Sunday, January 04, 2009

Comparative Shopping & Surgical Literature

I hate shopping. This declaration is certainly no surprise to SWIMBO, who through twenty years of marriage has unsuccessfully tried to get me to spend more than a few nanoseconds looking for clothes. To me, it's sort of a search and destroy mission. For SWIMBO --- and our female progeny --- it's a sport. I just don't know what the rules of that sport happen to be.

Now, guys like me do understand certain types of shopping --- the kind that involves major cash outlays, like cars or electronics. And this arena involves the important activity of comparative shopping. The internet has made comparative shopping into something of a sport for men. Looking for a car? Go to Edmunds and get the lowdown on all the cars in the universe. Want a new HDTV? There are more comparative sites out there than implants at "Howard Stern appreciation night" at a Vegas night club. The difficulty is figuring out what information is believable, and what is sheer opinion.

Despite what the average non-physician may belive, the same difficulty is faced by us docs trying to wade through articles in medical journals. Here's a case in point, made all the more poignant because the two articles were placed one after the other in the same journal:

Perioperative Treatment with Infliximab in Patients with Crohn's Disease and Ulcerative Colitis is Not Associated With an Increased Rate of Postoperative Complications.
Conclusions Preoperative IFX was not associated with an increased rate of cumulative postoperative complications.


Use of Infliximab within 3 months of Ileocolonic Resection is Associated wtih Adverse Postoperative Outcomes in Crohn's Patients.
Conclusions Infliximab use within 3 months before surgery is associated with increased postoperative sepsis, abscess, and readmissions in Crohn’s patients. Diverting stoma may protect against these complications.

Hmm. First, a little background. Crohn's disease and ulcerative colitis, while different diseases, are lumped together as "inflammatory bowel disease" (IBD), and are in large measure diseases that are a result of immune system problems that result in inflammation of the gut. As a result, the primary medical treatment involves medications that try to mitigate that immune system-mediated inflammatory process --- steroids, for example. One of the newer drugs availabe to treat IBD is Infliximab (trade name Remicade), which acts by blocking an the effects of an immune mediator called tumor necrosis factor-alpha (TNF).

Stay with me. Get a shot of C8H10N4O2 if needed. Infliximab is pretty strong stuff, and is not for use in the average patient with IBD. It is reserved as a final stand in the patient who has complications of their disease that are not responding to lesser drugs........of course, that is the same group of patients that would also be looking at the prospect of surgery. Since this stuff knocks the bejesus out of a patient's immune system, if a patient fails Inflixamib therapy, there is concern that complications would then ensue. Hence, the above studies.

So, in my shopping bag I now have two conflicting studies. Which one do I "keep" in my memory bank, and which one do I take to the return desk and ask for my cash back? This is where prior experience comes into play, where all of my biases are allowed to run as free as a Hollywood pop-tart in DUI court. My biases (and they are mine and mine alone, so don't read too much into this), based upon dealing with the patients I have cared for who have been given Infliximab are:
  • Surgical complications are more frequent in the patient who has been given Infliximab for either Crohn's disease or ulcerative colitis.
  • Patients who have been given Infliximab for IBD and then need surgery tend to be sicker and more malnourished than similar patients, and recovery from surgery is longer and more difficult for them even in the absence of complications.
  • Since ulcerative colitis can be cured with removal of all of the colon and rectum (a variety of surgical options exist), I am not sure that there is any benefit to treating these patients with Inflixamib. This is particularly true in the patient who desires a sphincter-sparing operation (ileoanal pull-through); if they have been given Inflixamib, I would probably avoid a pull-through initially, thereby setting up the need for three operations ([1] total colectomy; [2] proctectomy with ileoanal pull-through; [3] ileostomy closure). UC patients who are given Infliximab may be simply postponing an inevitable operation, and their surgical results may be associated with a higher risk of complications.
As unscientific as my biases may appear, for the time being they are about as reliable as the conflicting studies that are available from real surgical researchers (trust me, there are more). And, until some degree of consensus can be reached, they will continue to be at least one factor I have to consider when caring for individual patients --- and that is why there will always be a fair degree of art in the science of medicine.