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The impact of the new technologies in surgeryy: lights an shadows
This document discusses the impact of new technologies in surgery, highlighting both benefits and risks. It summarizes the development of key technologies like laparoscopy, endoscopy, and stapling devices. While these technologies increased efficacy, safety, and improved surgical outcomes, they also pose hidden dangers. Costs have risen substantially without clear evidence of benefits. Additionally, overreliance on technology and industry influence can undermine appropriate, sustainable healthcare systems. The document calls for more rigorous evaluation of new technologies and adoption of sustainable, cost-effective models of medicine.
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The impact of the new technologies in surgeryy: lights an shadows
- 1. The impact ofthe new technologies in surgery: lights an shadows Appropriateness and Sustainability Pier Paolo Dal Monte MD Bologna Italy 1° Congress of the Eurasian Colorectal Technologies Association Guangzhou November 13-15. 2009
- 2. The more sophisticatedthe machine, the more barbaric the worker Karl Marx
- 3. The new technologiesin surgery 30 years that changed the world The “technology tree” New diagnostic tools US, CT, MRI, Digestive endoscopy New surgical instruments Staplers Endoscopes Haemostasis and dissecting devices Minimally invasive instruments Safety for “old procedures” Feasibility for “new procedures Better indications (precision, target) (NOTES): Efficacy Safety Less invasivity Better results Less trauma Shorter hospital stay/faster recovery
- 4. 1) Imaging Newtechnologies 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
- 5. Suture/anastomosis: stapling devices 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
- 6. 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
- 7. Access: Digestive endoscopy 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
- 8. Access: Digestive endoscopy 1) Accurate diagnosis Image enhancement EUS 2) Operative treatments Haemostasis ERCP Excision Dilatation Palliation Clips Injective catheters Argon Plasma Laser Sphincteretomes balloons Advantages
- 9. Access: Laparoscopy 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
- 10. Access: Laparoscopy Outcomes(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)
- 11. Access: Laparoscopy Outcomes(colorectal cancer) 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
- 12. Access: Laparoscopy Economics(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.
- 13. Haemostasis/dissection: Phisical (energy) •1926.First use of electrosurgical device (Harvey Cushing) 1980’s-1990’s Computer controlled Bipolar electrosurgery Ultrasound dissection Argon Plasma coagulation Laser RF
- 14. Robotic surgery In1985 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
- 15. Advantages:??? Robotic surgery 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
- 16. Natural Orifice TransluminalEndoscopic 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
- 17. NOTES: Potential advantages 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
- 18. Assessment of thenew technologies Undiscussed technique advancement (revolutions): Endoscopy Laparoscopy Undiscussed technical advancement: Staplers New dissection/cauterisation devices Chemical/biological Haemostasis Meshes/Stents ?: Robotic Notes
- 19. The technical progresshave brought many undoubted advantages ....... 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 …but there are some shadows..
- 20. The hidden dangersof technology “Surgical” issues 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
- 21. The hidden dangersof technology “Surgical” issues Tecnology “addiction”: Surgeons risk of relying too much on the technical tools Organisation problems: The new technologies require a more complex organisation
- 22. The hidden dangersof technology Ethical and economic issues 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
- 23. The hidden dangersof technology Industry “pressures”: Conflicts of interest Biased studies (results, pathophysiology) Example: Is “rectal redundancy syndrome” just another way to name haemorrhoids ? (and related DRG)
- 24. The hidden dangersof technology Cost /benefits issues: Enthusiastic adoption of a new technique before scientific evidence Faecal incontinence Injectable 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 incontinence Jarrett ME, et al. Br J Surg 91(12):1559-1569, 2004
- 25. The hidden dangersof technology 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
- 26. “Technological” Healthcare Thecontemporary 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
- 27. Sustainability-Healthcare Costs versusbenefits (marginal returns) 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) Diminishing returns to increasing complexity J. Tainter, The collapse of complex society 1988)
- 28. Sustainability-Healthcare Diminishing marginalreturns 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
- 29. Health indicators inindustrialized countries 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 Country Life 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 22 United Kingdom 79.4 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 United Nations: World Population Prospects,2006
- 30. Health expenditure versuslife expectancy 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 WHO: World Health Statistics 2009
- 31. The contemporary model of scientific medicine 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
- 32. 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
- 33. The contemporary model of scientific medicine Result: Unsustainable economic pressures on all health care systems
- 34. Conclusions Technologies mustbe 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
- 35. Conclusions Sustainability Wedo 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.
- 36. A Sustainable system? The quiet conscience is an invention of the devil Albert Schweitzer, The philosophy of civilization What about the rest of the World?
- 37. Rank Country ASustainable system? Life expectancy at birth 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 United Nations: World Population Prospects,2006
- 38. A Sustainable system? Rank Country Infant Infant mortality 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 Rank Country Infant World: 49.4 73.7 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 United Nations: World Population Prospects,2006
- 39. Causes of deathin developing and developed countries Causes of death in developing countries A Sustainable system? Number of deaths Causes of death in developed countries Number of deaths HIV-AIDS 2,678,000 Ischaemic heart disease 3,512,000 Lower respiratory infections 2,643,000 Cerebrovascular disease 3,346,000 Ischaemic heart disease 2,484,000 Chronic obstructive pulmonary disease 1,829,000 Diarrhoea 1,793,000 Lower respiratory infections 1,180,000 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 1,021,000 Hypertensive heart disease 635,000 Chronic obstructive pulmonary disease 748,000 Tuberculosis 571,000 Measles 674,000 Suicide 499,000 Who 2009
- 40. A Sustainable system? Tanzania: 50000:1 Zambia: 50000:1 Italy: 230:1 Cuba: 170:1
- 41. Sustainability of the“World Healtcare system”? Modern technological healthcare is a reality only for 1/3 of the world population…
- 42. …a small partof the World is like this… Can we call sustainable a situation where…
- 43. …While a greaterpart Is like this?
- 44. Technique has arrivedat 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
- 45. Thank you foryour attention Shadows