History Surg Res

8/3/2019 History Surg Res

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HHISTORY ANDISTORY ANDPHIPHILOLOSOPHYSOPHYOFOF

SURGICAL RESEARCHSURGICAL RESEARCH

MihaiMihai IonacIonac, MD, PhD, Prof., MD, PhD, Prof.

SurgicalSurgical Clinic 2Clinic 2Victor Babes UniversitVictor Babes UniversityyTimisoara, RomaniaTimisoara, Romania


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QuestionQuestion

Are surgeons (clinicians) capable to makeAre surgeons (clinicians) capable to make

contributions in fundamental research (R)?contributions in fundamental research (R)?


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ArgumentArgument

Continuous exposure of the surgeons to humanContinuous exposure of the surgeons to human

disease stimulates them to carry questionsdisease stimulates them to carry questions

from bedside to the bench for study, and thenfrom bedside to the bench for study, and then

to carry the solutions back to the bedsideto carry the solutions back to the bedside


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Obstacles to ResearchObstacles to Research

1. Money1. Money

-- Students graduating from med schoolStudents graduating from med school -- lowlow

finances + marriage & childrenfinances + marriage & children-- R is an undercompensated activityR is an undercompensated activity


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2. Time2. Time

-- Salary structure discourages young surgeons fromSalary structure discourages young surgeons from

spending time in nonspending time in non--revenuerevenue--generating practice activitygenerating practice activity

as Ras R

--After many years of training young surgeons areAfter many years of training young surgeons are

reluctant to make time for R instead of operatingreluctant to make time for R instead of operating

patientspatients


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3. Discrimination by:3. Discrimination by:

a. Basic scientistsa. Basic scientists -- scientific background insufficientscientific background insufficient

b. Internists/pediatriciansb. Internists/pediatricians -- like basic scientistslike basic scientists

c. Doctorsc. Doctors -- label of animal doctorslabel of animal doctors

d. Fellow surgeonsd. Fellow surgeons -- do not operate enough to be skillfuldo not operate enough to be skillful

e. Promotion committeese. Promotion committees -- surgical journals do not countsurgical journals do not count

triple threats (clinician, teacher, researcher)triple threats (clinician, teacher, researcher)


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4. The surgical persona:4. The surgical persona:

-- decisiveness, confidencedecisiveness, confidence-- ability to act promptly, before complete data can be obtainedability to act promptly, before complete data can be obtained

This saves lives in the ER at night, but is not a a great formulThis saves lives in the ER at night, but is not a a great formula toa to

do great science.do great science.

The prototype of the surgeon is different than that of theThe prototype of the surgeon is different than that of the

prototypic scientistprototypic scientist -- has no time for discussions, contemplationhas no time for discussions, contemplation


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Why do Research?Why do Research?

1. To help mankind by improving patient care1. To help mankind by improving patient care

2. Academic advancement2. Academic advancement

3. Satisfaction and fun: young and bright people3. Satisfaction and fun: young and bright people

are curios as how things work, they are attractedare curios as how things work, they are attracted

to explorationto exploration


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Rules for the SurgeonRules for the Surgeon--ScientistScientist(recipe for becoming successful)(recipe for becoming successful)

1. Develop laboratory programs1. Develop laboratory programs

2. Focus on projects related to clinical interest2. Focus on projects related to clinical interest3. Cooperate with basic scientists3. Cooperate with basic scientists

4. Resubmit unfunded grants4. Resubmit unfunded grants

5. Work hard5. Work hard

Sam Wells, ASA President, 1996


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Rules for the SurgeonRules for the Surgeon--ScientistScientist(recipe for becoming successful)(recipe for becoming successful)

1. Luck may be the most important element: do not1. Luck may be the most important element: do not

overlook an unexpected findingoverlook an unexpected finding

2. Take advantage of unexpected findings by following2. Take advantage of unexpected findings by following

through with experimentsthrough with experiments

3. Resist any temptation to manipulate the data3. Resist any temptation to manipulate the data

4. Original results are usually built on earlier work4. Original results are usually built on earlier work

5. The scientific paper is a fraud5. The scientific paper is a fraudSir Peter Medawar, 1992


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The role of competitionThe role of competition

If you have no competitionIf you have no competitionyou are probably not studying anything importantyou are probably not studying anything important


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Surgical Science HistorySurgical Science HistoryA. Why studying surgical research history?

Study of the careers of scientistsStudy of the careers of scientists -- encouraging youngencouraging young

surgeons to believe they can make similar contributions, ifsurgeons to believe they can make similar contributions, if-- they adhere to rulesthey adhere to rules

--work hardwork hard-- have sufficient luckhave sufficient luck


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Surgical Science HistorySurgical Science HistoryA. Why studying surgical research history?

We should remember not to take ourselves too seriously,We should remember not to take ourselves too seriously,

because any success we may have in science is surely basedbecause any success we may have in science is surely based

on the findings of our predecessorson the findings of our predecessors

If we are fortunate to make an important new discoveryIf we are fortunate to make an important new discovery--

someone with less luck may have been there before ussomeone with less luck may have been there before us


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Surgical Science HistorySurgical Science HistoryB. Surgical science in remote times

JohnJohn HunterHunter (1728(1728 -- 1793)1793)

Don'tDon't thinkthink,, trytry

eexperimentationxperimentation andand directdirect observationobservation

instead of ainstead of academiccademic speculationspeculation

scientitifc approach to medicinescientitifc approach to medicine


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HunterHunter

oneone ofofthethe greatestgreatest surgeonssurgeons ofofallall timetime

hehe raisedraised EnglishEnglish surgerysurgeryfromfrom a merea mere

""technicaltechnical trade"trade" toto itsits positionposition asas equalequal totootherother medicalmedical specialtiesspecialties


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William S.William S. HHalstedalsted ((1852185219221922))

-- minimumminimum injuryinjuryofoftissuestissues

-- cocainecocaine regionalregional anesthesiaanesthesia

-- breastbreast cancercancer andand herniahernia operationsoperations

-- treatment of fracturestreatment of fractures

-- experimentalexperimentalworkworkonon thethe thyroidthyroid

-- rubberrubber glovesgloves..


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Surgical Science HistorySurgical Science History

C. Surgical science of the past 50 years

TRANSPLANTATION

CarrelCarrel

-- organ transplantation is feasible, but of little practical intorgan transplantation is feasible, but of little practical interesterest

-- interactionsinteractions ofofthethe organorgan andand itsits hosthost

Plastic surgeonsPlastic surgeons

Skin allografts for burnsSkin allografts for burnsPeter MedawarPeter Medawar (Nobel 1960)(Nobel 1960)

Induction of graft tolerance to allograftsInduction of graft tolerance to allografts


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TRANSPLANTATION

Joe MurrayJoe Murray -- Nobel prize 1990Nobel prize 1990

First successful kidney transplantFirst successful kidney transplant -- 1953 in identical twins1953 in identical twins First successful allograftFirst successful allograft -- 19591959 --whole body irradiationwhole body irradiation

Pioneered the use of immunosuppressive drugs inPioneered the use of immunosuppressive drugs in

animals and human transplantsanimals and human transplants

Cooperation withCooperation with -- Roy CalneRoy Calne -- 5 mercaptopurine5 mercaptopurine

-- Hitchings, Elion (Nobel, 1988)Hitchings, Elion (Nobel, 1988) -- ImuranImuran


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Surgical Science HistorySurgical Science HistoryC. Surgical science of the past 50 years

TRANSPLANTATION

Thomas StarzlThomas Starzl

First survival of liver transplantFirst survival of liver transplant -- 19641964

Long term survival > 80%Long term survival > 80% -- 19941994


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VASCULAR SURGERY

John HunterJohn Hunter

ligation of a carotid artery in a stagligation of a carotid artery in a stag

ligation of the femoral artery for popliteal aneurysmligation of the femoral artery for popliteal aneurysm

Jaboulay and CarrelJaboulay and Carrel

First successful anastomosisFirst successful anastomosis


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VASCULAR SURGERY

CarrelCarrel

MentorsMentors --JaboulayJaboulay-- head of Surgery in Lyonhead of Surgery in Lyon

-- MM--me Leroudierme Leroudier -- embroideress of local renownembroideress of local renown

CompetitorsCompetitors --JaboulayJaboulay-- everting sutures for a carotid repaireverting sutures for a carotid repair

-- DorflerDorfler -- running suturerunning suture -- 18991899

importance of asepsis & technical virtuosity in sewingimportance of asepsis & technical virtuosity in sewing

S i l S i HiS i l S i Hi t


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VASCULAR SURGERY

CarrelCarrel

fails the examination for a position in Lyonfails the examination for a position in Lyon

ChicagoChicago -- Charles GuthrieCharles Guthrie --vein interposition, transplantation ofvein interposition, transplantation of

the kidney, thyroid, ovary, heart, lung and small bowelthe kidney, thyroid, ovary, heart, lung and small bowel

Rockfeller Institute in New YorkRockfeller Institute in New York-- development of a pumpdevelopment of a pump--

oxygenator for open heart surgeryoxygenator for open heart surgery


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VASCULAR SURGERY

Vein graftsVein grafts

used to repair traumatic lesions only during the Korean Warused to repair traumatic lesions only during the Korean War

only after that saphenous vein is used for femoral poplitealonly after that saphenous vein is used for femoral popliteal

bypass as a common treatment for arterial disease of the lowerbypass as a common treatment for arterial disease of the lowerextremitiesextremities


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VASCULAR SURGERY

Vascular prosthesisVascular prosthesis

fresh or preserved arterial homografts for aortic aneurysm repafresh or preserved arterial homografts for aortic aneurysm repairir

Arthur VorheesArthur Vorhees -- misplaced ventricular suturemisplaced ventricular suture -- note of the errornote of the error --

check at the autopsycheck at the autopsy-- coated with endocardiumcoated with endocardium --Vorhees andVorhees and

Blackmore developed fabric prosthesis, than the group of DeBackeBlackmore developed fabric prosthesis, than the group of DeBackeyy


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Surgical Science: Present and FutureSurgical Science: Present and FutureAngiogenesis

Growth factors of new blood vesselsGrowth factors of new blood vessels -- treatment of ischemictreatment of ischemic

extremities, hearts, organsextremities, hearts, organs

Antiangiogenic factors (AAGF)Antiangiogenic factors (AAGF) --Judah FolkmanJudah Folkman-- excision of a tumorexcision of a tumor -- rapid metastasisrapid metastasis

--AAGF produced by the tumorAAGF produced by the tumor -- suppress metastasis bysuppress metastasis by

preventing the growth of new blood vesselspreventing the growth of new blood vessels

-- isolation of AAGFisolation of AAGF -- shrinking of established tumorsshrinking of established tumors

endostatinendostatin


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Surgical Science: Present and FutureSurgical Science: Present and FutureImportance of the surgeon-scientist (triple threat)

Scientific advances have to achieve clinical importanceScientific advances have to achieve clinical importance

Participation of doctors with active role in clinical care andParticipation of doctors with active role in clinical care and teachingteaching

The modern physicianThe modern physician--scientists arescientists are reductionistsreductionists (molecular biology)(molecular biology)

-- human diseases are disorders of macrohuman diseases are disorders of macro-- and not of microbiologyand not of microbiology

-- a reductionist will relate hard to spasm, ischemia, decompensata reductionist will relate hard to spasm, ischemia, decompensationion

A true physicianA true physician--(surgeon)scientist is involved with patients, he has(surgeon)scientist is involved with patients, he has

anan integrationistintegrationist (physiology(physiology--based) trainingbased) training


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ThankThankyou!you!

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History Surg Res