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EDITORIALS: Bruce E Keogh, Jules Dussek, Deirdre Watson, Patrick Magee, and David Wheatley Public confidence and cardiac surgical outcome BMJ 1998; 316: 1759-1760 [Full text]

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why does not GMC come forward

A Suman   (22 June 1998)

Just what are the benefits of bypass surgery?

Tom Oommen   (4 September 1998)

why does not GMC come forward 22 June 1998
A Suman, sho a&e qeqmh, margate Send response to journal: Re: why does not GMC come forward	It would have been very helpful for the public if the GMC had given a televised interview stating the following facts: 1. Audit is being carried out regularly. 2. The outcome of a surgery depends on many factors including anaesthaesia, itu care, equipment & facilities, emergency teams - it is a team work and the whole team needs to be investigated for poor performance. 3. Patients most likely to benefit from cardiac surgery are usually the sickest, with the most damaged hearts, who therefore have the greatest surgical risk and thus show a very high mortality rate. 4. Individual audits will lead to hesitancy in attempting surgery in high risk patients, delaying their treatment . I also feel that that the minister of health should have been informed before the GMC gave a verdict on the case - this could have avoided the conflict.
Just what are the benefits of bypass surgery? 4 September 1998
Tom Oommen, deputy executive editor, South Asian edn of BMJ Manipal Send response to journal: Re: Just what are the benefits of bypass surgery?	Keogh, Dussek , Watson et al, in their article entitled "Public confidence and cardiac surgical outcome" (BMJ 316; 13 June 1998: 1759-1760) have written that evidence-based medicine indicates that those patients most likely to benefit from cardiac surgery are usually the sickest, with the most damaged hearts, who therefore have the greatest risk. The Society of Cardiothoracic surgeons is also encouraging centralised and online data collection and warehousing for all interventional cardiology and cardiac surgical procedures (1). Arteriography provides only information about the anatomy of circulation. It is more like a roadmap. It is no indication of the blood flow volume or velocity or the physiological functions of the circulation. Frequently the arteriogram may underestimate or overestimate the extent of the disease present. In conditions where the coronory blood vessels are damaged or blocked, the patient would need to go through procedures such as stents, angioplasties or even a coronory artery bypass graft (CABG) surgery. However impressive it may appear, it is not free of risks. Dr. Thomas Preston, Chief of the Department of Cardiology at the Pacific Medical Centre, Seattle, Washington, observed that arterial bypass surgery possibly had a negative effect on the patient's health. In his opinion the operation does not cure patients, it is scandalously overused and its high cost drains resources from other areas of need. He further comments that among patients who suffer from coronory artery disease those who are treated without surgery enjoy the same survival rates as those who undergo open heart surgery. Could the bypass surgery then be just another placebo? (2) In April 1987, results of a Veterans Administration Cooperative Study were published in the New England Journal of Medicine (3). The study included 486 patients with atherosclerotic heart disease of the most critical kind with unstable angina. Half of them were subject to bypass surgery and the other half were treated without surgery. The overall two-year survival rate and incidence of myocardial infarctions were not significantly different between the two groups. Winslow and his colleagues studied the appropriateness of performing bypass surgeries and reported that 44% of all the bypass surgeries done in the US during the period of the study were done for inappropriate reasons (4). Balloon angioplasties were introduced in the 1980s as a way to avoid costly and dangerous bypass surgery. Instead, the number of bypass surgeries had increased from 200,000 in 1984 to 230,000 in 1988 and the number of angioplasties done increased from 46,000 per year to 200,000 per year during the same period. Angioplasties often fail in less than a year, leading to repeated angioplasties and even a bypass surgery. Angioplasties can also damage the blood vessels further, and is not the promising surgical alternative that it was thought to be. Similar cautions have been voiced against stents, atherectomies and laser angioplasties. Bypass surgery is popularised by the medical fraternity and the press and actively sought after by the gullible and lay public. However, the most common sign of cardiac illness is usually sudden death, for which surgery is certainly not any answer. Keogh and his colleagues have also confirmed that evidence-based medicine indicates that those patients most likely to benefit from cardiac surgery are usually the sickest, with the most damaged hearts, who therefore have the greatest risk (1). It is also now common knowledge that within the first year of the bypass surgery aproximately 70% of the patients have a recurrence of the arterial blockade and would perhaps need a redo (second) surgery. Most people would, if they could, avoid surgery. But not many suspect that they have an option. If the cardiac bypass surgery does not cure the patient, is scandalously overused, is frequently ineffective and is absurdly expensive, is there an option? Can the bypass be bypassed? Dr. Linus Pauling, winner of two Nobel prizes advocates a safer and much less expensive modality of management of such illnesses than cardiac surgery which has a rational scientific basis and the evidence for the clinical benefit seems to be quite strong. Scientific evidence indicates that a course of this therapy might eliminate the need for bypass surgery (5). It would be good if the Society of Cardiothoracic Surgeons considers such a possibility of non-invasive cardiology instead of spending time, money and efforts on invasive, traumatic and expensive cardiology. Dr. Tom Oommen, Dept. of Pharmacology, Kasturba Medical College, Manipal 576 119, India References: 1. Keogh BE, Dussek J, Watson D, et al. Public confidence and cardiac surgical outcome. BMJ: 316; 13 June 1998, 1759-1760 2. Preston TA Marketing of an operation: coronory artery bypass surgery. J Holistic Med. 1985; 7(1): 8-15 3. Luchi RJ, Scott SM, Deupree RH, et al. Comparison of medical and surgical treatment for unstable angina pectoris. N Eng J Med 1987; 316(6): 977-984 4. Winslow CM, Kosecoff JB, Chassin M et al. The appropriateness of performing coronory artery bypass surgery. JAMA 1988; 260: 505-509 5. Pauling L. Foreward to Textbook on Chelation Therapy. Published by American College for Advancement of Medicine, 1997.