In the presidential address delivered to the Western Surgical Association, Dr Richardson reiterates many of the points made in a symposium in the March issue of the ARCHIVES entitled "The Generation Gap." He presents the fact that surgery is losing applicants for residency training and relates this to 3 elements of professional satisfaction: loss of prestige, loss of economic incentives, and lifestyle issues. His solutions include an in-depth study of workforce needs in surgery, support for the American College of Surgeons' efforts to inform those making decisions on physician reimbursement of the current inequities, more emphasis on advocating surgical experience early in medical school and meaningful representation on the curriculum committee, and, perhaps most important, modifying many aspects of the surgical residency program, including work hours, more education and less service, better use of ancillary personnel, and attention to the requirements of women with regard to family planning.
The articles about sentinel node removal and analysis continue for both malignant melanoma and breast cancer. Many questions are raised regarding the proper indications for this technique, its value in this era of extensive use of adjuvant chemotherapy, the processing of the removed node or nodes, the morbidity of interval sentinel node dissection in melanoma, the value of performing bone marrow biopsies, the true role of "upstaging" related to sentinel node positivity, and the value of frozen section analysis of sentinel nodes. Sentinel node biopsy is now widely practiced and accepted. Is the new technology of immunocytochemical staining superseding our knowledge of how to deal with micrometastases? What are the characteristics that allow us to predict positivity of nodes? Will the sentinel node concept be time limited?
Emphasizing technique, the following articles are noted:
Sarmiento et al at the Mayo Clinic, Rochester, Minn, present 8 patients treated for their presumed benign duodenal polyps by a pancreas-sparing duodenectomy. Although the morbidity of the procedure is significant (same range as a Whipple procedure), the mortality is low, and the patient is left with a good absorptive capacity, weight gain, and an excellent quality of life. The procedure is a demanding one, involving reanastomosis of the biliary and pancreatic ductal systems to the neoduodenum and the individual ligation of all feeding vessels. To date, the Mayo group has been able to separate benign from malignant lesions by preoperative testing. Will this procedure supplant the Whipple procedure for duodenal lesions? What does one do if malignancy is noted on frozen or permanent sectioning of the lesion? These questions remain to be answered.
The need for donor kidneys greatly outweighs the supply. By combining the skills of laparoscopy with those of open donor nephrectomy (2 individuals), the problems of the learning curve are minimized. In this series from Seattle, Wash, only 1 of 100 laparoscopic attempts at live donor nephrectomy required conversion to an open technique, minimal complications developed (similar to the open technique), and fewer ureteral problems were encountered. The graft function was comparable to the open technique. This demonstration should stimulate continued use of living donor renal grafts countrywide.
This Month in Archives of Surgery. Arch Surg. 2002;137(5):514. doi:10.1001/archsurg.137.5.514