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Evidence-Based Surgery
  1. D ALDERSON

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Evidence-Based Surgery. Edited by T Gordon, J L Cameron (Pp 688; illustrated; $149.00). Canada: DB Decker Inc, 2000. ISBN 1-55009-116-6.

I might as well get it off my chest first! This is not a good book and I did not enjoy reading it. I would not recommend that you read it or advise your library to purchase it.

In the first instance, the title of the book is wrong. It should be called the “John Hopkins' Version of Evidence Based Surgery”: 90% of the multitude of authors involved come from that institution. One hesitates to say that the judgement of some of the authors seems to be clouded by institutional bias but words such as “prejudice” and phrases such as “tunnel vision” spring to mind. Like any North American textbook, the rest of the world largely does not exist: 90% of the quoted references are from North American texts with the token British author being a surgeon who has been retired for the last two years.

The first 250 pages are devoted to the principles of evidence based surgery. Within these pages are a series of chapters which have little to do with any healthcare system outside the USA. For those of you who believe that the worst elements of American medicine usually do get across the Atlantic sooner or later, you might wish to dip into this section briefly, especially if you are in the brigade that is totally fed up with the Health Service and wonder just how it might get any worse. This book is just the thing to convince yourself that fulfilment in the rest of your existence on this planet will not be in the field of clinical medicine.

To be honest, some chapters were so stultifyingly boring that I just could not finish them, notably “Administrative Data and Evidence-Based Surgery”, although “Leveraging Information Technology” ran it a close second! In the chapter on “Patient Reported Outcome Measures”, we are told that because surgery is primarily palliative for oesophageal malignancies, quality of life assessment may be less important. While it is disappointing to see such nonsense in print, it does hearten me that we have nothing to fear on intellectual grounds at least from the so-called leaders of American surgery.

Turning to the second half of the book which is described as the “Practice of Evidence-Based Surgery”, individual chapters are given up to the recognised surgical specialties. The first six of these cover various aspects of gastrointestinal surgery. One of them, the chapter on colon surgery, is well written and should have been given to the other authors as an example of how to write a good chapter on an evidence based element of surgery. The chapter on oesophageal surgery is a classic example of, “what we do at Hopkins and why”. Of the 29 references quoted, only one was from a non-USA publication. The chapter on gastric surgery wanders between the old fashioned “R” and the newer “D” notation to describe the extent of gastrectomy. The author's appraisal of the two European trials which compared D1 versus D2 gastrectomy is particularly superficial and it appears to me as if he has only read the abstract or is content to make the same type of uncritical appraisal perpetuated by individuals who do not wish to see the major flaws in both of these trials.

The chapter on pancreatic surgery contains one of the best examples of institutional bias in the entire book. The author quotes his own prospective, randomised, placebo controlled, double blind study to test the hypothesis that erythromycin improves gastric emptying and reduces the incidence of delayed gastric emptying after pancreaticoduodenectomy. The text clearly states that patients who received erythromycin had a shorter duration of nasogastric tube drainage and started foods earlier, and I suppose one can stretch a point and say that the author was not lying because on average, the group receiving erythromycin had their nasogastric tube removed after 5.5 days compared with 6.2 days in the controls and they were able to start solid feeding at 11.3 days versus 12.8 days. You will not be surprised to know that these differences were not statistically significant and it makes you wonder why people should write in this way.

So now you have a fair idea of exactly why I did not like this book! If you see it on a bookshelf, do not waste time on it and in particular, do not be tempted to part with £100.00!

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