This Month In Archives of Surgery FREE

The most common subject of conversation among any group interested in the future of surgical training in the United States is the state of the general surgery residency. Questions are raised about recruitment and retention, working hours and conditions for residents, debt levels, lifestyle patterns of residents and their significant others, and the current view of rewards in medicine and how surgery fits into the scheme of economic incentives.

If it were easy, there would already be solutions to these problems. Instead, the report by Neumayer et al presents a survey of program directors and their attempts at adjudication. The authors point out that we have not achieved an 80-hour week as is sought by many, that the most effective way of dealing with this problem is the use of physician extenders, that women remain underrepresented in the various programs (24% of residents), that attrition during the program is substantial, and that program directors feel the applicant pool is shrinking. Furthermore, the concept of continuity of care has been sacrificed because of resident concerns and that responsibility has been shifted, to some degree, to staff and attending surgeons. How can we resolve these issues?

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A second provocative article is that of Arya's group who ask, is evidence-based science the only worthwhile mode of surgical inquiry? This question is particularly important in light of the Lancet editor's remarks concerning the dearth of evidence in most surgical reports. Dr Arya and his coauthors take us through all the steps on the road to a realistic solution.

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Although the sample is relatively small, this study by Wasserberg et al points out the considerable rate of axillary metastases in patients with T1mic breast tumors. High nuclear grade and comedo configuration as well as a large number of involved ducts appeared to predict axillary metastases, with or without the obvious minimally invasive characteristics of ductal carcinoma in situ.

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Despite extensive experience with the "vacuum packed" technique for managing the open abdomen patient in the intensive care unit, Gracias et al from the University of Pennsylvania noted that some patients with the temporary abdominal dressings went on to develop abdominal compartment syndrome (called open ACS). Abdominal compartment syndrome developed between 1.5 and 12 hours after the operation with abnormal base deficit, pH, peak inspiratory pressure, PCO₂, and lactate levels. Crystalloid requirements were significantly higher in this group. Mortality was 60% vs only 7% in the control group. The authors felt that one could predict which patients would develop this syndrome by the volume of crystalloid required and the physiologic derangement.

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For you history buffs and hepatic surgeons, Dr Francis Sutherland and Julie Harris have reviewed the outstanding contributions of the French anatomist and surgeon Claude Couinaud, including his description of the segmental anatomy of the liver and the "controlled hepatectomy" based on his observations with liver casts. Their article is truly fascinating.

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