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Special Article
August 1998

The Best of the Best—1997

Author Affiliations

From the Department of Surgery, University of California, Davis-East Bay, Oakland.

Arch Surg. 1998;133(8):907-908. doi:10.1001/archsurg.133.8.907

In an attempt to highlight those articles published in 1997 that contributed most to the better understanding of the practice of clinical surgery, we have solicited opinions from a wide range of surgeons familiar with the literature of their area of expertise. From their thoughtful suggestions, we have distilled this list of "The Best of the Best––1997."

For future annual updating of this list, we invite your suggestions addressed to the Editor of the Archives of Surgery at the office listed in the JOURNAL. Articles may originate in any publication.

Our hope is that this list will be helpful to you in staying abreast of important practice-related innovations.

For 1997 our choices are as follows, in random order:

• Turner RR, Ollila DW, Krasne DL, et al. Histopathologic validation of the sentinel lymph node hypothesis for breast carcinoma. Ann Surg. 1997;226:271-278.

The authors evaluated 103 patients with breast cancer by examining their sentinel lymph node and nonsentinel nodes following completion of a level I and II axillary dissection. Patients had a median age of 55 years and had primary tumors of a median size of 1.8 cm (58%, T1; 40%, T2; 2%, T3). Examination of nodes included immunohistochemical staining. Overall, metatastic disease was noted in 42% of patients. Only 1 patient who was sentinel node negative (1.7%) and had undergone routine staining of nodal specimens (hematoxylin-eosin) was actually node positive on examination of all her axillary nodes and when the immunohistochemical processing was used, the probability of nonsentinel node involvement was less than 0.1%. This indeed validates the concept as set forth by the John Wayne Cancer Institute Group.

• ten Cate J, for The Columbus Investigators. Low molecular weight heparin in the treatment of patients with venous thromboembolism. N Engl J Med. 1997;337:657-662.

The value of low-molecular-weight heparin in the treatment of patients with pulmonary embolism or previous episodes of thromboembolism was studied in more than 1000 patients in a multi-institutional study. Randomly assigned patients with symptomatic venous thromboembolism were treated with fixed-dose, subcutaneous, low-molecular-weight heparin or adjusted-dose, intravenous, unfractionated heparin. Treatment with oral coumarin was started concomitantly and continued for 12 weeks. The outcome events studied included recurrent venous thromboembolism, major bleeding, and death. Fixed-dose, subcutaneous, low-molecular-weight heparin proved as effective and safe as adjusted-dose, intravenous, unfractionated heparin in all categories.

• Heslin MJ, Latkany L, Lung D, et al. A prospective randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg. 1997;226:567-580.

In an attempt to decrease morbidity, mortality, and length of stay in patients with upper gastrointestinal tract cancer, 195 individuals were randomized to an immune-enhancing feeding formula given via a jejunostomy tube or to intravenous crystalloid following curative resection. The feedings were begun within 24 hours and included supplemental nutrients. Despite receiving considerably more protein, carbohydrate, lipids, and immune-enhancing nutrients, the complication rate, mortality rate, and median length of hospital stay were not different between the groups. Thus, early enteral feeding should not be used routinely after operations for upper gastrointestinal tract malignancy.

• Murray JA, Demetriades D, Cornwell EE, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma. 1997;43:624-626.

This article points out the high incidence of diaphragmatic injury (42%) in 107 patients evaluated following penetrating left thoracoabdominal trauma. Among the patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had normal findings on chest x-ray film, and 49% had an associated hemopneumothorax. Patients underwent either celiotomy (peritonitis or hemodynamic instability) or laparoscopy. Of those undergoing laparoscopy, 26% had occult diaphragmatic injury. Thus, following penetrating left thoracoabdominal trauma, always rule out diaphragmatic injury even though the clinical and radiographic findings are unreliable. Laparoscopy is a vital tool in the process when the patient has no other indication for formal celiotomy.

• Bender J, Smith-Meek MA, Jones CE. Routine pulmonary artery catheterization does not reduce morbidity of elective vascular surgery: results of a prospective, randomized trial. Ann Surg. 1997;226:229-237.

Studying the value of pulmonary artery catheterization in major elective vascular surgery, 104 consecutive patients were randomized to have pulmonary artery catheters placed the morning of operation routinely or only if clinically indicated. Those in the group routinely catheterized then were optimized in the intensive care unit to a predetermined wedge pressure, cardiac index, and systemic vascular resistance and were kept at these levels both intraoperatively and postoperatively. The control group received standard care with insertion of a pulmonary artery catheter only if complications arose. The groups were comparable in all other respects. Results indicated that use of pulmonary artery catheter in elective vascular surgery, although increasing the amount of fluid given, did not reduce morbidity, mortality, cost, or length of hospital stay; thus, its use should be limited to specific clinical situations.

• Laborde F, Folliguet TA, Etienne PY, et al. Video-thoracoscopic surgical interruption of patent ductus arteriosus, routine experience in 332 pediatric cases. Eur J Cardiothorac Surg. 1997;11:1052-1055.

The introduction of video-thoracoscopic techniques to the armamentarium of the pediatric surgeon has lessened the trauma and shortened the convalescence of the newborn affected with patent ductus arteriosus during and after surgical interruption. This substantial series of 332 patients testifies to the place of this technique in modern practice.

• O'Connell JJ, Mailliard JA, Kahn MJ, et al. Controlled trial of fluorouracil and low dose leucovorin given for 6 months as post-operative adjuvant therapy for colon cancer. J Clin Oncol. 1997;15:246-250.

To determine the efficacy of an intensive course of fluorouracil plus low-dose leucovorin given for 6 months following potentially curative resection of colon cancer, 317 patients with high-risk stage II or III colon cancer were randomly assigned following operation to receive chemotherapy. Half were administered 6 cycles of fluorouracil plus leucovorin intravenously for 5 days every 4 to 5 weeks while the others were merely observed. Follow-up was 72 months. Results indicated significant improvement in the treated group in time to relapse and overall survival. There were no treatment-related deaths. These results affirm the value of this chemotherapeutic regimen in the continued treatment of patients with high-risk colon cancer.

• Thompson GB, Grant CS, Van Heerden, JA, et al. Laparoscopic versus open posterior adrenalectomy: a case control study of 100 patients. Surgery. 1997;122:1132-1136.

This controlled study of 50 patients undergoing laparoscopic transabdominal adrenalectomy and an equal number subjected to conventional open posterior adrenalectomy revealed an advantage for the laparoscopically performed procedure in mean hospital stay, narcotic need, return to normal activity, patient satisfaction, late morbidity, and operating room time. Although laparoscopic adrenalectomy is technically more demanding and slightly more expensive to perform, its advantages appear to outweigh these disadvantages.

• Zanfret LF, Ivating RR, Smith RS, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma. 1997;42:825-831.

To dispel the skepticism still existing regarding the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma, a retrospective analysis of 510 patients from 3 large urban trauma centers was undertaken. All patients were hemodynamically stable and had no urgent indications for celiotomy. Laparotomy was avoided by laparoscopy in 277 of the 510 patients. All were discharged uneventfully after a mean hospital stay of 1.7 days. Twenty-six patients had successful therapeutic procedures during laparoscopy (diaphragmatic repair, hepatic repair, and closure of gastrotomy). The overall incidence of nontherapeutic laparotomy was 10.2%. Thus, laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma.

• Taylor M, Forster J, Langer B, et al. A study of prognostic factors for hepatic resection for colorectal metastases. Am J Surg. 1997;173:467-471.

Now that liver resection has become an accepted treatment for selected patients with colon cancer metastatic to the liver, this study was conducted to clarify the selection process. One hundred twenty-three patients who underwent liver resection for colorectal metastases were categorized into those with solitary lesions (77), single lesions with satellite nodules (15), and multiple lesions (31). Synchronous lesions were found in 40 patients, and 83 had metachronous metastases. Overall 5-year survival was 34%, but patients with single lesions had a rate of 47% as opposed to 16% to 17% for all others. No other factor appeared to influence the significance of these results. Thus, an aggressive approach to the surgical management of colorectal liver metastases can result in prolonged survival in one third of patients with low operative risk. The most reliable predictor of long-term survival is the number of metastases in the liver.

Reprints not available from the author.