Year : 2022 | Volume
: 9 | Issue : 2 | Page : 127--128
Surgeon heal thyself…………
P Ilaya Kumar
Assistant Professor, Institute of Vascular Surgery, Madras Medical College, Chennai-3, Tamil Nadu, India
P Ilaya Kumar
Assistant Professor, Institute of Vascular Surgery, Madras Medical College, Chennai-3, Tamil Nadu
|How to cite this article:|
Kumar P I. Surgeon heal thyself………….Indian J Vasc Endovasc Surg 2022;9:127-128
|How to cite this URL:|
Kumar P I. Surgeon heal thyself…………. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jun 26 ];9:127-128
Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/127/347258
“A middle path,O bhikkus, avoiding the two extremes,has been discovered-a path which opens the eyes and bestows understanding, which leads to peace of mind,to the higher wisdom,to full enlightenment!”
This patient needs an Aorto-femoral bypass “stated my Senior resident confidently, showing me a CT-angiogram of a bedridden patient who was around 75 years old,barely able to speak, unable to even move on his own, crippled by a devastating CVA sometime back last year, presenting to us now with gangrenous toes, he had severe CAD,and other co- morbidities too, at that moment I was reminded of the often repeated aphorism of Dr.Gregory L. Monetta, former Professor of Vascular surgery, Oregan University, Portland, U.S.A and Former Editor-in -Chief of the year book of vascular surgery series in the late 90's “Patients who are bed ridden continue to be bed ridden after surgery and patients who are ambulant before surgery continue to do so after any vascular intervention ,with very few cross-overs in between”. This patient like a majority of vascular patients has a poor life expectancy and at best may be managed conservatively or if possible by an endo-vascular option or an extra-anatomical bypass and even if this is not possible may be an high-level amputation to relieve him of his rest pain will be the best option.
With advances in technology and techniques more and more “lesions” rather than patients like these are being treated by surgeons and interventionists for reasons best known for themselves. Thus, we have more and more claudicants undergoing vascular interventions and who, as we know, don't require any intervention since only 20% of these patients may progress to CLTI if not properly treated, interventions in this group is limited to only severe debilitating claudication in young individuals and interventions sometimes do more harm than good. Dr. Samuel Miller's article published in the Annals of Vascular surgery 2019, noted that women particularly had higher in-patient mortality after intervention for lifestyle limiting claudication and recommends treatment guidelines for this group of patients.
Another interesting paper by Dr. Joshua A.Gabel et al, published in the JVS2020,which found 78% healing rates in CLTI patients managed conservatively or by deferred revascularization and similar rates of healing (66% vs 57.6%), freedom from major amputation(81.8% vs 74.9%) and survival (54.5% vs %50.7%) when compared with immediate revascularization, underlining the need for either a conservative approach or deferred revascularization in these group of patients. One another group of patients are those with small aneurysms ,one intresting study by Dr. Frank. M Davis, published in the JVS 2019 found 12% of aneurysms below the size of 5.5 cm were being operated (SVS guidelines recommends surgery for AAA > 5.5 cm) and 30% of the surgeons disregarding these guidelines, inspite of the fact that previous studies like the PIVOTAL and CAESAR studies found no survival benefits with repair of small aneurysms,a worrying trend indeed!
Similar approaches are seen increasingly in managing venous diseases as well ,where corporate agencies hold massive screening programmes followed by mass surgical camps for treating even CEAP class 1 pts, all with attractive day care packages ,even though conventional teaching recommends surgery for complicated stages only ,while majority can be managed conservatively by compression and medicines alone,However 'corporate wisdom' thinks otherwise, once patient goes away he is lost for ever, so operate as early as possible seems to be thier guiding motto,they also pressurise the gullible surgeon to operate on these patients. One other cause of concern is the indiscriminate deployment of IVC filters, whose indications actually are shrinking world wide and so are the insertion of Venous stents for even patients with mild to moderate Vilalta scores; If you have a hammer in hand everything looks like a nail!
American author and surgeon Atul Gawande in his book “Bieng mortal” writes about certain hard facts about getting sick in old age “As people's capacities wane whether through age or ill-health, making their lives better often requires curbing our purely medical imperatives-resisting the urge to fiddle and fix and control, but it also poses a difficult question: when should we try to fix and when should we not?” He says that most of the times we make no choice at all and fall back on the default and the default is: Do something ,fix something. This is a very tough question to answer, with increasing costs of these interventions particularly in a country like ours where a majority of patients have to pay out of their own pockets, it imposes a tremendous financial and mental burden in their twilight years of their life, this poses a moral dilemma for the surgeon himself but most often it's the ego of the treating surgeon which determines the revascularization strategy for these poor risk patients putting the lives of these patients at risk, while a properly done amputation and good prosthesis would have saved the patient's life.
At the end of the day we have to introspect within ourselves and decide on whom to operate and whom not to operate, which by itself is a tough question to answer, in the early part of our career we definetly tend to intervene in each and every case we see but then as we age and gather more experience and knowledge ,we come to understand that not all patients need to be intervened and also experience teaches us what works for whom, so we tend to take to a middle path approach in most if not all cases, not only does it prolongs our patient's life , it also gives us some peace of mind and an inner satisfaction knowing that you have done your best for the patient, you may not become very rich but definetly you won't become morally bankrupt either and it also prevents “early burn out” in our career. To reiterate, it's time we follow a middle-path approach both in our life and career.
“Middle path is the balanced path-seeing the” complete truth “instead of illusionary half truth”
|1||Miller SM, Sumpio BJ, Miller MS, Erben Y, Cordova AC, Sumpio BE, et al. Higher Inpatient mortality for women after intervention for lifestyle limiting claudication. Ann Vasc surg 2019:58:54-62.|
|2||Gabel JA, Bianchi C, Possagnoli I, Abou-Zamzam AM, Bishop RNV, Eastridge RND, et al. A conservative approach to select patients with ischeamic wounds is safe and effective in the setting of deferred revascularization; J vasc surg 2020:71:1286-95.|
|3||Davis FM, Jerzal E, Albright J, Monsour A, Bore P, Henke PK, et al. Variation in the elective management of small abdominal aortic aneurysms and physician practice patterns. J vasc surg 2019:1-10.|
|4||Atul Gawande;Bieng Mortal;penguin books, India; P174.|