What happens after surgical innovation?

I have just returned home after the Asia-Pacific Hepato-pancreato-biliary Surgery Association meeting in Shanghai. It was a fascinating meeting in many of ways and some of the new technologies and approaches to surgical problems were highly innovative. The ingenuity of both surgeons and equipment manufacturers never ceases to amaze me. There is however a problem.

Innovation is one thing but validation and formal comparison with current best practice is often missed in the development of new techniques. In Shanghai I watched videos of needle cholecystectomy using tiny 1.5mm diameter instruments, natural orifice cholecystectomy, appendicectomy and even transtracheal thyroidectomy, laparoscopic pancreaticoduodenectomy and laparoscopic radical cholecystectomy, liver resection and lymphadenectomy for gall bladder cancer. Often these cases are highly selected in terms of body habitus and stage of disease to make technically extraordinary surgery easier and I accept this.  What I don’t accept is the complete absence of a next phase.

Innovators have a responsibility to compare their new technique or technology in an unselected way with current best practice. The ideal form to do this is a randomised controlled trial. The outcome measures of such trial should also be meaningful for example cosmetic appearance and length of stay are irrelevant or at least of secondary importance if we are comparing surgical approaches to cancer.

Surgery needs innovation and innovators, but to be taken seriously and leave a legacy in terms of changing treatment you have to be able to go to the next step and provide objective evidence in the form of a trial. I don’t know whether the barrier to doing such studies is lack of research training, finance or conflict because of private practice. I hope that some of the individuals who have pioneered these new techniques realise the importance of comparative studies and take the next steps to evidence their developments.

RichardsFig1Figure from Richards et al Laparoscopy Today

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2 Responses to What happens after surgical innovation?

  1. Deb Verran says:

    Hi Steve

    You make some incredibly important points here. With many health systems under financial duress and/or constraints these days it is essential to ensure that there is also some form of accurate financial is assessment made with respect to introducing new technology. I agree that this can only be achieved via validation in the setting of a prospective randomised pilot study(against current best practice), with comparable patient selection for both arms. There is always a cost to the system for introducing any new technology and this is not only the acquisition cost of the technology but also the maintenance costs and the costs of training staff. Plus deploying the technology can in fact end up being more costly than performing the surgical procedure via conventional methgods(due to costs of consumables and the actual operating time involved). This is all a cost to someone and the money has to come from somewhere.
    No doubt we will hear more on all of this!


  2. Good point Deb, the economic analyses are also sadly lacking in most studies but do have a major impact on the likelihood of treatments or procedures being adopted in most countries where there is a degree of health care rationing and accountability as you say.

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