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Newsletteralumni News of the Newyork-Presbyterian Hospital/Columbia University Department of Surgery Volume 12 Number 1 Spring 2009

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Newsletteralumni News of the Newyork-Presbyterian Hospital/Columbia University Department of Surgery Volume 12 Number 1 Spring 2009 NEWSLETTERAlumni News of the NewYork-Presbyterian Hospital/Columbia University Department of Surgery Volume 12 Number 1 Spring 2009 Outliers All requires several iterative improvements and sometimes a leap of faith to cross a chasm of doubt and disappointment. This process is far more comfortable and promising if it is imbued with cross- discipline participation and basic science collaboration. Eric’s early incorporation of internist Ann Marie Schmidt’s basic science group within his Department continues to be a great example of the pro- ductivity that accrues from multidiscipline melding. Several speakers explored training in and acceptance of new techniques. The private practice community led the way in training and early adoption of laparoscopic cholecystectomy, which rapidly supplanted the open operation, despite an early unacceptable inci- dence of bile duct injuries. Mini-thoracotomies arose simultaneous- ly at multiple sites and are now well accepted as viable approaches to the coronaries and interior of the heart; whereas, more than a de- cade after their introduction, video assisted lobectomies for stage I, non-small-cell lung cancer account for <10% of US lobectomies. Os- tensibly, this reluctance reflects fear of uncontrollable bleeding and not doing an adequate cancer operation, neither of which has been a problem in the hands of VATS advocates. The May 8, 2009, 9th John Jones Surgical Day was a bit of an Lesions that are generally refractory to surgical treatment, outlier because the entire day was taken up by a single program, ex- such as glioblastomas and esophageal and pancreas cancers merit cept for a short business meeting and a lovely evening dinner party. out-of-box thinking. Extended pancreatectomies to encompass vas- Henry Spotnitz and his committee assembled 24 beneficiaries of Eric cular encroachment together with neo-adjuvant down staging are A. Rose’s inspiration and guidance to produce a most enjoyable cel- being employed in an appropriately small number of centers with ebratory tribute to an organized, innovative leader. This was a gath- somewhat encouraging anecdotal results. This calls into question ering of outlier individuals who had become virtuosos in their re- the wisdom of tying ourselves to the p <0.05 mast, particularly, in spective fields, as defined by Malcolm Gladwell , by virtue of having poorly served clinical settings. Maybe a 20% probability that an completed a minimum of 10,000 hours of practice. Gladwell argues apparent advantage wasn’t just a chance event might be worthy of that extraordinary achievement is only moderately dependent on acceptance until more evidence accumulates or something more being personally gifted but is a culmination of hard work, and fortu- promising comes along. Similarly, survival and disease free survival, itous circumstances, such as the nurturing company of likeminded although conveniently dichotomous, are neither patient-centric, nor individuals and having a great coach. He is right about the constel- appropriately individualized outcome measures. Patients’ assess- lation of factors but is not so knowledgeable about surgical training’s ment of success and that of their families need more prominence duration: 10,000 hours equate to a mere 2.5 years of 80-hour weeks, in reported outcome measures. For example, tough drug regimens and to just 2 years of the virtuosos’ likely work-week hours. and big surgery need a home run outcome in children to qualify as This was not a guild meeting of cardiac surgeons, and those a success, not just the couple of comfortable years that might justify who stayed home thinking that it would be, will see the error of similar treatment for a 65-year old. their ways when the symposium is published as a supplement to the One speaker said: “People always tend to do things better when World Journal of Surgery, hopefully in December. The topics were they are around Eric,” which is what the day was all about. That is a conceptual and applicable to a broad swath of clinical and investi- treasured trait, which is hard to describe but often immediately ap- gative medicine. The focus was on innovative therapies and recog- parent, as in: “He’s really cool, Dad” [Nicholas Guillem, at age 8 (now 11), to his father José, after meeting Dr. Rose on Madison Avenue]. nizing that really new technology is inherently disruptive and risk ridden. Reaching the potential envisioned by its originators typically Jim Chandler 1. Gladwell M. The 10,000-hour Rule. In Outliers: the Story of Success. New York: Little, Brown and Company; 2008. 2. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. AnnThorac Surg 2006;81:421-5. Ludwig Rehn Alexis Carrel Elliott Cutler Sir Henry Claude S. Beck Successful Stephen Herbert Milton Canine Trans- Souttar Epicardial closure of a Paget Introduces Cervical Aorto- ventricular Trans-atrial pectoralis R. ventricle Heart surgery clinical median heart coronary valvulotomy for mitral stenosis pedicle grafts stab wound naysayer sternotomy allograft bypass mitral stenosis finger fracture for ischemia l l l l l l l l Sept 10, 1896 1897 1897 1905 1910 1923 May 6, 1925 1935 John H Gibbon, Jr. Robert E. Gross Paul Swenson to Alfred Blalock- D.W. Richards, Jr. Claude Beck Artificial Elective G H Humphreys II: Helen Taussig André Cournand Arterialized circulation closure of "Patent ductus favors L. subclavian to R. heart pressures coronary during pulmonary patent ductus Tetralogy of Fallot L. pulmonary artery with mitral stenosis, sinus for artery occlusion arteriosus patients' survival" bypass CHF, or COPD ischemia l l l l l l 1937 Aug 26, 1938 1941 Nov 29, 1944 1946 1948 Arthur Robert Gross F. John Lewis John H. Henry Swan Charles P. Bailey C. Walton Lillehei Vineberg Atrial well Richard Varco Gibbon, Jr. Hypothermia for Post infarction Donor cross ITA for closing Hypothermia Total CPB for pulmonic valve ventricular circulation to myocardial atrial septal for atrial septal atrial septal and infundibular aneurysm repair cardiac implants defects defect closure defect closure stenosis resection anomalies l l l l l l l 1950 1952 Sept 2, 1952 May 6, 1953 1953 Apr 15, 1954 1955 Denis Melrose Charles P. William P. F. Mason Åke Senning Moses H. Cass Nina Braunwald Elective Bailey Longmire Sones Atrial inflow Russel C. Brock Dwight E. Harken potassium Coronary Left ITA to Selective correction for Bi-atrial Albert Starr citrate arrest artery R. coronary coronary aorto-pumonary transection Successful total and recovery endarterectomy anastomosis arteriography transposition plane valve replacement l l l l l l l 1955 Oct 29, 1956 1958 1958 Oct 1958 1959 Mar-Oct 1960 Dick Lower Domingo Liotta David H. Edward Jean Paul Binet Donald Norm Shumway Donald Ross E. Stanley Blumenstock Garrett Alain Carpentier Ross Viable canine Sub-coronary Crawford 6-wk graft Saphenous V. Mercurochrome Pulmonary orthotopic aortic valve Post-cardiotomy survival with aortocoronary treated pig valve transplants homograft LVAD methotrexate bypass valves autograft l l l l l l l 1960 Jun 24, 1962 July 19, 1963 1963 Nov 23, 1964 1965 1967 Barnard Kantrowitz Denton Jay Ankeney Alain Francois Terry King Kantrowitz Will C. Sealy Intra-aortic Cooley Locally Carpentier Fontan Noel Mills Shumway Intraoperative balloon 64-hr. TAH stabilized Mitral and Valved atrium Transcatheter Five human arrythmia counter- "bridge to beating heart tricuspid ring Rt. ventricular Rx of atrial allotransplants mapping pulsation transplant" CABG annuloplasies bypass septal defects l l l l l l l l 12/3 '67-1/ 9 '68 1968 1968 Apr 4-6 '69 1969 1971 1971 1974 Adib Jatene Andreas Eric Rose G.Wieselthaler Eric Rose Yau-Lin V. Segars Anatomical Grüntzig Humorally Clinical use Randomized Alain Cribier Tseng R. Lee correction of Coronary mediated graft of valveless, mechanical Percutaneous GT-knock out Cardiac great vessel artery arteriosclerosis continuous assist vs. med aortic valve pig-to-baboon stem cell transposition angioplasty and rejection flow [L]VAD Rx for CHF replacement xenografts therapy l l l l l l l l 1975 Sept 16, 1977 1989 Nov 13, 1998 2001 2002 2005 2008 Principal events in cardiac surgery's insurgent evolution: blue type indicates association with the Columbia University Medical Center and its antecedents in this figure, as well as in the list of references. 2 John Jones Surgical Society Volume 12, Number 1 Spring 2009 Cardiac Surgery’s Insurgent Evolution James G. Chandler and Stephen E. Novak, Head, Archives and Special Collections, Augustus C. Long Health Sciences Library Insurgent evolution is an oxymoron, linking insurrection with attributed to Theodor Billroth its near opposite, orderly progression. Yet, both are good descriptors (1829-94), in an informative and of cardiac surgery’s largely 20th century development and the 18th entertaining article entitled, Nihil- century guerilla warfare that won independence for America.1 Each ism: A Benign Denial. For cardiac was essentially an American-British endeavor, with significant con- surgery, Skandalakis’ title was in- tributions from German and French speaking Europeans. Both were appropriate: hierarchical denial idealistically imbued, hallmarked by successful probes, and cowing was often vituperative and would push backs that marginalized the insurrectionists. Certain advances harass cardiac surgery’s evolu- came at great cost to unwitting, desperate patients in one campaign tion for half a century. Its tenacity and to unwitting, colonial bystanders in the other. Bold moves and is well illustrated by attitudes to- perseverance eventually triumphed, paving the way for evidenced- wards the treatment of debilitating based, sustained achievements that continue to mitigate cardiac dis- mitral stenosis. Daniel Samways6 ability and advance political discourse throughout the world. analyzed post mortem findings in Stephen Paget (1855-1926) 70 Guy’s Hospital mitral stenosis Founder, Research Defense Society cases in 1896, noting that left atrial Fin de Siècle Beginnings hypertrophy, or a combination of Insurgency cannot exist without an establishment.
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