AW: AW: [HSF] The fallacy of surgical research
prof.dr.axel laczkovics
axel.m.laczkovics at ruhr-uni-bochum.de
Fri Aug 3 09:54:30 EDT 2007
concerning theodor kocher i recall an information which i guess is of
great importance:
after total thyroidectomy he saw some of his patients phlegmatic and
simply looking stupid with all the now well-known symptoms of myxedema.
he then made a follow-up on as many pts as he could, which was extremly
progressive and analytical for the time 100 years ago. and he realized
a correlation between his operation and the outcome of his pts and
acknowledged this as a surgical mistake - his mistake! the
consequence was the partial thyroidectomy as performed today.
this for me is a great consequence and also demonstrates a great
character.
axel laczkovics
bochum
Am Donnerstag, 02.08.07 um 19:23 Uhr schrieb psimha:
> 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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>>>>
>> things
>>
>>>>
>>> are infinite; the universe and human stupidity;> >nd I am> > not sure
>>>
>> about
>>
>>> the universe.> > Albert Einstein> >> > The greatest> >bstacle to
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>>> is not ignorance --- it is the> > illusion of knowledge.>> > Daniel J
>>> Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant>
>>>
>>>> ardiothoracic Surgeon> >
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>>> FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> > Two things are
>>>
>> infinite;
>>
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>>> universe.>
>>> Albert Einstein> > The greatest obstacle to discovery is not
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