AW: AW: [HSF] The fallacy of surgical research
psimha
prasannasimha at gmail.com
Fri Aug 3 17:21:21 EDT 2007
Very true- because of this he later correlated the association between
both myxedema and cretinism to hypothyroidism.
Prasanna
prof.dr.axel laczkovics wrote:
> 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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>>>>> ----------------------------------------->> >> >> > --> >> >> > 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> >
>>>>> _______________________________________________>
>>>>>
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>>>>> ----------------------------------------->> >> > > > -- > Prasanna
>>>>> Simha
>>>>>
>>> M>
>>>
>>>>>
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>>>>> 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 ---
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