This Month in Archives of Surgery

Several controversies regarding surgical treatment of disease are discussed in this issue. The first concerns the approach to patients with primary hyperparathyroidism. There appears to be a good deal of pressure to perform preoperative localization with sestamibi scanning, focused unilateral minimally invasive operations, and intraoperative parathyroid hormone analysis. Lee and NortonArticle present a literature review of 2095 patients operated on with a focused unilateral approach that yielded 92.5% of patients with a single adenoma and 5.3% with multiple adenomas, whereas of 2166 patients who underwent bilateral neck exploration, 19.3% had multiple-gland disease. In their own series of bilateral open-neck exploration, 20.6% of patients had multiple-gland disease. The best explanation of this discrepancy appears to be selection, with an alternative being the function of the second- and third-gland disease. As part of this discussion, please review the cost-benefit analysis by Fahy et alArticle, indicating that limited parathyroid surgery using any localizing strategy is cost-effective, safe, and efficacious in the management of primary hyperparathyroid disease.

The other point of contention is the potential gain from systematic postoperative evaluation for second primary lung cancer in patients with non–small cell lung cancer. Lamont et al contend that in experienced hands, regular computed tomographic scanning detects second primary lesions earlier, distinguishes them from benign areas, and allows longer survival as a result of early resection. The author of our Invited Critique, an experienced thoracic surgeon, points out that current evidence is insufficient to justify the expenditure, but encourages the authors to continue their objective assessment in the current climate of "evidence-based" medical practice.

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In a study of 118 trauma patients who underwent splenectomy, 60 developed postoperative sepsis, and 58 did not. Toutouzas et al identified 3 independent predictors of sepsis by stepwise regression analysis: (1) day 5 platelet–white blood cell count ratio below 20, (2) Injury Severity Score of 17 or above, and (3) day 5 white blood cell count above 15 × 10³/µL. The probability of sepsis when all 3 predictors were present was 97.4%. Thus, the authors concluded that a white blood cell count above 15 × 10³/µL and a platelet–white blood cell count ratio below 20 are strongly associated with sepsis and should not be considered part of the physiologic response to splenectomy.

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To establish that contemporary reconstructive vascular procedures can be safely used to permit resection of tumors invading major vascular structures, a multidisciplinary group of authors studied 49 patients who required vascular resection and reconstruction to allow complete tumor resection. Despite the horrendous nature of the primary tumors, they achieved a 30-day mortality of only 2.1% and morbidity of 12.2%. No patient died or lost a limb because of occlusion of the vascular reconstruction. Overall, 31 patients (63%) were alive, without tumor recurrence, and with a patent vascular reconstruction at 24 months. We are making strides.

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These technically skilled authors performed 20 laparoscopic adrenalectomies for various primary and metastatic adrenal malignancies with excellent margin control and minimal conversion. They had unreliable results with fine-needle aspiration preoperatively and a high recurrence rate with adrenal cortical cancer, but they suggest this technique for suspected adrenal metastases.

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