- Email: [email protected]
Sleep Deprivation and Results in Cardiac Surgery: Dangerous Study With Very Dangerous Conclusions
2420
CORRESPONDENCE
MISCELLANEOUS
who are not deemed suitable candidates for formal tracheal surgery. Our multidisciplinary approach comprises input from cardiothoracic surgeons, physicians, and anesthetists, intensive care specialists, pulmonologists, and pathologists. We are very aware of the different pathologies that can give rise to endobronchial compromise. We have weekly theatre lists in a multidisciplinary setting to address patients with diverse endobronchial pathologies leading to large airway compromise. As we and others have shown, we believe that expandable metallic stents do indeed have a role to play in the management of carefully selected patients with diverse endobronchial pathologies including non-malignant conditions. We strongly disagree with Drs Pramesh and Mistry’s dogmatic statement that expandable metallic stents should be reserved for patients with malignant disease. As with many other centers, we believe that patients need to be considered for the best and most appropriate treatment on an individual basis. We agree that certain lesions in the airways can be effectively stented using fiberoptic as opposed to rigid bronchoscopy, and indeed many centers have encouraging experience using the fibreoptic bronchoscope. Our preference is to deploy the stents through a rigid bronchoscope in a controlled environment with multidisciplinary input. We perform an average of 20 endobronchial interventions (ie, stent deployment, Nd YAG laser fulguration, dilatation techniques, foreign body retrieval, and pediatric bronchoscopies) per month. During the past 5 years we have had no mortality; 2 patients developed a pneumothorax and each was successfully treated by intercostal chest drain insertion. One patient had significant bleeding and was successfully treated by endobronchial maneuvers. To date we have deployed 130 expandable metallic stents, and our median time for rigid bronchoscopy and stent deployment is 10 minutes. With more and more centres worldwide using expandable metallic stents to manage patients with diverse airway pathology we believed it most important to report complications which may develop in the medium term and to describe our approach to problems which we have encountered. We look forward to reading publications from Drs Pramesh and Mistry relating to their practice and would warmly invite them to visit our unit. Brendan Madden, MD, MS Abhijat Sheth, MBBS, FRCS Department of Cardiothoracic Surgery St. Georges Hospital Tooting, London, SW17 0QT UK e-mail: [email protected]
References 1. Pramesh CS, Mistry RC. Self-expandable metal stents for endobronchial pathology (letter). Ann Thorac Surg 2005;80: 2419. 2. Madden BP, Stamenkovic SA, Mitchell P. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation. Ann Thorac Surg 2000;70: 1191–3. 3. Madden BP, Datta S, Charokopos N. Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology. Ann Thorac Surg 2002;73:938 – 44. 4. Madden BP, Park JES, Sheth A. Medium-term follow-up after deployment of Ultraflex expandable metallic stents to manage endobronchial pathology. Ann Thorac Surg 2004;78:1898 – 902. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;80:2419 –23
Sleep Deprivation and Results in Cardiac Surgery: Dangerous Study With Very Dangerous Conclusions To the Editor: I read with interest the article by Ellman and co-authors [1] addressing the very important issue of a surgeon’s working time restriction. In their article, Ellman and co-authors [1] wanted to demonstrate that sleep deprivation does not affect the performances of cardiac surgeons, and therefore that a restriction in the working hours for surgeons is not mandatory. To support their thesis, they also state that “. . . the surgeon’s long hours working were what it took to become a skilled surgeon. . . .” Furthermore they definitely do not agree to the “. . . pervading sentiment that the sleep-deprived surgeon should be eliminated . . .” I do believe that, although based on a correct statistical analysis, the conclusions of this study are very dangerous. I agree that “. . . the tired surgeon is a stereotype glamorised in books, television and movies. . . .”, but I think that the attempt to controvert (using a modern statistical analysis) the physiological evidence that any human being needs proper rest to perform at his best is really concerning. Surely some individuals need less sleep then others, and sometimes the incentives they could receive from a challenging situation could overwhelm any effect of sleep deprivation. To achieve optimal results, even if working in extreme circumstances is however a peculiar talent of few surgeons (and probably makes the differences between a good surgeon and a leading surgeon) and cannot be considered the standard for every surgeon. Therefore, a regulated and restricted working time should only be considered as the way to avoid having doctors working in sleep deprivation circumstances rather than a barrier to become a skilled surgeon. The scientific limitations of the study (such as the questionable definitions of sleep deprivation and surgical performances considered) have been clearly underlined in the discussion. I would like to stress that the lack of restriction of a doctor’s working hours (especially those in training) has eventually been recognized as an important matter. Relevant progresses have been achieved in Europe with the approval of the European Working Time Directive (EWTD), which clearly quotes the maximum working time for doctors in training. Therefore, the final statement of this study that sleep deprivation does not affect operative results in cardiac surgery is very dangerous, because it could be used to contest the legitimacy of such an important achievement. Pasquale Totaro, MD Cardiac Surgery Division Regional Cardiac Center Morriston Hospital Swansea, SA6 6NL UK e-mail: [email protected]
Reference 1. Ellman PI, Law MG, Tache-Leon C, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg 2004;78;906 –11.
Reply To the Editor: We appreciate very much Dr Totaro’s interest [1] in our study [2]. We recognized that such a study would be controversial and 0003-4975/05/$30.00
CORRESPONDENCE
MISCELLANEOUS
who are not deemed suitable candidates for formal tracheal surgery. Our multidisciplinary approach comprises input from cardiothoracic surgeons, physicians, and anesthetists, intensive care specialists, pulmonologists, and pathologists. We are very aware of the different pathologies that can give rise to endobronchial compromise. We have weekly theatre lists in a multidisciplinary setting to address patients with diverse endobronchial pathologies leading to large airway compromise. As we and others have shown, we believe that expandable metallic stents do indeed have a role to play in the management of carefully selected patients with diverse endobronchial pathologies including non-malignant conditions. We strongly disagree with Drs Pramesh and Mistry’s dogmatic statement that expandable metallic stents should be reserved for patients with malignant disease. As with many other centers, we believe that patients need to be considered for the best and most appropriate treatment on an individual basis. We agree that certain lesions in the airways can be effectively stented using fiberoptic as opposed to rigid bronchoscopy, and indeed many centers have encouraging experience using the fibreoptic bronchoscope. Our preference is to deploy the stents through a rigid bronchoscope in a controlled environment with multidisciplinary input. We perform an average of 20 endobronchial interventions (ie, stent deployment, Nd YAG laser fulguration, dilatation techniques, foreign body retrieval, and pediatric bronchoscopies) per month. During the past 5 years we have had no mortality; 2 patients developed a pneumothorax and each was successfully treated by intercostal chest drain insertion. One patient had significant bleeding and was successfully treated by endobronchial maneuvers. To date we have deployed 130 expandable metallic stents, and our median time for rigid bronchoscopy and stent deployment is 10 minutes. With more and more centres worldwide using expandable metallic stents to manage patients with diverse airway pathology we believed it most important to report complications which may develop in the medium term and to describe our approach to problems which we have encountered. We look forward to reading publications from Drs Pramesh and Mistry relating to their practice and would warmly invite them to visit our unit. Brendan Madden, MD, MS Abhijat Sheth, MBBS, FRCS Department of Cardiothoracic Surgery St. Georges Hospital Tooting, London, SW17 0QT UK e-mail: [email protected]
References 1. Pramesh CS, Mistry RC. Self-expandable metal stents for endobronchial pathology (letter). Ann Thorac Surg 2005;80: 2419. 2. Madden BP, Stamenkovic SA, Mitchell P. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation. Ann Thorac Surg 2000;70: 1191–3. 3. Madden BP, Datta S, Charokopos N. Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology. Ann Thorac Surg 2002;73:938 – 44. 4. Madden BP, Park JES, Sheth A. Medium-term follow-up after deployment of Ultraflex expandable metallic stents to manage endobronchial pathology. Ann Thorac Surg 2004;78:1898 – 902. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;80:2419 –23
Sleep Deprivation and Results in Cardiac Surgery: Dangerous Study With Very Dangerous Conclusions To the Editor: I read with interest the article by Ellman and co-authors [1] addressing the very important issue of a surgeon’s working time restriction. In their article, Ellman and co-authors [1] wanted to demonstrate that sleep deprivation does not affect the performances of cardiac surgeons, and therefore that a restriction in the working hours for surgeons is not mandatory. To support their thesis, they also state that “. . . the surgeon’s long hours working were what it took to become a skilled surgeon. . . .” Furthermore they definitely do not agree to the “. . . pervading sentiment that the sleep-deprived surgeon should be eliminated . . .” I do believe that, although based on a correct statistical analysis, the conclusions of this study are very dangerous. I agree that “. . . the tired surgeon is a stereotype glamorised in books, television and movies. . . .”, but I think that the attempt to controvert (using a modern statistical analysis) the physiological evidence that any human being needs proper rest to perform at his best is really concerning. Surely some individuals need less sleep then others, and sometimes the incentives they could receive from a challenging situation could overwhelm any effect of sleep deprivation. To achieve optimal results, even if working in extreme circumstances is however a peculiar talent of few surgeons (and probably makes the differences between a good surgeon and a leading surgeon) and cannot be considered the standard for every surgeon. Therefore, a regulated and restricted working time should only be considered as the way to avoid having doctors working in sleep deprivation circumstances rather than a barrier to become a skilled surgeon. The scientific limitations of the study (such as the questionable definitions of sleep deprivation and surgical performances considered) have been clearly underlined in the discussion. I would like to stress that the lack of restriction of a doctor’s working hours (especially those in training) has eventually been recognized as an important matter. Relevant progresses have been achieved in Europe with the approval of the European Working Time Directive (EWTD), which clearly quotes the maximum working time for doctors in training. Therefore, the final statement of this study that sleep deprivation does not affect operative results in cardiac surgery is very dangerous, because it could be used to contest the legitimacy of such an important achievement. Pasquale Totaro, MD Cardiac Surgery Division Regional Cardiac Center Morriston Hospital Swansea, SA6 6NL UK e-mail: [email protected]
Reference 1. Ellman PI, Law MG, Tache-Leon C, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg 2004;78;906 –11.
Reply To the Editor: We appreciate very much Dr Totaro’s interest [1] in our study [2]. We recognized that such a study would be controversial and 0003-4975/05/$30.00