This month we bring you a series of articles designed to make you think about ongoing problems and techniques in our surgical armamentarium. The first of these considers whether to stent bilioenteric anastomoses after iatrogenic injury. Dr Miguel Angel Mercado and associates recommended using a stent when nonhealthy (scarred, ischemic) and small ducts (<4 mm) are found.
The second article deals with the value of an extended lymphadenectomy for distal bile duct cancers and prognostic indicators after such procedures. In a significant series (26 patients), Dr Takanori Yoshida and associates achieved a 37% 5-year survival rate (comparable to the best results in current literature) and noted that patients with up to 2 positive lymph nodes and negative resection margins had a more favorable prognosis.
The beautifully illustrated third article concerns the technique of modified radical mastectomy. Drs Valerie L. Staradub and Monica Morrow explain in wonderful detail how they develop flaps, remove the pectoralis major fascia, and clear the axilla with a cold knife rather than the electrocautery.
Finally, Dr Charles P. Morrison and his colleagues review the problems of islet yield in pancreatic islet autotransplantation. They propose that reducing warm ischemia time may significantly increase the likelihood of postautotransplantation insulin independence.
The question of quality care has become a national issue in light of the expectations of an informed public and the advances in surgical physiology and techniques. Many definitions of quality and many sets of data regarding surgical outcomes are available, and it is our objective to present these to you, along with the thoughts of those who have devised them, so you may take an educated position in this modern health care debate. Therefore, we present 7 articles—by Drs Copeland (POSSUM system), Khuri (VA system), Grover (cardiothoracic system), Knaus (APACHE system), Carney (nutritional assessment), Ireson (outcome report card system), and Shuhaiber (commentary and proposal)—that will inform you of the current literature in this process. A commentary by Dr Gerald W. Peskin introduces this series of articles.
Although fortunately few, patients with prolonged pain (neuralgia) and burning (paresthesia) in the inguinal and thigh areas after inguinal herniorrhaphy are potentially incapacitated and represent a therapeutic challenge. In an interesting article, Dr Parviz K. Amid of the Lichtenstein Hernia Institute, Los Angeles, Calif, proposes a new approach to this problem with very fine results. In a 1-stage procedure, he resects all 3 nerves and implants their proximal ends within muscle.
Dr Lloyd Nyhus, an expert at variations of hernia repair and their complications, presents an informed invited critique of Dr Amid's paper.
There has been much discussion regarding the immunological value of autotransplanted splenic fragments in trauma patients as well as those with splenic diseases. In this small series, Dr Hongwei Zhang and his associates identify a group of portal hypertensive patients with a degree of secondary hypersplenism who maintained splenic function after a Sugiura procedure and splenectomy with implantation of splenic fragments in the retroperitoneum. They used serum tuftsin and IgM as indicators of continuing immunologic function.
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