The Best of the Best—2002 FREE

After consultation with members of the editorial board, following are the 10 best clinical articles of the year 2002. During the year, many innovative and informative articles appeared in surgical and medical journals. Our selections appear in random order. We hope that this list will prove helpful to you in staying abreast of significant practice-related innovations. Each article is preceded by a comment regarding the reason for its choosing.

There has been a great deal written about morbid obesity, a plague on this country. Most of these articles have dealt with the technical aspect of the surgical treatment of morbid obesity and the indications for operation. Obviously the wave of the future is in the pharmacological management of these patients. The following report introduces us to this topic. Cummings DE, Weigle DS, Frayo S, et al. Plasma Ghrelin Levels After Diet-Induced Weight Loss or Gastric Bypass SurgeryN Engl J Med. 2002;346:1623-1630. Ghrelin is a hormone that increases food intake in humans. Because ghrelin is produced primarily by the stomach, weight loss after gastric bypass surgery is associated with a marked suppression of ghrelin levels and an absence of its normal diurnal rhythm. A diet-induced weight loss of 17% of initial body weight in a nonoperative patient group caused sharp rises in ghrelin profiles. Thus, the hypothesis that this hormone has a role in the long-term regulation of body weight has been established, and the search begins for antagonists that eventually may be the treatment of obesity.

With the introduction of minimally invasive techniques to the practice of parathyroidectomy, there has been a challenge to the use of bilateral neck dissection as the gold standard for the surgical treatment of primary hyperparathyroidism. Using a preoperative sestamibi scan to localize the diseased gland and drops in intraoperative parathyroid hormone (PTH) levels of 50% or more after removal of the offensive gland, the authors of this randomized, prospective study have provided valuable information regarding the advantages of this strategy. Bergenfelz A, Lindblom P, Tibblin S, et al. Unilateral Versus Bilateral Neck Exploration for Primary HyperparathyroidismAnn Surg. 2002;236:543-551. In comparing unilateral and bilateral neck exploration for primary hyperparathyroidism, the authors found that under the appropriate circumstances (preoperative scanning and intraoperative PTH levels), patients undergoing a unilateral procedure had a lower incidence of significant hypocalcemia, a shorter operative time, a cost comparably equal to that of the bilateral procedure, and a 97% cure rate (equal to that of the bilateral operation). Be sure to read the "Invited Commentary" that follows.

Everyone is looking for a more accurate means of prognosticating the outcome of patients with breast cancer in the hope of improving the use of adjuvant systemic therapy. This article provides an insight into a technique that may be useful. Van de Vijver MJ, He YD, Van't Veer LJ, et al. A Gene-Expression Signature as a Predictor of Survival in Breast CancerN Engl J Med. 2002;347:1999-2009. Using a microarray analysis to evaluate their 70-gene prognosis profile, 295 breast cancer patients younger than 53 years with stage I or II disease were placed in a good (n = 115) or a poor category (n = 180). The mean survival rates were 85% and 55%, respectively, at 10 years regardless of nodal status. Thus the gene expression profile seemed to be a more powerful predictor of outcome than standard systems based on clinical and histological criteria.

Autopsy remains a valuable tool in the final examination of all patients dying in the hospital, especially in those patients, recently traumatized, residing in an intensive care unit (ICU). The large trauma experience at the University of Miami provides a fine background for what can be gained by careful evaluation of autopsy results.Ong AW, Cohn SM, Cohn KA, et al. Unexpected Findings in Trauma Patients Dying in the Intensive Care Unit: Results of 153 Consecutive AutopsiesJ Am Coll Surg. 2002;194:401-406. The true incidence of missed injuries in trauma-related deaths is unknown because an autopsy is performed in only 60% of injury-related deaths nationwide. As a result of 153 consecutive autopsies of all trauma- and burn-related deaths in the ICU during a 2-year period, 4 patients (3%) had the following class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) had missed diagnoses that, if treated, would not have changed outcomes, and 12 (8%) had minor diagnoses that were missed. Thus, autopsy findings can provide valuable feedback in improving the quality of care of critically ill trauma patients.

A number of contributions dealt with the use of adjuvant therapy (radiation, chemotherapy, or both) for rectal carcinoma, treated eventually by radical extirpation. This report presents a 30-year series of patients who underwent local excisional therapy for small lesions (T1 and T2 adenocarcinomas). Paty PB, Nash GM, Baron P, et al. Long-Term Results of Local Excision for Rectal CancerAnn Surg. 2002;236:522-530. Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, it has definite limitations related to the uncertainty of oncologic outcome. The authors, from Memorial Sloan-Kettering Cancer Center, reviewed medical records of 125 patients with T1 and T2 rectal lesions undergoing local excisional therapy supplemented with radiation therapy in 31 cases. Median follow-up was almost 7 years. Ten-year local recurrence and survival rates were 17% and 74%, respectively, for T1 lesions and 26% and 72%, respectively, for T2 lesions. Median time to local recurrence was 1.4 years; for distant recurrence, 2.5 years. Intratumoral vascular invasion was the only predictor of survival. Some patients with local recurrence were treated by means of more radical resection. Thus, the long-term risk of local excision of T1 and T2 rectal cancers is substantial. Perhaps better current preoperative therapies are available in this more modern era to alleviate part of this problem.

On the assumption that organ dysfunction occurs at least in part by oxidative metabolites or reactive oxygen species derived from inflammatory cells and/or reperfusion injury, a study was undertaken in critically ill patients to determine the effectiveness of early, routine antioxidant supplementation using α-tocopherol and ascorbic acid. With the failure of anti-infection cytokines to limit sepsis, this approach seemed reasonable, particularly as related to pulmonary morbidity.Nathens AB, Neff MJ, Jurkovich GJ, et al. Randomized, Prospective Trial of Antioxidant Supplementation in Critically Ill Surgical PatientsAnn Surg. 2002;236:814-822. Oxidative stress has been associated with the development of the acute respiratory distress syndrome and organ failure through direct tissue injury and activation of genes integral to the inflammatory response. In addition, depletion of endogenous antioxidants has been associated with an increased risk for nosocomial infections. Thus, 595 patients (91% trauma victims) were randomized to antioxidant supplementation (n = 301) or routine care without supplementation (n = 294). Results showed that pulmonary morbidity was reduced, as was multiple organ failure. Along with this, patients receiving antioxidant supplementation had a shorter duration of mechanical ventilation and length of ICU stay. Thus, the use of early antioxidant supplementation proved useful in this group of patients.

Much has been written regarding the use of virtual reality machinery in the training of surgeons and in the practice setting. Dr Satava, the father of this concept in the United States, at Yale University School of Medicine, and his colleagues have produced a standardized testing procedure applicable to trainees and practicing surgeons whereby they can sharpen their skills of technique using virtual reality as a training tool. Seymour NE, Gallagher AG, Roman SA, et al. Virtual Reality Training Improves Operating Room PerformanceAnn Surg. 2002;236:458-464. Taking 16 surgical residents (postgraduate years 1-4) into the Virtual Reality Training Facility, this group obtained a baseline assessment of their skills at laparoscopy and then randomized them to supervised virtual reality training or none (control). Videotapes of their performance were reviewed. The results were astonishing. Those residents who underwent virtual reality training were 29% faster and displayed only one sixth of the errors of the control group. Thus the use of virtual reality surgical simulation significantly improved the operating room performance of these residents and set the stage for more sophisticated uses of the experience, perhaps in the certification of surgeons.

Over the years, the Eastern Association for the Surgery of Trauma has taken a leadership role in the development of evidence-based practice guidelines. This year has been highlighted by the steps necessary to prevent venous thromboembolism (VTE) in trauma patients. In this high-risk area, there are few level 1 recommendations but much speculation regarding areas in which future investigation may yield level 1 information.Rogers FB, Cipolle MD, Velmahos G, et al. Practice Management Guidelines for the Prevention of Venous Thromboembolism in Trauma PatientsTrauma. 2002;53:142-164. Such information as the following was developed by this group: (1) Existing evidence supports only spinal fractures and spinal cord injuries as the 2 risk factors in posttraumatic VTE. (2) Low-dose heparin (LDH) has very little proven efficacy in the prevention of VTE after trauma. (3) Arteriovenous foot pumps have not been demonstrated to provide benefit but may be useful in those patients at high risk who have a contraindication to the use of heparin. (4) Clinical studies demonstrating the benefit of pneumatic compression devices are few, and their mechanism of action is unknown, although it is thought to be a combination of addressing stasis and the fibrinolytic system. (5) Low-molecular-weight heparin seems to be superior to LDH for prophylaxis in moderate- to high-risk trauma patients. (6) No class 1 studies exist to support insertion of a vena cava filter in a trauma patient without an established deep vein thrombus (DVT) or pulmonary embolus. (7) Numerous studies attest to the accuracy of ultrasound in the symptomatic patient, but as a screening test in asymptomatic patients, its overall accuracy is less clear. (8) Venography still has a role in confirming DVT in trauma patients when other less invasive studies are inconclusive.

A lot of information can be gleaned from this next analysis. Colorectal cancer ranks second as a cause of death. The 5-year survival rate of patients undergoing curative surgery is often only 50%, with a high local recurrence rate. Radiotherapy has been suggested as an adjunct, as has total mesorectal excision. This is a report that demonstrates the advantages of preoperative radiotherapy and mesorectal excision for stage T3 low rectal cancers (<8 cm). Delaney CP, Laverly IC, Brenner A, et al. Preoperative Radiotherapy Improves Survival for Patients Undergoing Total Mesorectal Excision for Stage T3 Low Rectal CancersAnn Surg. 2002;236:203-207. To examine the effect of preoperative radiotherapy on patients who underwent rectal resection with total mesorectal excision (TME) for stage T3 low rectal cancers, 259 of these patients were grouped by receiving preoperative radiotherapy (n = 92) or not (n = 167). Overall survival was increased by 11% in those receiving preoperative treatment (all in node-negative patients). It was established that T3 low rectal cancer patients undergoing resection with TME have an improved survival with preoperative radiotherapy, most beneficial in node-negative patients and those with larger tumors. This policy deserves continued consideration.

The principle of early treatment is solidified in the next article. Although this pertains to the therapy of burns in a pediatric population, the idea of early intervention is important in any surgical situation involving acute injury or illness. Xiao-Wu W, Herndon DN, Spies M, et al. Effects of Delayed Wound Excision and Grafting in Severely Burned ChildrenArch Surg. 2002;137:1049-1054. From 1995 to 1999, 157 children with acute burns involving 40% or more of their total body surface area and with more than 10% full-thickness burns were treated on days 0 to 2, 3 to 6, and 7 to 14 after burns. Demographic data of all groups were similar. Hospitalization was longer in the delayed groups and was associated with a high incidence of wound contamination. An increased incidence of sepsis was seen in children with delayed excision and grafting as well as delayed wound closure. The data indicate that early excision within 48 hours is optimal.

Happy reading!

Corresponding author: Gerald W. Peskin, MD, Associate Editor, Archives of Surgery, 1411 E 31st St, Oakland, CA 94602 (e-mail: archsurg@jama-archives.org).