Off-pump or off handed?
I love being in an era where new technology is being evaluated. I sat in a lecture by a famous liver surgeon (Alan Johnson) in Sheffield (UK, where they filmed the `Full Monty’) prior to his retirement. He said that he had seen it all with regards to surgical research. It always follows the same pattern. First everyone loves a new surgical advancement, then everyone hates it, then we find indications for its appropriate use.
I think off-pump surgery is between phase 1 and 2 of the `Johnson chronology’. What really amuses me is how evangelical surgeons can be when defending their preferred technique. The sentiments are best reflected in this great quote:
`To cut things short, it is extremely important to understand that there is abundant clinically relevant though not necessarily statistically significant, scientific evidence to validate the midterm safety and efficacy of OPCAB.’ Anesthesiology 2005; 103: 902.
Frankly, surgical research can never be 100% replicable and reporting can never be 100% free from bias. The variances in patient response to a tablet (due to pharmacokinetics, pharmacodynamics differences) are usually balanced out if a trial is large enough, but no two surgeons will operate with the same skill. A new procedure that is shown to be superior compared to the standard in the hands of gifted surgeon A, may be inferior to the standard in two-left-hands surgeon B.
The guardians of information usually lies in the hands of the people most interested in the new technique. To give you an unbiased opinion about a new technique, would you employ a team of people who hate it? No, but you wouldn’t object if we recruited a team of people who already love it? A balanced panel is difficult, simply because people who are not interested in a technique do not usually want to get involved in its evaluation.
Therefore, how much of what can we believe about anything has been reported about off-pump surgery, except for our own intrepretation on the applicability of the raw results of the (randomized) clinical trials?