I have often wondered why so many of us
continue to do things that are clearly established as inferior. I am not
talking about ignoramii, I am talking about surgeons like Isma, who are
well read, and can qoute the JT June article.
I have often thought of the reason, and I think I know it now. Let me
share my new insight with you: These surgeons are prudently doing what is
safer for them, not what is in the best interest of their patient.
Take the case in question. It is clear that either way you may get a
complication. Contrary to what surgeon is implying, stool in the bowel does
not GUARANTY that there would be no leak
. We simply know that there
are FEWER complications with primary anastomosis than with the combined
hartman/closure method, not that there are none.
Now suppose Isma had done a primary anastomosis and the patient had a
leak, and died of peritonitis or required multipe operations for salvage.
It is likely that the majority of surgeons around him, including his
superiors and hospital administrators, do not subscribe to for-surgeons.com, don't
know the color of the cover of the JT, and have never seen the EAST web
site, if they know what a web site looks like.
Conseqently, at M&M or at an internal audit, Isma would have been
crucified. It matters not that he will bring a bunch of papers begining
with Stones paper to prove his point, it will be totally ignored.
He would be judged as lacking surgical judgement. We all will loud his
action, but in Isama's environment (and mine) our vote doesn't count.
In contrast, if he does a Hartman procedure, and there are complications,
they will be dismissed as insignificant technical problems.
Only those of us who practice in major University centers, or who are
lucky to be surrounded by academically oriented and enlightened surgeons
can afford to do what is best for the patient. When Han says that
Isma chose a safe course, he is right. Isma chose a safe course for
himself, and so would Han, I suppose.
BTW, the 50% circumferential limit for primary repair is from Burch papers. If you look at the data, it is not altogether clear why he chose that number.