This Month in Archives of Surgery FREE

Despite interesting figures showing that more is better, Dimick, Lipsett, et al use data from hospitals in Maryland to demonstrate that patients who undergo hepatic resection at low-volume hospitals (<60 cases during the 5-year study period) have a substantially increased risk of postoperative complications, including pulmonary failure, acute renal failure, and acute myocardial infarction. Another arrow in the heart of those who dabble in everything rather than focus on a special area.

In an attempt to clarify the need for trauma coverage by in-house attending physicians, Arbabi et al conclude that an in-house call surgeon policy had no effect on mortality or length of hospital and intensive care unit stays at 31 academic, level I trauma centers (32% had in-house call, and 36% had fellowship programs in trauma and critical care). However, the presence of fellowship programs was associated with a significant decrease in blunt trauma mortality and length of stay both in the hospital and the intensive care unit. No significant difference was noted with fellowship programs on penetrating trauma outcomes. As David B. Hoyt, MD, our invited commentator, points out, the authors assume that "in-house" vs "out of house" leads to an actual difference in surgeon response (not controlled for), the association of a teaching program with improved outcomes makes sense, and commitment is the key. "Where we sleep is not the issue," he writes. Availability to sick patients is our responsibility.

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Will we ever resolve the issue of sentinel node biopsy? Guenther et al pose the question, Do all patients with breast cancer and positive sentinel nodes require axillary dissection? As you can see, the controversy rages on.

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Everyone has encountered patients with peritoneal carcinomatosis. This article by Shen et al points out the factors predictive of improved survival after resection of gross disease and a 2-hour intraoperative perfusion of mitomycin C (20-40 mg) into the peritoneal cavity at a temperature of 40.5°C. These factors include nonadenocarcinoma histologic features, the appendix as the primary site, the absence of hepatic metastases, and complete resection of all gross disease. Despite the generally poor prognosis for these patients, selected patients do show improved survival.

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In an attempt to further define the problems associated with wound healing in patients with diabetes, Black et al have demonstrated, in a small number of patients, that collagen deposition is impaired in patients with type 1 diabetes mellitus and that glycemic control has no influence on this phenomenon. The findings are surprising.

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This article, by Kao et al from the University of Washington, Seattle, describes the difficulties encountered at a single institution participating in a multicenter drug study (phase 3) and reviews the problems involved in developing a high-quality randomized control study.

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Several review articles, including "The Spectrum of Pneumatosis Intestinalis" and "Breast Cancer in Pregnancy," are presented for your scrutiny.