This Month in Archives of Surgery FREE

Two of the pioneers of the treatment of pancreatic adenocarcinoma present an interesting view of the role of surgical treatment for this disease. They both agree that a "cure" is unlikely with pancreatoduodenectomy. The best we can do is palliate, but for significant periods of time. The reduction in mortality associated with the Whipple procedure has afforded those who perform this operation a wonderful opportunity to provide long-term palliation for a disease that causes death in short order if merely bypassed or afforded nonoperative treatment. But, as both Drs BradleyArticle and TredeArticle point out, tiny T1a N0 M0 tumors of this region cause patients to succumb to a recurrence even years beyond the 5-year standard. Thus, the hope of the future is somewhere in the realm of gene therapy, more effective targeted chemotherapeutic agents, or some as yet undiscovered approach.

Lest we forget the clinical and economic costs of misdiagnosed appendicitis, Drs Flum and Koepsell surveyed widely and found that patients who underwent negative appendectomies had longer hospital stays, greater hospital charges, greater case fatality, and a higher rate of infectious complications. At least 85% of patients with symptoms and signs of appendicitis can be diagnosed by medical history and physical examination. Misdiagnosis is more common among the very young and very old, women, and those with higher levels of comorbidity. Despite the expense and time constraints, isn't computed tomographic scanning of the abdomen an appropriate test? Although this is advocated, the test should be supervised by the attending surgical consultant so that its use can be limited to "in doubt" situations.

This study from a community hospital points out the advantage of fine-needle aspiration of all thyroid nodules preoperatively to aid in planning operations and advising patients. Although one could argue with the overall yield in terms of specific diagnoses, it is apparent that the need for an operation can be established by this technique and that only the experience of the surgical team and the cytologist are determinants of success.

Conventional Crohn disease activity indices do not reflect perianal disease activity or allow prognostic implications from surgical intervention. Accordingly, Pikarsky et al have devised a somewhat complicated but useful system to incorporate perianal disease with the prognostic evaluation. The series is small, but the correlation is good. With further validation, this system may prove to be a valuable adjunct to current therapeutic applications.

In a multicenter prospective study of 96 patients, Cinat et al champion percutaneous image-guided drainage for intra-abdominal abscesses of all types, with a 70% success rate with a single treatment and an 82% success rate with a second attempt. Successful outcomes were most likely in postoperative abscesses that were neither pancreatic nor infected with yeast. The authors note that percutaneous image-guided drainage is commonly used as a staging method for resolution of intra-abdominal sepsis prior to a corrective operation.