Dr. Eric Lim's Weblog

Don’t be too amused by recent reports of a “small but significant” increase in thrombosis with drug eluting stents nor expect a windfall of patients queuing up, returning to the joyous cries of cardiac surgeons slapping themselves on the back singing “I told you so!”.

While monitoring for complications, the FDA states that it still currently “believes that coronary drug-eluting stents remain safe and effective when used for the FDA-approved indications”. Furthermore, the meta-analysis by Camenzind (presented to the 2006 European Society of Cardiology Annual Meeting) reported death and Q-wave MI increased in drug-eluting to bare-metal stents. The conclusions imply selective return to bare metal stents as opposed to a mass exodus towards coronary artery surgery.

As a group, we naturally extol what we like to hear and ignore what we don’t. Before peering over the fence at our neighbor’s gardens, maybe we should look at the results off pump graft patency. This month (December 2006) in the Journal of Thoracic and Cardiovascular Surgery, we reported a significant increase in graft occlusion in randomised trials of off pump compared to conventional surgery, but maybe you don’t really want to hear about that…

Posted by Eric Lim at 05:40 PM | Permalink

Ok, maybe hate is too strong a word… I suppose I don’t really “hate” minimal access surgery, but rather the propaganda around a subject laced with soft secondary benefits whilst ignoring the primary aim for surgery.

Just because the access is smaller, it does not make what is done inside the body cavity less traumatic or invasive. If an equivalent procedure is performed, it will be as equally invasive. What saving is the “trauma” associated with a 4 inch versus an 8 inch sternotomy or the cumulative sum of 3 x 1.5 inch port sites versus a 8 inch limited thoracotomy, or a 6 inch limited thoracocomy and 2 x 1.5 inch port sites with VATS assistance versus 10 inch thoracotomy? If the procedure takes longer than conventional access surgery, would the duration of surgical trauma result in greater overall physiologic stress?

Many surgeons use the minimally invasive route as a self / institution promoting strategy hoping to gain more referrals and better patient acceptance for procedures where primary efficacy and safety are usually unconfirmed by randomised trials. Indeed, the primary aim is often forgotten in pursuit of surrogate marker to justify the performance of a possibly more expensive, less accessible, less complete and more compromising (during the initial learning curve) procedure. Why do most trials on VATS surgery for pneumothorax report pain and length of hospital stay instead of recurrence rates, and observation studies on minimal access revascularisation report pain and hospital stay instead of angiography graft patency, recurrence of angina and survival?

Reports of new techniques are often undertaken by enthusiasts in the field, who have a vested interested in proving what they are doing is better, and are often reviewers of papers related to these techniques, therefore how many papers critical to what they do would receive a good review?

My own views are that state of the art is not necessarily better, efficacy must be proven in the primary reasons for surgery before patients and referring physicians are “sold” the soft benefits of minimal access surgery.

Posted by Eric Lim at 01:38 PM | Permalink

Surely species are on the road to extinction when they are no longer able to adapt sufficiently to survive in a changing environment. But friends are important, and a good evolutionary deal is a symbiotic relationship, where two organisms can exist mutually reliant on each other for food. It’s much worse to be in a relationship like hyenas to lions where two animals feed on the same source but with the hyena relying on the lion for food.

Ok, so surgical revascularisation rates are down and percutaneous coronary intervention rates are on the rise, but don’t worry, there’s always aortic valve surgery, the second most commonly performed operation in cardiac surgery?

Hate to burst your bubble, but read it and weep, 50 percutaneous valve implants for aortic stenosis, regurgitation and failed prosthetic valves.

Ah ha! You may exclaim that the founder of CoreValve is a cardiac surgeon. He may have been involved in the development of the percutaneous valve! So, we will be able to participate in this new technology? Sure, all we need is for suitable patients to be referred for…. Oh! they already are experts in percutaneous interventions...

Posted by Eric Lim at 12:26 AM | Permalink