GERALD W. SHAFTAN
1926 - 2019
Gerald W. Shaftan M.D., who died on October 10th, 2019, was born in 1926 in New York. He will be remembered as one of the classic clinical surgical scientists who changed the course of surgery using the power of simple observation. Under his guidance, "mandatory exploration" for abdominal trauma evolved into what he termed "selective conservatism". While a PubMed review shows he had 96 publications, his seminal work led to thousands of papers on this theme and brought diagnostic peritoneal lavage to life.
After attending NYU medical school, Dr. Shaftan completed the surgical residency at Kings County Hospital, at SUNY Downstate Medical School, in 1957. He was appointed Professor in 1977 and Professor Emeritus in 1997. He served as chair of surgery at Brookdale Hospital (a community hospital just up the block from Downstate) from 1983 to 1996, and thereafter as chair at Nassau University Medical Center on Long Island from 1997 to 2004. He retired around 2010.
Gerry described how as a junior attending at Kings County Hospital, he noted that not all knife and gunshot wounds required a laparotomy. After a series of negative laparotomies were presented at the departmental morbidity and mortality conferences, he suggested that there are many "unnecessary surgeries". Under the leadership of Clarence Dennis, MD, the chairman at SUNY Downstate, his group instituted a clinical protocol to study surgical conservatism. This culminated in the classic 1960 paper in American Journal of Surgery where, in 180 consecutive patients with abdominal trauma, 125 were successfully treated without surgery. The only death was from a head injury.
In 1978, a follow up paper in the Journal of Trauma brought the total number of patients treated with selective conservatism to 1364. The methodology he preached was very specific- mandatory serial examinations. Patients underwent laparotomy if they had signs of peritoneal irritation (involuntary guarding, loss of bowel sounds), hemodynamic instability, signs of gross blood in the GI tract and bowel evisceration, free air on abdominal X ray, unexplained shock or a positive abdominal paracentesis. This later evolved to diagnostic peritoneal lavage. This methodology worked for both penetrating and blunt trauma, with a 1.3% and 11.1% mortality in the selective non-operated groups, respectively.
In the 1978 paper, Dr. Shaftan concluded that in the care for "the troops in the Battle of Brooklyn" there is no need for mandatory exploration for abdominal trauma, and that "there is no longer any excuse for unnecessary operations dictated by dogma in abdominal trauma."
Drs. Shaftan and Dennis started the first trauma service in New York State in July 1957. They inaugurated a fracture service three years later. The two services were assigned five full time trauma surgeons and the SUNY surgical residents. This talented group fixed everything- papers were even published on fractures of the tibia, radius, wrist, and knee. They even implemented selective management of hip fractures and wrote about hand replantation.
In further promoting non-operative care, in 1977 Dr. Shaftan incorporated radiology into the trauma service. In a publication in Journal of Trauma in 1982, he showed how over a four-year period, 51 patients treated radiographically for hemorrhage in 45 sites succeeded 38 times. In the discussion Dr. Shaftan called the trauma radiologist a "tremendous help" who "has done procedures …which would have been very difficult for us". Of course, non-invasive radiologic tests like the CT and FAST ultrasound eventually replaced the DPL. In another first, Dr. Shaftan described the importance of early aggressive non-operative management of geriatric trauma patients in 1990, in the Journal of Trauma. His group showed that the increased mortality in patients older than 65 years of age was likely due to occult low cardiac output in "seemingly stable" patients. When they intervened and provided rapid triage to an ICU, survival improved.
Not surprisingly, Dr. Shaftan also employed selective conservatism to gastrointestinal surgery. In May 1965 he presented to the American Surgical in Philadelphia 403 cases of massive upper gastrointestinal hemorrhage over a 10-year period at KCHC, showing a mortality of 16.8%. Once again, he showed no difference in survival between nonoperative, selective therapy when compared to mandatory immediate surgery. They did note that survival was improved if an actual peptic ulcer was identified as the source of the bleeding. Aside from our surgical society, Gerry was a member of the American College of Surgeons, the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Brooklyn Surgical and the New York Surgical Societies. He gave the annual Scudder Trauma oration at the ACS Clinical Congress in 1988.
While my personal interactions with Gerry and his posse started before I attended medical school, I had the most fun with them during my tenure as Chair of Surgery at SUNY Downstate. I loved sitting next to Gerry and his crew at the Brooklyn Surgical Meetings. I was stunned one evening when a world-renowned breast surgeon gave an update on the National Surgical Adjuvant Breast and Bowel Project and three of them grinned. These trauma surgeons whispered how they enrolled their breast cancer patients into the original NSAPB studies, saving many from radical mastectomy. Just another opportunity to employ conservative management, I thought, to a disease that used to be lethal. Later, I was honored to coauthor with Gerry a tribute to Clarence Dennis for the medical school"s sesquicentennial in 2010.
Upon my return to Brooklyn in 2017 after what Gerry termed "yet another hiatus at Johns Hopkins", he emailed me- "Welcome Back to Brooklyn.…. I spent more than half my life there. I hope this [tenure] proves safe and healthy for you … without the headaches you had when you were here last. So hearty congratulations and "Illegitimi non carborundum" (Don't let the bastards grind you down)". He hit all the right points if you ask me.
Gerry and his wife Bernice are lifelong New Yorkers. They lived in same apartment building in Gramercy Park since they were married in 1949, where they raised their two children Richard, a political consultant, and Susan, an artist. Gerry was an avid reader of mystery stories, was always fixing everything from the electricity to the appliances and was a passionate horticulturalist; he enjoyed making things live. His wife is a well-known shoe designer, who worked with many companies (from high end designers to Keds, Converse, and Rockport). Her career archives were donated to the Costume Institute at The Metropolitan Museum of Art.
Gerry died at the age of 93 years and is survived by them and two grandchildren. His loss is the loss of a generation of surgeons who had profound surgical judgement, who could fix anything, anywhere and changed the course of surgery by employing practical observation to scientific scrutiny. Locally, Gerry"s group might have seemed like a hardened group of characters, but they really made a difference in bringing the best care to the injured patients of our Borough and saved many from the trauma of an unnecessary operation.
MICHAEL E. ZENILMAN, MD