From the Department of Surgery, University of California, San Francisco[[ndash]]East Bay, Oakland.
This year we again present our selection of the 10 best clinically relevant articles. During the year 2001, many innovative and informative articles appeared in surgical and medical journals. After careful consideration, the editors have selected the following articles in random order. We hope that this list will prove helpful to you in staying abreast of significant practice-related innovations.
Three areas seem to have piqued the interest of surgeons during the past year: sentinel node biopsy, mammography, and pancreatoduodenectomy. Accordingly, we have selected the following reports.
Derossis AM, Fey J, Yeung H, et al. A Trend Analysis of the Relative Value of Blue Dye and Isotope Localization in 2,000 Consecutive Cases of Sentinel Node Biopsy for Breast CancerJ Am Coll Surg. 2001;193:473-478.
The Sloan-Kettering Group found that using an isotope dose of 0.1 MCi of unfiltered technetium Tc 99m sulfur colloid intradermally as well as introducing 4 to 5 mL of isosulfan blue dye into the breast parenchyma surrounding the tumor or biopsy site, and the subsequent removal of all blue or focally hot sentinel lymph nodes, produced a success rate of 97% (94% with the isotope alone). Although they continue to recommend the use of both methods in sentinel node mapping, their experience shows a declining benefit for blue dye. Among the final 500 cases of this group, only 3% of all sentinel lymph nodes and 2% of positive nodes were identified using blue dye alone.
Olsen O, Gotzsche PC. Cochrane Review on Screening for Breast Cancer With MammographyLancet. 2001;358:1340-1342.
A reassessment of the findings of these investigators, paying close attention to the standard dimensions of methodological quality in 7 frequently quoted trials (randomization method, baseline comparability, exclusions after randomization, and unbiased assessment of outcome), led to the conclusion that screening (mammography) is unjustified because there is no reliable evidence that it reduces mortality. Organizations including the National Institutes of Health and the American Cancer Society have responded to this conclusion, so the controversy rages on.
Balcom JH IV, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-Year Experience With 733 Pancreatic Resections: Changing Indications, Older Patients, and Decreasing Length of HospitalizationArch Surg. 2001;136:391-398.
This large series included 489 patients undergoing pancreatoduodenectomy and demonstrates that older patients are increasingly being selected for pancreatic resection. Because of delayed gastric emptying, pylorus-sparing operations were discontinued during the last 130 resections. Although the mortality rate was low (about 1%) and the length of hospital stay diminished to 8 days, complications have remained the same, including pancreatic fistula. This experience creates a benchmark for the care of these patients.
Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and Safety of Recombinant Human Activated Protein C for Severe SepsisN Engl J Med. 2001;344:699-709.
The authors conducted a multi-institutional randomized, double-blind, placebo-controlled trial of recombinant human activated protein C in patients with systemic inflammation and organ failure due to acute infection. A total of 1690 patients were treated, with a mortality rate of 30.8% in the placebo group and 24.7% in the activated protein C group; this represents a relative reduction in the risk of death of 19.4%. The incidence of serious bleeding was higher in the activated protein C group (3.5%). Thus, in patients with severe sepsis, an intravenous infusion of activated protein C at a dose of 24 µg/kg for 96 hours was associated with a significant reduction in mortality and an acceptable safety profile.
van den Berghe G, Wouters P, Weekers F, et al. Intensive Insulin Therapy in the Critically Ill PatientsN Engl J Med. 2001;345:1359-1367.
This group performed a prospective randomized controlled study involving adults admitted to a surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to the intensive insulin therapy group (maintaining the blood glucose at a level between 80 and 110 mg/dL) or the conventional treatment group (insulin given only if the blood glucose level exceeded 215 mg/dL, and maintenance at levels between 180 and 200 mg/dL). During a 12-month period, 1548 patients were enrolled. The mortality rate was reduced from 8.0% with conventional treatment to 4.6% with intensive insulin therapy. The greatest reduction in mortality involved deaths due to multiple organ failure with a proven septic focus. Overall in-hospital mortality was reduced by 34%, bloodstream infections by 46%, acute renal failure requiring dialysis or hemofiltration by 41%, and red blood cell transfusion by 50%; in addition, less days of ventilatory support were required. Intensive insulin therapy reduced morbidity and mortality among critically ill patients in the surgical intensive care unit regardless of whether they had a history of diabetes.
Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?Ann Surg. 2001;234:395-403.
To evaluate the safety of a policy of selective nonoperative management in patients with abdominal gunshot wounds, the authors reviewed the records of 1856 patients treated selectively during an 8-year period. Patients who did not have evidence of peritonitis, were hemodynamically stable, and had undergone a reliable clinical examination were observed. Initially, 792 patients (42%) were observed, with 4% developing symptoms requiring delayed laparotomy. Five patients (0.3%) experienced complications potentially related to the delay in laparotomy, all managed successfully. The rate of unnecessary operations was low, with 712 patients treated without an operation; this saved approximately 3500 hospital days and $9.5 million in hospital charges. Thus, selective nonoperative management is a safe method for treating abdominal gunshot wounds in a level I trauma center with an in-house trauma team. It should not be the rule where less attentive coverage is noted.
Cushman JG, Agarwal N, Fabian TC, et al. Practice Management Guidelines for the Management of Mild Traumatic Brain Injury: The EAST Practice Management Guidelines Work GroupJ Trauma. 2001;51:1016-1026.
As the years have passed, this group has taken the initiative in preparing practice management guidelines for many trauma situations and is deserving of our accolades. Their set of recommendations is for mild traumatic brain injury or concussion, a common cause of admission at trauma centers. This condition is defined as an injury caused by blunt acceleration and deceleration forces that produce a period of unconsciousness for 20 minutes or less and/or brief retrograde amnesia, a Glasgow Coma Scale score of 13 to 15, no focal neurologic deficit, no intracranial complications, and normal findings on computed tomography (CT). Under these circumstances, CT of the brain is recommended as the gold-standard diagnostic study. A patient with a normal head CT scan result has a 0% to 3% probability of neurologic deterioration; this usually occurs in patients with a Glasgow score of 13 or 14. Neuropsychological testing may help identify high-risk patients during short-term hospitalization and/or may be useful 1 to 2 months later to evaluate patients with persistent postconcussive symptoms. These recommendations represent the opinion of the group, which they developed after reviewing all of the current literature in the field.
Lieberman DA, Weiss DG. One-time Screening for Colorectal Cancer With Combined Fecal Occult-Blood Testing and Examination of the Distal ColonN Engl J Med. 2001;345:555-560.
This analysis was conducted to determine if 1-time screening with both a fecal occult blood test with rehydration and sigmoidoscopy is adequate to detect neoplasia of the colon and rectum. At 13 Department of Veterans Affairs medical centers, a total of 2885 patients returned the 3 specimen cards and underwent a complete colonoscopic examination. Of these patients, 23.9% with advanced neoplasia had a positive test result for fecal occult blood. Sigmoidoscopy identified 70.3% of all subjects with advanced neoplasia. Combined screening for fecal occult blood and sigmoidoscopy identified 75.8% of subjects with advanced neoplasia. Thus, these tests failed to detect advanced colonic neoplasia in 24% of subjects with this condition. (Advanced colonic neoplasia was defined as an adenoma >10 mm in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer.) Only a complete colonoscopy can be relied on to discover the presence of colorectal neoplasia.
Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative Radiotherapy Combined With Total Mesorectal Excision for Resectable Rectal CancerN Engl J Med. 2001;345:638-646.
This study by the Dutch Colorectal Cancer Group was conducted at multiple centers with experienced surgeons and standardized and quality-controlled measures to ensure the consistency of radiotherapy, surgery, and pathological techniques. They randomly assigned patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of 5 days) followed by total mesorectal excision or to total mesorectal excision alone. There was no difference among the eligible patients in the overall rate of survival at 2 years (82%). However, the rate of local recurrence at 2 years was 2.4% in the radiotherapy-plus-surgery group and 8.2% in the surgery-only group (P<.001). The therapeutic challenges we face are the determination of optimal regimens for radiation therapy and/or chemotherapy and the merits of preoperative compared with postoperative therapy. The answers lie in clinical trials that have yet to be performed.
Marescaux J, Smith MK, Fölscher D, Jamali F, Malassagne B, Leroy J. Telerobotic Laparoscopic Cholecystectomy: Initial Clinical Experience With 25 PatientsAnn Surg. 2001;234:1-7.
Beginning in 1999, computer-assisted surgery was used to perform cholecystectomies on 25 patients. The operations were performed by surgeons with previous experience using the computer interface and who remained at a distance from the patient while in the operating room. Four of the 25 patients had acute cholecystitis. Twenty-four of the 25 laparoscopic cholecystectomies were successfully completed using computer-assisted surgery. There was 1 conversion to conventional laparoscopic cholecystectomy. No intraoperative complications occurred. One patient was suspected of having a pulmonary embolus and was treated with anticoagulation. Operative times compared favorably with those published in the literature. This procedure has the potential to revolutionize the way surgery is performed in the future.
Corresponding author: Gerald W. Peskin, MD, Associate Editor, Archives of Surgery, 1411 E 31st St, Oakland, CA 94602 (e-mail: firstname.lastname@example.org).
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