Domo arigato, Dr. Roboto — Maybe
Hospitals across Oklahoma City have invested in a da Vinci surgical robot, a highly marketed robot that can be used to perform a variety of surgeries. I’ve interviewed several doctors who use the robot to perform surgeries, and many of them rave about it.
They say patients recover faster, have fewer complications and leave the hospital faster than patients who don’t have the same kinds of surgeries using the robot.
But there’s a catch to some of their claims — comprehensive data to back it up.
As this article points out, recently published medical research has found that robotic surgery might not always prove to be more beneficial.
In the dozen years since the Da Vinci robot has been approved for surgeries in the United States, it’s been embraced by health care providers and patients alike. Surgeons routinely use the multi-armed metal assistant to remove cancerous prostate glands and uteruses, repair heart valves and perform gastric bypass operations, among many other procedures.
Lately a key study and reports of problems have raised questions about robotic surgery’s safety and cost-effectiveness, leading to a review of the Da Vinci system by the Food and Drug Administration and causing some experts to wonder whether the benefits of undergoing robot-assisted surgery may have been overstated.
To make any claim in medicine that one approach works better than the other, you need a study published in a medical journal that says “Yes, this is very, very true.” Actually, you probably need several studies by different academic institutes that agree and say, “Yes, that study is very, very true, and here’s what we found that says it’s still very, very true.”
Surgeons I’ve talked to with say the da Vinci robot allows them to operate inside a patient and affect the least amount of tissue while inside. And so far, the debate continues, with the U.S. Food and Drug Administration currently reviewing the system.
Complications can occur with any type of surgery, and so far it’s unclear if they are more common in robotic operations. That’s part of what the FDA is trying to find out.
Intuitive Surgical disputes there’s been a true increase in problems and says the rise reflects a change it made last year in the way it reports incidents.
The da Vinci system “has an excellent safety record with over 1.5 million surgeries performed globally, and total adverse event rates have remained low and in line with historical trends,” said company spokeswoman Angela Wonson.
But an upcoming research paper suggests that problems linked with robotic surgery are underreported. They include cases with “catastrophic complications,” said Dr. Martin Makary, a Johns Hopkins surgeon who co-authored the paper.
Should angioplasty fall out of favor?
USA Today had an interesting story yesterday about how the popularity of angioplasty, a commonly performed procedure in which doctors use a balloon to open blocked coronary arteries, may be eroding.
“The rise of angioplasty procedures has leveled off and appears to be on the decline,” Duke University’s Eric Peterson, who reviewed results of the analysis by the National Cardiovascular Data Registry, told the newspaper.
Three studies in the last two years that indicate that angioplasty may be no more beneficial than medication, and may be riskier. According to the newspaper, the research suggests angioplasty is used too often and its benefits don’t justify the procedure’s $10,000 to $12,000 cost.
The newspaper’s analyses found:
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The number of annual procedures performed each year has declined by 10% to 15% over the last two years.
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Angioplasty and stent use began dropping in June 2006, after two “landmark” studies cast doubt on them. Doctors often implant stents — both bare metal and drug-coated — after angioplasty to keep the artery open.
Angioplasty is used to treat the terrible chest pain, called angina, that comes from a heart without enough oxygen. The slight decline is important because Centers for Medicare and Medicaid Services guidelines seek to have angioplasty available within 90 minutes of a patient’s arrival at the hospital. This is often called door-to-balloon time.
Many medical authorities tout the benefits of angioplasty.
Because hearts suffer from an inadequate blood supply, Bonnie Weiner, president of the Society for Coronary Angiography, told the newspaper, “(Angioplasty) is very effective at achieving more blood flow to the heart.”
“I personally wasn’t surprised by the results,” says Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis who will debate the study at the heart meeting.
Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis, said angioplasty won’t prolong a person’s life or decrease the risk of a heart attack but will decrease the symptoms of one.
“The analyses conducted for the newspaper also reflect what may be the beginning of a broader change in medicine: a move toward ‘evidence-based’ care drawing on reams of data from medical research and patient treatment,” USA Today reported.
Jeff Raymond, Medical Writer
A new way of looking at diabetes
Researchers have seen that weight-loss surgery appears to cure type 2 diabetes, which they have attributed to the huge drop in pounds. After all, being overweight is a risk factor for diabetes, and losing weight can effectively take care of the problem.
An article that appeared in a supplement to last month’s issue of Diabetes Care argues that the bowel is the site of mechanisms that lead to diabetes.
The study’s author, Dr. Francesco Rubino of New York-Presbyterian Hospital/Weill Cornell Medical Center, presents evidence on the mechanisms of diabetes control after surgery.
“Clinical studies have shown that procedures that simply restrict the stomach’s size (i.e., gastric banding) improve diabetes only by inducing massive weight loss. By studying diabetes in animals, Dr. Rubino was the first to provide scientific evidence that gastrointestinal bypass operations involving rerouting the gastrointestinal tract (i.e., gastric bypass) can cause diabetes remission independently of any weight loss, and even in subjects that are not obese,” according to a press release.
Rubino’s previously has shown that the main way gastrointestinal bypass controls diabetes is by skirting the upper small intestine — the duodenum and jejunum.
“It has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism,” according to the release.
Rubino’s findings suggest bypassing the upper intestine may work by reversing abnormalities of blood glucose regulation.
He guesses the upper intestine of diabetic patients may be the site where an “abnormal signal” is produced that causes or predisposes one to diabetes.
Gastrointestinal surgery offers the possibility of complete disease remission. This is a major shift in the way we consider treatment goals for diabetes. It is unprecedented in the history of the disease,” he said.
What do you think of using surgery to treat diabetes? Have you had an experience with it? Leave me a comment at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
C-section stats
Almost 1 in 3 American woman had babies delivered by C-section in 2005, the Agency for Healthcare Research and Quality reports.
The number of C-sections was 38 percent less in 1995.
AHRQ also found:
- -Vaginal deliveries declined from about 3 million in 1995 to 2.9 million in 2005.
-Vaginal deliveries among women who previously had given birth via C-section dropped 60 percent –157,200 in 1995 to 62,300 in 2005.
-Hospitals charged $17.4 billion for deliveries by C-section in 2005.
The Oklahoman’s Heather Warlick wrote this story about C-sections in September.
Jeff Raymond, Medical Writer
Waiting for a liver
The need for donor livers outstrips their supply. Each year, about one-third of those with end-stage liver disease who need an organ will receive one. Some die while on the waiting list.
The February issue of Mayo Clinic Proceedings examines how the current system for allocating organs in the United States affects recipients’ outcomes.
The United Network for Organ Sharing (UNOS) oversees organ allocation. With the goal of giving organs to the most critically ill transplant candidates, UNOS adopted the MELD — Model for End-Stage Liver Disease — scoring system in 2002. The score is calculated from the results of three lab tests.
“Unlike past evaluation systems, the MELD score de-emphasizes the length of time a patient has been waiting for a donor organ. … Research has shown that although the donor liver shortage persists, implementing this allocation system has decreased the number of patients who die while waiting for donor organs,” according to a Mayo Clinic press release.
The study looked at the evaluation practices and acceptance criteria for liver transplant used by the Mayo Clinic Jacksonville Transplant Center after implementation of MELD scoring. Researchers examined medical records from 555 patients referred for liver transplants at the Jacksonville center from Jan. 1 through Dec. 31, 2005. Of these patients, 53 percent were denied for a transplant. Half of those denied were considered too early to have the procedure, while the rest were excluded because of medical conditions and psychosocial issues — poor support systems or continuing substance abuse problems, for example.
Many were subsequently accepted.
“Patients seeking referral often undergo repeated assessments by selection committees, as their eligibility can change over time or following treatment and/or changes in conditions that led to their initial exclusion,” according to the release.
Data suggest a “broad range” of patients could benefit from early referral to a transplant center, according to the release.
Basically, management of their disease and other medical and psychosocial conditions could make them transplant candidates sooner.
To read the report, click here.
People seldom realize transplant waiting lists are anything but static: They constantly change, depending on organ availability and patients’ medical states. They’re definitely moving targets. People move up, they move down; they drop off, they’re added back.
“Our study suggests that early referral for LT (liver transplant) evaluation is beneficial for reasons unrelated to the time patients spend on the LT waiting list. If patients too early for LT were evaluated but not listed, LT centers could initiate management of ESLD (end-stage liver disease) and address psychosocial issues in a sub-group of patients who could also ultimately benefit from LT,” the authors wrote.
Although not exactly the same thing, last month I wrote about this man, Dr. Ludvik Artinyan, left, who registered on organ waiting lists in California and Oklahoma. He was able to receive a liver transplant quicker by traveling to Integris Baptist Medical Center to have the procedure performed rather than having it done in Los Angeles. Because patients’ MELD scores typically are higher in California for various reasons, double-listing likely allowed the Armenia-born physician to shave months off his wait time and perhaps saved his life.
UNOS allows potential transplant recipients to be listed in multiple regions – they must meet each site’s criteria and be ready to respond to the phone call or page when an organ becomes available.
Is the current organ allocation system fair? E-mail me at jraymond@oklahoman.com or post your thoughts at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
Healthy Heart Fair
The Fifteenth Annual Healthy Heart Fair will be from 9 a.m. to 1 p.m. Saturday at the Oklahoma City Community College Union Building, 7777 South May Avenue.
People from across the state are invited to have their cardiovascular health evaluated via a free health screening (fasting is not required for the screening) including cholesterol, blood pressure, glucose and body fat analysis. Attendees can also learn the signs and symptoms of an ailing heart while trained staff will be on-hand to give CPR classes.
An “Ask the Cardiologist” booth will be set up for those that need answers to their heart health questions.
Three one-hour presentations will also be given:
9:30 a.m.
Kris Mullins, M.D.
Heart Checkup: The Many Cardiac Tests Available at Integris Heart Hospital
10:30 a.m.
Terrie Gibson, M.D.
Herbal Medicines: Helpful or Harmful?
11:30 a.m.
Terrie Gibson, M.D.
Health Screenings: Which Ones to Get, Which Ones to Skip
The Healthy Heart Fair is sponsored by Integris Heart Hospital at Baptist Medical Center.
For health and medical news and commentary, visit The Medicine Bag blog at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
Stroke guidelines at Baptist
The Integris Cerebrovascular & Stroke Center at Baptist Medical Center is participating in the American Stroke Association’s Get With The Guidelines–Stroke program.
The goal is to improve stroke treatment and prevent future strokes.
The program was developed to help hospitals employ “science-based treatment guidelines,” according to an Integris press release. The guidelines address stroke management and prevention, and the establishment of stroke centers.
“As a GWTG-Stroke participating hospital, Integris Cerebrovascular & Stroke Center at Baptist Medical Center is encouraged to develop a comprehensive system for providing rapid diagnosis and treatment of stroke when patients are admitted to the emergency department. This includes always being equipped to provide brain-imaging scans, making neurologists available to conduct patient evaluations and using clot-busing medications when appropriate,” according to the release.
Treatment and prevention of strokes includes use of statins and anti-platelet medications, treatment of atrial fibrillation and atherosclerosis, and management of weight, diabetes and cholesterol.
Through the GWTG-Stroke program, the American Stroke Association provides Baptist with training and staff recommendations, “care maps,” discharge protocols, standing orders, and data collection and measurement tools.
According to the stroke association, approximately 700,000 people suffer a stroke each year.
For health and medical news and commentary, read The Medicine Bag blog at http://blog.newsok.com/health.
Jeff Raymond, Medical Writer
Treating aneurysms at OU Physicians
An OU Physicians surgeon has used a new technique to treat thoracic aortic aneurysm patients. The endovascular stent graft procedure is less invasive than other therapies.
In the procedure, used on patients for whom open-chest surgery would pose serious risks, the surgeon inserts a stent endoscopically from the leg or abdomen using X-rays as a guide. The stent reinforces the aortic walls and helps prevent rupture. The procedure is safer than thoracic surgery and allows patients to recuperate quicker.
“The stent graft is … deployed in the diseased segment of the aorta and ‘relines’ the aorta like a sleeve to divert blood flow away from the aneurysm,” according to the Cleveland Clinic Web site.
Blood passes through the graft without pushing on the aneurysm. Thoracic aortic aneurysms affect approximately 15,000 people in the United States annually.
Jeff Raymond, Medical Writer
