What leads to surgical innovations that do not work as surgeons and patients hope, and what makes these ineffective methods fade away?
Per a Panel Session yesterday, A Stroll Down Surgical Blind Alleys: The History of Surgical “Progress” Gone Awry, incomplete understanding of disease and frustration with limited options for helping patients have led to multiple innovations now known to be less than helpful. The session, which was co-moderated by Peter J. Kernahan, MD, FACS, of the University of Minnesota in Minneapolis, and Theodore N. Pappas, MD, FACS, of Duke Health in Durham, North Carolina, examined several historical examples.
Panelist Joshua D. Mezrich, MD, FACS, a transplant surgeon from the University of Wisconsin-Madison, discussed how 19th-century neurologist Charles-Edouard Brown-Séquard, FRS, gained partial insight into gland physiology and eventually concluded that transplanting testicles excised from monkeys or human cadavers into men could restore their overall vitality. A prevailing lack of standardized experimental technique initially made outcomes unclear. Nonetheless, Dr. Mezrich said, “Over time, the data got him, because it didn’t work.”
The data also got gastric freezing for peptic ulcer. Presenter Dr. Kernahan explained that the technique involved introducing a balloon of cooled fluid into the stomach as an alternative to gastrectomy, and legendary surgeon Owen H. Wangensteen, MD, FACS, championed the approach. It was first used in 1961, and rapid proliferation came via what Dr. Kernahan termed “desperation-reaction diffusion,” or the adoption of an innovation out of frustration and a lack of better options. Two years later—after roughly 25,000 US patients had been treated—a plethora of research showing ineffectiveness ended the practice.
Presenter Susan E. Pories, MD, FACS, of Harvard Medical School in Boston, Massachusetts, described a slower, more complicated shift away from radical and super-radical mastectomy for breast cancer, despite the procedure’s promotion by great surgeons, including William Halsted, MD, FACS(Hon). A combination of less disfiguring, evidence-based care via lumpectomy and radiation, plus a cultural shift empowering women to make choices about their care, gradually led to change.
Still other panelists noted that some so-called blind alleys have in fact been partially successful. Neurosurgeon Francis J. Jareczek, MD, PhD, of Penn State Health in Hershey, cited lobotomy for mental illness as rooted in the fundamentally sound modern concept of neuromodulation. Dr. Jareczek noted that, while ablating the frontal lobes has long been discredited, “Placing a lead is safer than making a lesion.”
As a result, the use of deep brain stimulation for essential tremor, Parkinson disease, and other conditions has gradually increased since the late 1990s.
In addition to noting that ill-fated innovations often arose via partial insights into complex physical systems, all the speakers emphasized that surgical missteps arose from earnest efforts by well-meaning physicians. These included many surgeons who, like Drs. Wangensteen and Halsted, otherwise experienced abundant success in scientific research and patient care.
The panelists also noted that future blind alleys are highly likely. Dr. Kernahan said, “You don’t know it’s a blind alley until you’re in it. I think one of the lessons was that everyone who went in one of these alleys went in with the best of motives, thinking they were moving patient care forward.”
“It’s so valuable, looking back at history, because it gives you discipline to understand what’s happening today,” Dr. Pappas noted.
