Wednesday, June 24, 2009


Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs.

I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?"

Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics. I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy. The linked article describes a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?


rlbates said...

I'm with you on the surgery -- watching to see what happens. Still, I do pine the lost of Kodachrome as I did Polaroid film. I love my digital camera, but there will always be my love of Polaroid.

Spiny Norman said...

Damn skippy on the divergence of marketing and effectiveness. On Kodachrome? Well, that's harder. The process was no longer viable. There's only one processor remaining in the U.S. - Dwayne's, in Kansas. But make no mistake: no other photographic medium looks the same. It's as though painters were being told that they could no longer purchase a range of shades of blue. It is the end of the line for a medium.

And the best digital cameras -- we're talking about cameras that cost a minimum of $2-8k -- are only now catching up with the best 35 mm cameras and Kodachrome.

I have 70 megapixel (no, that is not a typo) scans of 35 mm Kodachrome slides, where there's still detail that can be extracted by a good enlarger that is not present in the scans. Most people would never have seen this detail; most people had their 35 mm film processed by a minilab at the drugstore or the mall.

Of course, to put that detail on the slide in the first place one must use superlative optics and superior technique -- better optics and technique than most 35 mm photographers will have of be capable of. Most consumers will never have either the optics or the technical ability to max out a 6 Mpixel sensor, let alone a 15 or 25 Mpixel sensor.

This is why most photographers are happy with digital. With their (consumer-grade) lenses, and their sloppy technique, digital gives results better than they or their mini-labs got before.

I've gone about 70% digital, too. But there's more to photography than convenience or even numbers. The difference between Kodachrome and digital is the difference between a Hammond organ and a synthesizer keyboard that sounds almost -- but never quite -- the same.

Sid Schwab said...

S'Norm: I don't doubt it. I'm at or below the amateur line vis a vis photography, although I am aware the technology is rapidly evolving. There are those that prefer vinyl over CDs for equivalent reasons. And, as I understand it, there are advances in digital sound that address the differences.

But, of course, that wasn't the point of the post.

Spiny Norman said...

On-topic? Well, there's this propaganda piece from DaVinvi, which not-so-subtly equates fuddy duddies like Sid to the witch doctors who trepanated patients with obsidian knives.

egomosperficio said...

since the photography debate is beyond me, i will offer a brief comment about CDs vs. vinyl:

"And, as I understand it, there are advances in digital sound that address the differences."

the truth is, the supposed superiority of vinyl over CDs is largely a myth. vinyl puts out a lot of noise that we often interpret as 'ambience' or 'headspace'. this effect largely disappears over a short period of time, especially when listening in an environment with decent acoustical properties [and with decent speakers].

the changes we undergo as we age go much further in explaining our preferences than any loss of fidelity through digital technology. nostalgia is a powerful placebo.

Sid Schwab said...

Well, I can't deny aging.

Anonymous said...

"vinyl puts out a lot of noise that we often interpret as 'ambience' or 'headspace'. this effect largely disappears over a short period of time, especially when listening in an environment with decent acoustical properties [and with decent speakers]."

Anonymous said...

NOTES may be a good niche procedure for professional models, but the patient & surgeon handling the complication would probably prefer a ventral hernia later on to know where.

isn't it very plausible to see greater infection rates w/ this method of entry as well (thus increasing costs/hospital stays)?

Ironically, I'll be attending a presentation from a single port laparascopy device maufacturer soon. What do you think keeps the "mini-chole" from being promoted by hospital admins/insurance companies/surgeons as an effective/safe cost cutting measure?

Precordial Thump

Sid Schwab said...

P.T: hernias aren't very common with any type of laparoscopy, although they do occur.

I think I mentioned infection in my original post on NOTES. I'd think it'd be an increased risk.

I don't know the answer regarding mini cholecystectomy. A big factor, I'd say, is hype: laparoscopy (and, initially, laser along with it) got sold as the latest thing and hospitals made bucks hyping it. Another factor is that mini chole isn't taught, possibly for the same reason. It is, in fact, harder in some ways than lap chole. I did have people seek me out for their surgery because they'd heard about the increased risk of bile duct injury with lap chole (still true); but for the most part I lost the battle. Not that I ever tried to sell it. I just did it, and those who knew, appreciated it.

egomosperficio said...



guess i won't bother responding to someone who can't be bothered to offer a username. shouldn't go more off-topic anyways, but feel free to message me with any evidence of an inherent superiority in vinyl recording that isn't completely subjective and demonstrably false and i shall recant my claim.

sorry sid, it's my birthday, so cut me a bit of slack. =D

Sid Schwab said...

Not a problem, perfico. Happy day.

Anonymous said...

I've been reading your blogs, and trying to figure out what my problem is. I feel so bad this evening. I'm bloated and look fatter now than I did when I had my kids!. I had my gallbladder removed in 2003, and the surgeon told me it was "completly full of stones" I've had an array of problems over the years, the latest is that I have SOD as you so lovingly described. I'm not sure if that is it. I can go for days, sometimes 2 weeks without having a bowel movement. Today is my 6th day of feeling horrible. I've been taking laxitives...I had a few bowel movements yesterday. I know it's gross, but I decided to examine my stool. Wednesday I has loose yellow, fatty looking stool. On Friday (after 5 laxitieves and miralax) I had a green slime covered 2 small pebble turds. I put on some gloves, fished them out of the stool and broke them apart. They were hard, and the inside looked like dried tobacco. So green, slimy on the outside, but dryer than a desert inside. Since then I've had maybe 2 or 3 BM that were varing shades of green/yellow all soft. I've had some heartburn and my blood pressure is slightly high (even though I'm on med for that) but my biggest problem is the BLOATING! I feel horrible. The pain from my gallbladder I didn't really notice, until I started to feel better after removal. I know something is seriously wrong with my digestion....Just don't know what it is for sure. I've thought of going to the ER, but I'm afraid they will tell me that I just need to poop and give me an enema. For now, I've taken more laxetives and I'm waiting to see if my swelling goes down. I feel so much better when I am not extremely bloated! And it happens once in a blue moon that I am not bloated. I was wondering if you had any thoughts or suggestions about my condition. I'm supposed to have ERCD (or whatever that is) With. Dr. Slavonavich, in St. Louis, Missouri, but I have to wait for medicaid approval. In the mean time, I suffer. Thanks for your time! Michelle

Sid Schwab said...

Michelle: I sort of hate getting comments like yours, because I'd like to help but it's nearly impossible from so far away. There's so much that needs to be known, that I can't know.

If you're truly having bloating, meaning your abdomen is distended, it needs to be diagnosed: I doubt there's much to be found on ERCP that would explain true abdominal distention; on the other hand, the kind of doc who does ERCP would also be the kind of doc to evaluate the bloating.

If you have SOD, though, ERCP is a good way to evaluate and, probably, treat it. So I'm not saying you don't need it. I'd just make sure the doc understands the bloating issue as well.

Meanwhile, if you develop abdominal pain, crampy or steady, or fever, or vomiting, I'd say you should go to an ER or be in touch with your doctor right away. And, because I need to say it, I will: there's no way I can know enough about your situation to make useful recommendations. So you should NOT consider this better advice than what you'd get by checking with your doctor or going to an ER or walk-in clinic. Okay?

Anonymous said...

Thanks, for the info. I know that my Dr. or the ER is the best to evaluate my problem. I was just wondering if you had come across the same issue...I've seemed to baffle everyone so far. I just hate getting another procedure done to be told, there is nothing wrong with me. I have no family support. It is very frustrating to feel horrible, and not have anyone believe you.


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