [HSF] Inotropes,> ventricular fibrillation and myocardial protection> CC: > > What this does> is once again ask the question, how do we measure > myocardial> preservation?> > We can look at the highly sensitive markers such as> Troponin which > indicate some element of damage to components of the> myofibrils. and > so on. Echo - RWMA ECG and the list goes on.> We need to> look at use of inotropes, IABP, survival. Khuri published > on his> intramyocardiall pH device stating that poor preservation as > reflected by> pH changes resulted in altered long term survival.> > Much of the cocktails'> components have been determined by isolated > rat heart experiments. They> have translated well to the human, but it > is very hard to measure total> water content of an intact heart or > regional blood flow distribution in a> human model.> > Why is it that there is no universal cocktail. Put 100> cardiac teams > in a room and you will have 120 different ways of preserving> the > myocardium.> I review papers that look at different methods of> preservation and > they use markers such as inotrope use to determine> improvement. How > variable that is is a whole new debate.> > > > > >Tomas,>> >> > A fibrillating heart is a dying heart? Is this an edict of some >> >sort? I've seen plenty of hearts that fibrillated during some part > >of> their open heart operation only to have a completely, and I mean >> >completely, normal EF on remote echo. Speaking in absolutes serves > >no> purpose.> >> >> >> >Hal> >> >> >-----Original Message-----> >From: Salerno,> Tomas <TSalerno at med.miami.edu>> >To: OpenHeart-L at lists.hsforum.com> >Sent:> Wed, 1 Aug 2007 11:19 am> >Subject: Re: [HSF] Inotropes, ventricular> fibrillation and > >myocardial protection> >> >> >> >> >A fibrillating heart> is. "Dying" heart.> >The brain does not have seizure during CPB; neither> should the heart > >fibrillate.> >Tomas> >> >----- Original Message ----->> >rom: openheart-l-bounces at lists.hsforum.com >> ><openheart-l-bounces at lists.hsforum.com>> >o: OpenHeart-L at lists.hsforum.com> <OpenHeart-L at lists.hsforum.com>> >ent: Wed Aug 01 10:45:53 2007> >ubject:> Re: [HSF] Inotropes,ventricular fibrillation and myocardial > >rotection>> >Ani,> >aving graduated from voodoo homemade cocktails to blood and its>> >ariants, you would easily be able to see that the bad cardioplegia's> >id> have a higher (more accurately uniform) incidence of fibrillation> >hich> came down with better modifications of cardioplegia's. That does> >ake us> wary and anyway fibrillation is not something by any stretch>> >ormal.Transient defibrillation may appear innocuous but then it has> >een> shown that such hearts have indeed been improperly preserved (from> >orks of> Buckberg and Kirklin).Remember that sometimes speed etc etc may> >ompensate> but this may become an issue in longer case.> >rasanna> >ni Anyanwu wrote:>> > I still do not understand why we are alarmed about transient ventricular>> >ibrillation on reperfusion and why using drugs to suppress it will have> any> >mpact on outcome.> >> > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007> 11:51:47 +0530> From: prasannasimha at gmail.com> To:>> >penHeart-L at lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular>> >ibrillation and myocardial protection> CC: > > I am not saying that the>> >rocaine or lignocaine is still acting. What I> meant is that since the>> >ibrillation is occurring with the hotshot delivery> with high local> lignocaine> >hanging the drug class may be beneficial.> Prasanna> > On> 8/1/07, Ben Bidstrup> >benjamin.bidstrup at bigpond.com> wrote:> >> > I beg> respectfully to differ. The> >idocaine (a fast Na channel> > blocker) is all> but gone after a short while in> >he cardioplegia> > scenario. Getting a> suitable level back into the > >circulation> >nd thus> > the heart at> release of the clamp is what is > >needed.> >> > Perhaps a> >andomised study> is in the offing.> >> > >> >http://circ.ahajournals.org/cgi/content/abstract/79/5/1106>> >> > This> reference relates to defib energy levels but i think you will> > see> >here> I am coming from.> >> > At James Cook, I was involved in the development> >f> a non> > depolarising cardioplegia solution, which is slowly > >working its> way>> > up the development path. The main components are lidocaine and> >> adenosine.>> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all> emazes > >>(and postop)> >nd> > >Amiadorone in the pump for all aortic> valves. Since the St Thomas> >> >Cardioplegia (which we mix in blood)> already has procaine > >adding> > >Lignocaine> >ould be> redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> >>> >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some>> >erfusion, the electrolyte> > >>imbalances within the myocardium would> correct> >nd SR ensue. If> > >>anything use lidocaine. Less toxic and> cheaper, not a> >egative> > >>inotrope. It is what Yacoub taught me many> years ago, and I have>> > >>used it to good effect (infrequently I might >> >add).> > >>> > >>>Tohru,> > >>>> > did an AVR on an 87 yo man as a 2nd case> just a couple of> > >>>hours ago.> >gain, no LV vent, only a sump. While> closing the> > >>>aortotomy, I began the>> > >>>continuous warm retrograde> blood. The heart began fibrillating> > >>>after> > couple of> > >>>minutes.> I gave amio and then cardioverted. The > >heart had a> >> >>>slow> junctional> > >>>rhythm until the clamp was released. A sinus rhythm>> >eveloped shortly> > >>>afterwards. He came off with no inotropes. It's> much> >asier on> > >>>the heart and> > >>>your nerves to cardiovert a >> >clamped, flaccid> >eart rather than> > >>>trying to do it> > >>>after the> clamp has been> >eleased.> > >>> I look forward to your visit at the STS. As> I said before,> >'ll> > try to> > >>>have a couple of interesting cases for> you and other> >nterested> > >>>members of HSF> > >>>to watch and criticize> to your heart's> >ontent.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> >> >>>**************************************> >et a sneak peek of the> >> >>>all-new AOL > >at> > >>>http://discover.aol.com/memed/aolcom30tour>> >> >>>_______________________________________________> > >>>OpenHeart-L> mailing> >ist> > >>>> > >>>Send postings to:> > >>> >> >OpenHeart-L at lists.hsforum.com> > >>>>> > >>>To UNSUBSCRIBE, to CHANGE email> address, or to view archives:> >>> >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All> messages> >ransmitted by the OpenHeart-L are subject to the policies> > and>> >> >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> >>> >>>-----------------------------------------> > >>> > >>> > >> >>> >_______________________________________________> > >OpenHeart-L > >mailing> list> >> >> > >Send postings to:> > >OpenHeart-L at lists.hsforum.com> > >> >> >To> >NSUBSCRIBE, to CHANGE email address, or to view archives:> >>> >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages>> >ransmitted by the OpenHeart-L are subject to the> > >policies and> disclaimers> >osted > >at:> > >http://www.hsforum.com/listdisclaim> >> >----------------------------------------->> >> >> > --> >> >> > Two things> are infinite; the universe and human stupidity;> >nd I am> > not sure about> the universe.> > Albert Einstein> >> > The greatest> >bstacle to discovery> is not ignorance --- it is the> > illusion of knowledge.>> > Daniel J> Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant>> >ardiothoracic Surgeon> > _______________________________________________>> >> >penHeart-L mailing list> >> > Send postings to:> > >> >OpenHeart-L at lists.hsforum.com>> >> > To UNSUBSCRIBE, to CHANGE email> address, or to view archives:> >>> >ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages> transmitted> >y the OpenHeart-L are subject to the policies> > and> >> disclaimers > >posted at:>> > http://www.hsforum.com/listdisclaim> > >> >----------------------------------------->> >> > > > -- > Prasanna Simha M>> > >>_______________________________________________>> >penHeart-L mailing> list> > Send postings to:> OpenHeart-L at lists.hsforum.com> >> >o UNSUBSCRIBE,> to CHANGE email address, or to view archives:>>> >ttp://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted> by> >he OpenHeart-L are subject to the policies and > disclaimers posted> at:>> >ttp://www.hsforum.com/listdisclaim>> -----------------------------------------> >> > >> _________________________________________________________________> > 100's> of Music vouchers to be won with MSN Music> > >> >https://www.musicmashup.co.uk/index.html___________________________________> ____________> > OpenHeart-L mailing list> >> > Send postings to:> >> OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address,> or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> > All messages transmitted by the OpenHeart-L are subject to the policies> and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> >> -----------------------------------------> >> >> > >> >_______________________________________________> >penHeart-L mailing list>> >Send postings to:> >OpenHeart-L at lists.hsforum.com> >To UNSUBSCRIBE, to> CHANGE email address, or to view archives:>> >ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >All messages transmitted> by the OpenHeart-L are subject to the policies and> >isclaimers posted at:>> >ttp://www.hsforum.com/listdisclaim>> >----------------------------------------> >> >> >>> >_______________________________________________> >penHeart-L mailing list>> >Send postings to:> >OpenHeart-L at lists.hsforum.com> >To UNSUBSCRIBE, to> CHANGE email address, or to view archives:>> >ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >All messages transmitted> by the OpenHeart-L are subject to the policies and> >isclaimers posted at:>> >ttp://www.hsforum.com/listdisclaim>> >----------------------------------------> >> >>> >________________________________________________________________________>> >AOL now offers free email to everyone. Find out more about what's > >free> from AOL at AOL.com.> >_______________________________________________>> >OpenHeart-L mailing list> >> >Send postings to:> >> OpenHeart-L at lists.hsforum.com> >> >To UNSUBSCRIBE, to CHANGE email address,> or to view archives:> >http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >All messages transmitted by the OpenHeart-L are subject to the policies> and> >disclaimers posted at:> >http://www.hsforum.com/listdisclaim>> >-----------------------------------------> > > -- > Ben Bidstrup FRACS> FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> > Two things are infinite;> the universe and human stupidity; and I am > not sure about the universe.>> Albert Einstein> > The greatest obstacle to discovery is not ignorance ---> it is the > illusion of knowledge.> Daniel J Boorstin> > >> _______________________________________________> OpenHeart-L mailing list> >> Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to> CHANGE email address, or to view archives:>> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted> by the OpenHeart-L are subject to the policies and > disclaimers posted at:>> http://www.hsforum.com/listdisclaim>> -----------------------------------------> _________________________________________________________________> The next generation of MSN Hotmail has arrived - Windows Live Hotmail> http://www.newhotmail.co.uk_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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