AW: AW: [HSF] The fallacy of surgical research
psimha
prasannasimha at gmail.com
Thu Aug 2 23:53:23 EDT 2007
Emil Theodor Kocher
Swiss surgeon, born August 25, 1841, Bern; died July 27, 1917, Bern.
Nobel prize in 1909
Associated eponyms:
Kocher zonde
Spoon-shaped probe for goitre operations.
Kocher's arced incision
Oblique incision for opening the knee joint.
Kocher's incision I
Oblique abdominal incision paralleling the thoracic cage on the right
side of the abdomen for cholecystectomy.
Kocher's incision II
Tranverse incision over glandula thyreoidea in the neck for thyroidectomies.
Kocher's method I
A method for fixation of the uterus. Fundus uteri is fixated to the
abdominal wall.
Kocher's method II
Invagination method for radical operation for hernia inguinalis.
Kocher's method III
Method for reducing dislocations of the shoulder.
Kocher's reflex
Contraction of abdominal muscles following moderate compression of the
testicle.
Kocher's sign
Eyelid phenomenon in hyperthyreosis and Basedow's disease.
Kocher's syndrome
Splenomegaly with or without lymphocytosis and lymphadenopathy in
thyrotoxicosis.
Kocher's tweezers
Vascular tweezers.
Kocher-Debré-Semélaigne syndrome or disease
A syndrome of hypothyroidism associated muscular enlargement to give the
appearance of an infant Hercules.
Kocherisation
Operative technique in opening the duodenum to expose the ampulla of the
common bile duct. Dr. Roberto Battellini wrote:
> What did they investigate? You mean Kocher from the Kocher clamp?
> Roberto
>
> -----Ursprüngliche Nachricht-----
> Von: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von psimha
> Gesendet: Donnerstag, 2. August 2007 16:11
> An: OpenHeart-L at lists.hsforum.com
> Betreff: Re: AW: [HSF] The fallacy of surgical research
>
> Roberto , you forgot Theodore Kocher and Egaz Moniz .
> Prasanna
> Dr. Roberto Battellini wrote:
>
>> 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>> >
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>> 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> > >
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