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This Month in Archives of Surgery
Arch Surg. 2003;138:581.
Papers of the Western Surgical Association
Directed Parathyroidectomy: Feasibility and Performance in 100 Consecutive Patients With Primary Hyperparathyroidism
Although this is not the first study indicating that one can, under appropriate circumstances, perform directed parathyroidectomy, this article by Burkey et al reviewed 100 consecutive patients with untreated, sporadic primary hyperparathyroidism. Following preoperative imaging (sestamibi scintigraphy and ultrasonography), patients underwent parathyroidectomy with intraoperative parathyroid hormone monitoring through either a limited neck incision or bilaterally through a standard collar incision. In 70 of these individuals, a limited incision was possible, with excellent results and shorter operative time and length of hospital stay. All patients were eucalcemic postoperatively. The authors present an algorithm for your perusal.
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A Survey of Residents and Faculty Regarding Work Hour Limitations in Surgical Training Programs
Niederee et al from the University of Kansas, Wichita, obtained a large return of their questionnaires (1653, or 46% of all approved surgical training programs). They found that (1) current duty hours for most surgical residents exceed proposed ACGME limits; (2) most surgical residents support duty hours limits, whereas surgical faculty are less supportive; and (3) significant alterations in the current design and structure of surgical training programs will be required to meet ACGME guidelines. Further, approximately one quarter of residents regret choosing a career in surgery. The discussion raises the question of continuity of care and the increasing role of surgical faculty in providing this valuable aspect of care. Should the length of residency time be increased?
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The Role of Temporary Inferior Vena Cava Filters in Critically Ill Surgical Patients
Offner et al treated 44 high-risk patients, mostly following severe injury (mean Injury Severity Score, 33), by the insertion of a temporary inferior vena cava filter. There were no complications associated with insertion or removal of these filters and no documented instances of venous thromboembolism, thus their conclusion that inferior vena cava filters are safe and effective in critically ill surgical patients. This concept has been disputed on a cost-benefit basis as well as the determination of who is sick enough to warrant such treatment.
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Although no women are represented, we must thank Thompson et al for refamiliarizing us with the temporal patterns of postoperative complications resulting from intra-abdominal procedures. As was pointed out in their presentation to the Western Surgical Association, the highest incidence of major complications occurred within 1 to 3 days postoperatively. Complications presented in distinct temporal patterns, and knowledge of these patterns should aid clinical management.
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Most institutions now offer core needle biopsy using a stereotactic technique, but we have not learned how to handle a diagnosis of atypical ductal hyperplasia when 11-gauge vacuum-assisted core needle biopsy and surgical pathological analysis confirm this entity. In an effort to establish the benignancy or malignancy of such a diagnosis, Winchester et al evaluated this finding in 65 patients who underwent excisional biopsy; 17% had their condition upstaged to breast cancer, and most of these patients had presented at a later age than those retaining a benign diagnosis after excisional biopsy. In the authors' opinion, surgical excision is still indicated in this situation.
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I am sure that all who deal with trauma have noticed the significantly higher incidence of abdominal compartment syndrome in recent years; this increase is thought to be related to the greater volume of resuscitative fluid administered. Balogh et al have completed an interesting study demonstrating that resuscitating similarly injured patients to a supranormal level (oxygen delivery index, 600 mL/min per square meter) rather than just a normal level (oxygen delivery index, 500 mL/min per square meter) required more lactated Ringer solution and produced twice as much abdominal compartment syndrome and greater mortality. This is a lesson for all of us to ponder carefully.
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SECTION EDITOR: GERALD W. PESKIN, MD
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