Wednesday, January 19, 2011


Before a Dept of Surgery meeting the other day, a rep from some company called Proxy Biomedical gave a presentation on a newer anti-adhesion barrier called Human Peritoneal Membrane (HPM). HPM is similar to the more well known Seprafilm--- marketed as a product that can theoretically reduce adhesions that form between the bowel and mesh/abdominal wall after open surgery. Fewer adhesions can potentially mean fewer subsequent bowel obstructions and certainly will make any re-operative surgery much less difficult.

The rep was very smooth and tall and quite possibly has a minor recurring role in Mad Men. The crux of his argument rested on an article that had been published in some on-line outfit called the Journal of Surgical Research last year. The "study" had been entirely funded and conducted by researchers affiliated with Proxy Medical---i.e. propaganda under the guise of scientific inquiry. Usually I just use these faux-science articles as a placemat for my morning bagel. But I read this particular one because one of the "authors" was Michael Rosen MD, an eminent local surgeon here in Cleveland, well known for his work on abdominal wall hernias. Plus, the rep's gleaming white cinder block teeth were too much for me to look at any longer.

The study was conducted as follows. Nine pigs were anesthetized and then had an anti-adhesion barrier sewn into its abdominal wall after laparotomy. Laparoscopies were then conducted at day 30 and day 90, noting the degree of relative tenacity of visceral adhesions. Then the pigs were killed and the extent of tissue inflammatory response was determined microscopically.

Now I'm certainly no fan of PETA. I actually have a pronounced distaste for most animals. Cats suck. I don't believe dogs should live under the same roof as a human. I hate movies where the animals talk and perform human-esque feats. I'm especially averse toward the porcine species. If I had to choose a favorite Winnie the Pooh character, it's certainly not the lugubrious, wimpy Piglet (Tigger is the pick here). No moral compunction prevents me from enjoying one or three hot dogs layered in brown mustard at the ballpark. Every time I read The Three Little Pigs to my little girl I make sure to change the plot such that the wolf actually gets to eat the cheap assed pigs who built their houses out of sticks and straw. I don't allow any books about Porky the Pig in my house.

So I'm not some bleeding heart porkophile. Nevertheless I found myself feeling strangely disturbed by the article. Nine pigs were basically sliced and diced and then euthanized in order to determine that.... some new-fangled anti-adhesion barrier (which costs 800 bucks per 10 cm square, incidentally) may lead to a decrease in intra-abdominal adhesion formation? Really? That's it? What's next on Proxy Medical's to-do list of Mengelian science experiments? Chop off 58 monkey hands in order to determine which brand of gauze is more highly absorbent of blood (squaring off against competitors from Johnson & Johnson and Brawny)? Forcibly break the front legs of 17 cougars to assess the relative comfort of their new knee immobilizer (based on decibel levels of cougar screams)?

I dunno. It all seems like a hell of a macabre business to me.


HMS said...

Unjustifiable "bloody business"....


It's good to hear from you again, Dr. Buckeye!

BladeDoc said...

How are they supposed to evaluate adhesion barriers? Or do you think we should just accept the 20% sbo rate post laparotomy?

ubermedic said...

Even though I place a near infinitely higher value on human lives versus animals, I find myself sharing your sense of unease with regards to many of these experiments.

I work on the neonatal resuscitation program, and in reviewing the research proposals/ results on neonatal piglets it all just seems wasteful at times. I want to believe that we are laying the ground work for saving newborns who are not salvageable given current protocols, but destroying 50 piglets just to compare .01 mg/kg of epi to .03 mg/kg just seems cruel and pointless (and yes, that study was really funded).

Jeffrey Parks MD FACS said...

Blade Doc-
Who cares? Why is this a pressing line of scientific inquiry? Only from the perspective of an entrepreneur does it make any sense. And why slaughter them after 90 days? Why not just make subjective determinations of adhesion formation based on laparoscopic examination?

Paracelsus said...

@BladeDoc: To your question, no. But I think we certainly need to look at what can be done from the point of view of our basic surgical technique, and there's a lot of room for improvement.

I've seen a concerning number of senior surgeons overlooking the ancient principles of tissue manipulation, i.e., a clean, bloodless field, minimal contamination, minimal tissue damage - all factors that promote adhesions. Also, let's revisit and improve wall repair techniques that allow for foreign material to be placed away from the bowels.

I have seen digestive surgeons using close to perfect technique and having close to zero adhesional SBOs, medium to long-term. Sure this is anecdotal information, and sure, we're supposed to be evidence-based now, but what this article shows is exactly how you can easily manipulate even that and, basically, cross into the realm of the absurd, when you discard the most powerful tool at the surgeon's disposal: common sense.

Anonymous said...

Reps are really aliens aren't they?! Perfect human specimens usually ...very suspicious.

Glad you are back (are you really?)
Very cute picture BTW!!


Attorney Andy said...

Welcome back, Buckeye, glad to see you found your way out of your garage.

Would you still enjoy your three hot dogs at the game if you knew what they did to those pigs? Have you seen the documentary on HBO about the hog farm in Wooster, Ohio? I would much rather have animals used for medical research, and theoretically provide you with better materials to do your job, than to torture them so I can enjoy a Ball Park frank.

Cute kid, congrats.

Anonymous said...

OHIO STATE SUCKS!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Seriously, I thought you'd been suspended along with your overrated/underachieving QB.
OK, you did beat Arkansas, which makes you ummm about 4th in the SEC West, home of 3 of the last 4 BCS Champs...
Thats right, 1/2 of the SEC has more titles in the last 4 years than the entire Big 10(11? 12?) has had since Woody Hayes was punching Clemson Defensive Backs...

And I like Cats, especially with Soy Sauce.

Frank "14-0" Drackman

Anonymous said...

Oh yeah,
How bout them Cavaliers!
I mean Browns!!!
Oh well, you've still got the Indians.


BladeDoc said...

@Buckeye -- 1. what do you mean who cares? I mean, I have a car payment too but if I could avoid re-lapping people for their third bowel obstruction at 2 AM I'd figure out some way to make up the payments.

2. They are pigs. If they didn't get anesthetized and operated on they would get shot in the head and eaten. Minimal difference from the pig's standpoint I would think.

3. Why laparoscope them to determine the adhesion reduction? Do you then think they would go to some piggy petting zoo to live out their happy lives? No, they would get killed. Because they are pigs. Did you ever wonder why you only see piglets in petting zoos? It's because they grow up to be 2000 pound sacks of meat and mean.

Seprafilm works OK but not great, it doesn't conform well and about half of it ends up on my gloves when I wrap it around an ostomy that I plan to come back and take down. If someone would come up with a conformable, more tenacious substance I'd love it.

@Parcelsus -- as you stated there is no data to support your assertion that certain techniques reduce adhesion formation. I have an idea, why don't you study it -- I have an animal model you can use. :-)