Space Invaders

Many readers will still recall the legendary “Space Invaders,” one of the first video games introduced in 1978 and immensely popular on the Atari consoles (remember them?). The player with a gun at the very bottom could only move from right to left and back, hiding behind crumbling barriers from the relentless attacks of the various invaders. And he could shoot them down. Getting them all without being hit first prompted the message: “Well done, earthling! This time you won.” Invasion averted. Today, when walking with open eyes through the streets of Paris, the Eastern parts of London, or many other big cities, one can yet encounter the familiar beasts—put together from colorful small tiles by the street artist Invader (www.space-invaders.com). Looking harmless, even cute, the little buggers pop up where least expected, proving the invasion. They are among us.

Invasion is a negative word. A surgeon, however, does nothing else but to invade the body of his patients. Patients, understandably, want help, but would also like to keep any kind of invasion to a minimum. This is why the phrase “Minimally Invasive Surgery” was coined, soon to be followed by whole new scientific societies such as the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS). Can cardiothoracic surgery ever be really “minimally invasive”? It is, after all, about entering the chest. If you perform an aortic valve replacement through a partial sternotomy, bone is severed nevertheless. If you do a lobectomy through a muscle-sparing thoracotomy, ribs have to be spread still. If you do a video-assisted thoracic surgery (VATS), the patient is left behind with a couple of admittedly small incisions, but through one or two of which troublesome drains will poke out.

Mischievous critics talk about maximally occult complications, and they do have a point. In case of problems or doubt, a conversion has to be done, often leading to a somewhat unfortunate combination of less and more radical incisions. Conversion of a partial sternotomy, for instance, will result in a complete midline separation with the addition of at least one transverse sternal fracture. Adequate stabilization is challenging. As the problem of pain and discomfort is of such paramount importance for our patients, part of this issue is dealing with chest wall incisions and their uncomfortable consequences.

The probably most aggressive invasion a patient may have to endure is that of the part of another person, that is, transplantation—our second main topic. Whole myths have been spun around the transmission of character traits or personality attributes when transplanting an organ, especially the heart. The first moderately successful heart transplantation by Christiaan Barnard was young woman to elderly man. Louis Washkansky had only 18 days, not long enough to reflect about a potential influence Denise Darvall might have had on him other than keeping him alive with her heart. Novels have been written about this enigma since, movies made. Large transplant programs employ psychologists to deal with this side-effect, this invasion, which is only too natural to understand.

Given this highly emotional environment, it is sad that organ transplantation has fallen into disregard in the German public opinion because of the alleged machinations of some surgeons trying to push their patients up the much too long waiting lists by manipulating data. This cannot be tolerated by the medical community. On the other hand, the current methods of organ distribution (a terribly prosaic term) tend to assign organs to the desperately ill who might have a very limited prognosis despite the transplantation. Are we giving the scarce organs to the “wrong” patients—if there can ever be someone like a “wrong” patient? The Lung Allocation Score tries to introduce more objective data about longevity for patient selection instead of the usual controversial high urgency schemes. A similar strategy for the heart is currently being developed, thoracic organ transplantation once again leading the way of innovation.

To say it with the words of Victor Hugo: “One resists the invasion of armies; one does not resist the invasion of ideas.”