Copyright 2003 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2003
This month several clinically important issues are discussed and amplified with new material. First, are volume and operative mortality important in cancer surgery? Finlayson and her Veterans Affairs associates point out that trends toward lower operative risks at high-volume medical centers were observed for 7 of 8 major cancer procedures; this effect was greatest among elderly patients. On the other hand, in his invited critique of this article, Davies raises a bevy of questions, such as the numbers used to define low volume, which are different than those used in the Institute of Medicine study, and the emphasis on hospital rather than individual physician volume. More studies with access to clinical rather than administrative data will be necessary before radical changes in health policy seem warranted.
Second, how should we deal with gallbladder cancer based on information available before resection? Kokudo et al, after a careful study of their own large series, have proposed an algorithm for each level of staging of this cancer based on integrating T factor (image-T) and intraoperative histological examination of key lymph nodes. In general, radical procedures, such as bile duct resection and pancreatoduodenectomy, provided no survival advantage. In his critique, Polk points out the expense involved, even at tertiary medical centers, making this technique cost-ineffective. Further, he notes that the ever-increasing laxity of indications for laparoscopic cholecystectomy and symptomatic relief for hepatobiliary iminodiacetic acid scan–only positive patients may render all discussion moot.
Biancofiore et al studied 108 consecutive orthotopic liver transplantation patients and measured their intra-abdominal pressure (IAP) 3 times daily for 3 days. Acute renal failure developed in 17 patients (16%), 11 (65%) of whom had high IAPs. High transfusion rates, respiratory failure, and high IAPs were all independent risk factors for renal failure. This article points out that elevated IAPs are common after liver transplantation and are significantly associated with renal failure, reduced urinary output, and intensive care unit mortality.
Kreitz and Rovito carefully reviewed the records of 9 patients with body mass indices of 70 or more (calculated as the weight in kilograms divided by the height in meters squared) who underwent laparoscopic gastric bypass. The authors found remarkably little morbidity, low conversion rates, rapid operative times, and good relief of symptoms. They demonstrated that this procedure is safe and effective in this group of patients. Skill is important, as are instruments of appropriate length, as is pointed out by the author of the invited critique.
In their effort to bring gender into the trauma and injury picture, Kuebler, Chaudry, and associates have demonstrated in the ovariectomized female rat that the administration of a single dose of progesterone following trauma-hemorrhage in progesterone-deficient animals ameliorates the inflammatory response and hepatocellular damage. They establish this by pointing out the direct action of the agent on immunocompetent cells.
This Month in Archives of Surgery. Arch Surg. 2003;138(7):699. doi:10.1001/archsurg.138.7.699