history surg res
TRANSCRIPT
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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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Obstacles to ResearchObstacles to Research
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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Obstacles to ResearchObstacles to Research
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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Obstacles to ResearchObstacles to Research
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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Surgical Science HistorySurgical Science HistoryB. Surgical science in remote times
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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Surgical Science HistorySurgical Science HistoryB. Surgical science in remote times
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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Surgical Science HistorySurgical Science History
C. Surgical science of the past 50 years
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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Surgical Science HistorySurgical Science HistoryC. Surgical science of the past 50 years
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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Surgical Science HistorySurgical Science HistoryC. Surgical science of the past 50 years
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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Surgical Science HistorySurgical Science History
C. Surgical science of the past 50 years
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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Surgical Science HistorySurgical Science HistoryC. Surgical science of the past 50 years
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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Surgical Science HistorySurgical Science HistoryC. Surgical science of the past 50 years
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!