The impact of the new technologies in surgeryy: lights an shadows

The impact of the new technologies in surgery: lights an shadows

Appropriateness and Sustainability

Pier Paolo Dal Monte MDBologna

Italy

1° Congress of the

Eurasian Colorectal Technologies Association

Guangzhou

November 13-15. 2009

The more sophisticated the

machine, the more barbaric the

worker

Karl Marx

30 years that changed the world

The new technologies in surgery

New diagnostic tools

US,

CT,

MRI,

Digestive endoscopy

The “technology tree”

New surgical instruments

Staplers

Endoscopes

Haemostasis and dissecting devices

Minimally invasive instruments

Safety for “old procedures”

Feasibility for “new

procedures

Better indications

(precision, target)

Efficacy

Safety

Less invasivity

Better results

Less trauma

Shorter hospital stay/faster recovery

(NOTES):

1) Imaging

2) Suture/anastomosis: stapling devices

3) Access: Endoscopic surgery

minimally invasive surgery (laparoscopy)

digestive endoscopy

4) Haemostasis/dissection: physical (energy)

chemical/biological (glues)

5) Meshes/stents

6) New devices for proctological conditions

7) Frontiers: Robotic Surgery, NOTES, Single Access Laparoscopy

New technologies

History

1946

V.F. Gudov: 1° vascular stapler

1960

Androsov, Belkin Kalinina: Cut and suture

staplers

Gastric resection

Perioperative mortality reduced from 10,4 to 3,6%

Anastomosis time: 50% less

Dehiscence reduced from 20-25% to 5-10%

Gritsman J.J. :Mechanical Suture by Soviet apparatus in gastric

resection Use in 4000 operations. Surgery 59 (5): 663-669, May 1966

70’s

(USSC)First single use devices

Suture/anastomosis: stapling devices

Advantages

• Standardisation of the technique

• Reduction of operative time

• Better feasibility for “difficult“ anastomoses

(oesophago-gastric, colo-anal)

• “Endo-staplers”: feasibility of laparoscopic colo-rectal

surgery

Disadvantages

• Cost

• Waste managment

• Not applicable as widely as the hand

suture

Suture/anastomosis: stapling devices

1868, Kussmaul performed the first esophagogastroscopy on

a professional sword swallower, initiating efforts at

instrumentation of the gastrointestinal tract

1928-1932 Schindler-Wolf: semi-flexible gastroscope

1954 H.Hopkins- N.Kapany: fiber-optic image transmission

1957 Hirschovitz: 1° fibersope (gastroscope)

1969 Olympus: 1° colonoscope

Access: Digestive endoscopy

1) Accurate diagnosis

Image enhancement

EUS

2) Operative treatments

Haemostasis

ERCP

Excision

Dilatation

Palliation

Access: Digestive endoscopy

Clips

Injective catheters

Argon Plasma

Laser

Sphincteretomes

balloons

Advantages

1977, First Laparoscopic assisted appendicectomy was

performed by Dekok. Appendix was exteriorized and ligated

outside.

1983, Semm, a German gynaecologist, performed the first

laparoscopic appendicectomy.

1985, The first documented laparoscopic cholecystectomy

was performed by Erich Mühe in Germany in 1985.

1987, Phillipe Mouret, has got the credit to perform the first

laparoscopic cholecystectomy in Lyons, using video

technique. Cholecystectomy is the laparoscopic procedure

which revolutionized the general surgery

Access: Laparoscopy

Access: LaparoscopyOutcomes (colorectal cancer)

Equivalence LS-OS

In oncological clearance and cancer-related

mortality

Liang Y, Li G, Chen P, Yu J. Eur J Surg Oncol. 2008 Nov;34(11):1217-24

Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J.Cancer Treat Rev. 2008 Oct;34(6):498-504.

Abraham NS, Byrne CM, Young JM, Solomon MJ. NZ J Surg. 2007 Jul;77(7):508-16

Schwenk W, Haase O, Neudecker J, Müller JM.. Cochrane Database Syst Rev. 2005 Jul 20;(3)

Better outcomes for LS

Operation time: LS > OS (30-60min)

Blood loss: LS<OS

Pain: LS<OS

Bowel function: LS<OS (1-1,6 days)

Hospital stay: LS<OS (1,6-3,5 days)

General morbidity:LS<OS (24 vs 31%)

Postoperative hernias): LS<OS (13vs33% at 5years)

Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J.Cancer Treat Rev. 2008 Oct;34(6):498-504.

Abraham NS, Byrne CM, Young JM, Solomon MJ. NZ J Surg. 2007 Jul;77(7):508-16

Schwenk W, Haase O, Neudecker J, Müller JM.. Cochrane Database Syst Rev. 2005 Jul 20;(3)

Laurent C, et al. Br J Surg. 2008 Jul;95(7):903-8.

Reza MM et al. Br J Surg. 2006 Aug;93(8):921-8

Guillou PJ, et al. Lancet. 2005 May 14-20;365(9472):1718-26

Access: LaparoscopyOutcomes (colorectal cancer)

Access: LaparoscopyEconomics (colorectal surgery)

Comparable cost between lap and open access

Vignali et alAnn Surg. 2005 December; 242(6): 890–896.

Park et al.World J Surg (2007) 31:1827–1834

Noblett et al.Surg Endosc (2007) 21: 404–408

Dows et al.Dis Colon Rectum. 2007 Jun;50(6):908-19

…But this is true only for the countries with high

labour cost.

•1926.First use of electrosurgical device (Harvey Cushing)

Haemostasis/dissection:

Phisical (energy)

1980’s-1990’s

Computer controlled Bipolar electrosurgery

Ultrasound dissection

Argon Plasma coagulation

Laser

RF

In 1985 a robot, the PUMA 560 brain

biopsy using CT guidance.

In 1988, the PROBOT, developed at

Imperial College London, was used to

perform prostatic surgery.

Further development of robotic

systems was carried out by Intuitive

Surgical with the introduction of the da

Vinci Surgical System and Computer

Motion with the AESOP and the ZEUS

robotic surgical system

Robotic surgery

Advantages:???

Developement of a new approach with possible

Improvements in surgical technique

Possible applications in remote surgery

(war surgery, space)

Routinary use?: Expensive

>operating time

Organisation

Robotic surgery

Natural Orifice Transluminal Endoscopic Surgery

(NOTES):

Natural Orifice Transluminal Endoscopic Surgery

(NOTES) is an emerging experimental alternative to

conventional surgery that :

Eliminates abdominal incisions and incision-related

complications

Combining endoscopic and laparoscopic techniques

in order to access the peritoneal cavity by means of

mouth, anus, or vagina

Absence of incisional complications including pain,

hernias and external wound infections.

Novel advanced technologies and instruments must

be developed specifically for NOTES.

The most promising potential advantages:

development of new instruments both for

laparoscopy and digestive endoscopy

NOTES: Potential advantages

Undiscussed

technique advancement

(revolutions): Endoscopy

Laparoscopy

Undiscussed

technical advancement: Staplers

New dissection/cauterisation

devices

Chemical/biological Haemostasis

Meshes/Stents

?:

Robotic

Notes

Assessment of the new technologies

Safety for “old procedures”

Feasibility for “new

procedures

Better indications

(precision, target) Efficacy

Safety

Less invasivity

Better results

Less trauma

Shorter hospital stay/faster recovery

The technical progress have brought many

undoubted advantages .......

…but there are some shadows..

The hidden dangers of technology

Different technical skills:

Different surgical training

Young surgeons sometimes are not

trained enough in “old techniques”

“Fashionable”: “New is better”

Acritical preference of the new

techniques

“Surgical” issues


“Surgical” issues

Tecnology “addiction”: Surgeons risk of relying too much

on the technical tools

Organisation problems: The new technologies require a

more complex organisation

Industry “pressures”: Conflicts of interest

Biased studies (results,

pathophysiology)

Cost /benefits issues: Enthusiastic adoption of a new

technique before scientific

evidence

Increase of costs for healthcare: Tranfer of money from the

taxpayer to the industry

Non sustainability for the

system

Industry driven instead of surgeon driven technological progress


Ethical and economic issues


Industry “pressures”: Conflicts of interest

Biased studies

(results, pathophysiology)

Example:

Is “rectal redundancy syndrome” just

another way to name haemorrhoids ?

(and related DRG)


Cost /benefits issues: Enthusiastic adoption of a new

technique before scientific evidence

Faecal incontinenceInjectable bulking agents

Artificial anal sphincter

Sacral nerve stimulation

The introduction of new technology is encouraging, both in

the evaluation and treatment , and it is hoped will advance

these muchneeded procedures.

Despite this plethora of exciting advances, a stoma still

remains the best option in patients with severe fecal

incontinenceJarrett ME, et al. Br J Surg 91(12):1559-1569, 2004

Increase of costs for healthcare: Tranfer of money from the taxpayer

to the industry

Non sustainability for the system

In the United States the estimate is that from 40% to 50% of

cost increases can be traced to the technological factor,

similar in Europe.

The net result has been an average general system-wide cost

increase of 10%-15% a year for the past several years, and

with no end in sight

D. Callahan Sustainable Medicine: Two Models of Health Care

Giannino Bassetti Foundation - 2005


The contemporary model is based on infinite

progress

The constant introduction of new, and usually

more expensive, technologies and the

intensified use of older technologies.

Unlimited, infinite, vision can not be paid for with

finite funds

“Technological” Healthcare

Diminishing returns to increasing complexity J. Tainter, The collapse of complex society 1988)

In economics, diminishing marginal returns refers to how the

marginal contribution of a factor of production usually

decreases as more of the factor is used.David Ricardo. On the Principles of Political Economy and Taxation (1817)

Sustainability-HealthcareCosts versus benefits (marginal returns)

Productivity of the U.S. health care system, 1930-1982.

Productivity index = (Life expentancy)/(National health expenditures

as percent of GNP).

J.Tainter, The collapse of complex society ,1988

Sustainability-HealthcareDiminishing marginal returns

Rank Country Infant

mortality

rate

(X/1,000)

Under-five

mortality

rate

(X/1,000)

3 Japan 3.2 4.2

4 Sweden 3.2 4.0

9 Switzerland 4.1 5.1

11 Belgium 4.2 5.3

12 France 4.2 5.2

13 Spain 4.2 5.3

14 Germany 4.3 5.4

16 Austria 4.4 5.4

17 Australia 4.4 5.6

19 Netherlands 4.7 5.9

22 United

Kingdom

4.8 6.0

23 Canada 4.8 5.9

25 Italy 5.0 6.1

28 Cuba 5.1 6.5

33 United States 6.3 7.8

Rank CountryLife expectancy

at birth (years)

1 Japan 82.6 79.0 86.1

4 Switzerland 81.7 79.0 84.2

5 Australia 81.2 78.9 83.6

6 Spain 80.9 77.7 84.2

7 Sweden 80.9 78.7 83.0

10 France 80.7 77.1 84.1

11 Canada 80.7 78.3 82.9

12 Italy 80.5 77.5 83.5

16 Austria 79.8 76.9 82.6

17 Netherlands 79.8 77.5 81.9

20 Belgium 79.4 76.5 82.3

22United

Kingdom79.4 77.2 81.6

23 Germany 79.4 76.5 82.1

37 Cuba 78.3 76.2 80.4

38 United States 78.2 75.6 80.8

Health indicators in industrialized countries

United Nations: World Population Prospects,2006

Health Expenditure

Country % GNP Pro Capita (intl $)

2000 2006 2000 2006

USA 13,2 15,3 4570 6719

Switzerland 10,3 10,8 3265 4179

Belgium 9,1 9,9 2514 3673

Austria 9,9 10,2 2858 3608

Nederlands 8 9,4 2337 3481

Germany 10,3 10,6 2670 3465

France 10,1 11 2542 3420

Sweden 8,2 9,2 2283 3162

Australia 8,3 8,7 2271 3119

UK 7,1 8,2 1846 2815

Italy 8,1 9 2061 2631

Japan 7,7 8,1 1967 2581

Spain 7,2 8,4 1536 2461

Cuba 6,7 7,7 353 674

Health expenditure versus life expectancy

WHO: World Health Statistics 2009

A. Goals

-- unlimited scientific progress and technological

innovation regardless of their long-term cost

–- medical progress and technological innovation

are allowed to set medical goals and to

change and redefine those goals

The contemporary model

of scientific medicine

B. Outcomes

Considerable medical progress and creation of

massive medical-industrial complex

Powerful bias toward:

-- cure rather than care

-- technological interventions rather than health

promotion/disease prevention



Result:

Unsustainable economic pressures on all

health care systems



Technologies must be much more toughly

evaluated

Evaluation is generally aimed only at the

efficacy , not at its likely economic impact.

That impact needs to be evaluated as well

Conclusions

We do not have at present sustainable health care

systems in any country.

Constant medical progress, adding to costs, and

aging populations, also adding to cost, guarantees

they will be unsustainable

If medicine is unaffordable, it can not be equitably

distributed; only the wealthy will be able to get it.

Conclusions Sustainability

The quiet conscience is an

invention of the devilAlbert Schweitzer,

The philosophy of civilization

A Sustainable system?

What about the rest of the World?

Rank Country

Life expectancy at

birth (years)

Both Male Female

1 Japan 82.6 79.0 86.1

2 Hong Kong 82.2 79.4 85.1

3 Iceland 81.8 80.2 83.3

4 Switzerland 81.7 79.0 84.2

5 Australia 81.2 78.9 83.6

6 Spain 80.9 77.7 84.2

7 Sweden 80.9 78.7 83.0

8 Israel 80.7 78.5 82.8

9 Macau 80.7 78.5 82.8

10 France 80.7 77.1 84.1

Rank Country

Life expectancy at

birth (years)

Both Male Female

185 Rwanda 46.2 44.6 47.8

186 Liberia 45.7 44.8 46.6

187 Congo D.R.. 44.7 43.3 46.1

188 Afghanistan 43.8 43.9 43.8

189 Zimbabwe 43.5 44.1 42.6

191 Lesotho 42.6 42.9 42.3

192 Sierra Leone 42.6 41.0 44.1

193 Zambia 42.4 42.1 42.5

194 Mozambique 42.1 41.7 42.4

195 Swaziland 39.6 39.8 39.4



Life expectancy at birth

Rank Country Infant

mortality

rate

(X/1,000)

Under-five

mortality

rate

(X/1,000)

1 Sierra Leone 160.3 278.1

2 Afghanistan 157.0 235.4

3 Liberia 132.5 205.2

4 Angola 131.9 230.8

5 Mali 128.5 199.7

6 Chad 119.2 189.0

7 Cote d'Ivoire 116.9 183.2

8 Somalia 116.3 192.8

9 Congo, D.R. 113.5 195.9

10 Guinea-

Bissau

112.7 194.8

World: 49.4 73.7

Rank Country Infant

mortality

rate

(X/1,000)

Under-five

mortality

rate

(X/1,000)

186 Korea, South 4.1 4.8

187 Switzerland 4.1 5.1

188 Czech

Republic

3.8 4.8

189 Finland 3.7 4.7

190 Hong Kong 3.7 4.7

191 Norway 3.3 4.4

192 Sweden 3.2 4.0

193 Japan 3.2 4.2

194 Singapore 3.0 4.1

195 Iceland 2.9 3.9


Infant mortality


Causes of death in

developing countriesNumber of deaths

Causes of death in

developed countriesNumber of deaths

HIV-AIDS 2,678,000Ischaemic heart

disease3,512,000

Lower respiratory

infections2,643,000

Cerebrovascular

disease3,346,000

Ischaemic heart disease 2,484,000Chronic obstructive

pulmonary disease1,829,000

Diarrhoea 1,793,000Lower respiratory

infections1,180,000

Cerebrovascular disease 1,381,000 Lung cancer 938,000

Childhood diseases 1,217,000 Car accident 669,000

Malaria 1,103,000 Stomach cancer 657,000

Tuberculosis 1,021,000Hypertensive heart

disease635,000

Chronic obstructive

pulmonary disease748,000 Tuberculosis 571,000

Measles 674,000 Suicide 499,000

A Sustainable system?Causes of death in developing and developed countries

Who 2009

Tanzania: 50000:1

Zambia: 50000:1

Italy: 230:1

Cuba: 170:1


Modern technological healthcare is a

reality only for 1/3 of the world

population…

Sustainability of the “World

Healtcare system”?

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…a small part of the

World is like this…

Can we call sustainable

a situation where…

…While a greater part

Is like this?

Technique has arrived at such a point in

its evolution that it is being transformed

and is progressing almost without

decisive intervention by man.

Jacques Ellul

La tecnique enju du siecle

Thank you for your

attention

Shadows

The impact of the new technologies in surgeryy: lights an shadows

Health & Medicine

Transcript of The impact of the new technologies in surgeryy: lights an shadows