AW: AW: [HSF] The fallacy of surgical research
prof.dr.axel laczkovics
axel.m.laczkovics at ruhr-uni-bochum.de
Fri Aug 3 16:18:47 EDT 2007
ani,
thank you very much for more detailed information. i could not remember
the full story, which i heard some 25 years ago when i still lived in
vienna. but his honest follow-up is true and also his confirmation
and consequences.
thx again, axel laczkovics
> More importantly though Kocher's example goes to confirm my rant about
> surgeons' biased observations of their own data and how you can never
> know the truth if you do not measure your own outcome.
>
> Remember at the time, and indeed till this date, Kocher was regarded
> as the greatest thyroid surgeon. The full story is that actually
> Kocher heard of this complication from a colleague and, like the rest
> of us, first denied it had occurred in his patients. He however
> decided to recall his patients though and what he found shocked him.
> He said while he thought he was helping patients he turned them into
> cretins living a life worth not living. I suspect it is the case with
> some of the patients we operate on today, many of whom we claim
> success because they are extubated the next day or even better leave
> hospital in a few weeks. If you don't do a systematic follow-up you
> will never know the truth.
>
> ANi
>
>
>
>> Date: Fri, 3 Aug 2007 08:54:30 +0200> Subject: Re: AW: AW: [HSF] The
>> fallacy of surgical research> From:
>> axel.m.laczkovics at ruhr-uni-bochum.de> To:
>> OpenHeart-L at lists.hsforum.com> CC: > > 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> > > >>>>>>
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>> -----------------------------------------> > > -- > 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> > >> >>> _______________________________________________>
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