This Month in Archives of Surgery

This ARCHIVES issue attempts to resolve several important issues of surgical practice. We trust that the articles and discussions of these problems will help you determine the best method of dealing with these controversies. First, does the use of computed tomography (CT) and laparoscopy improve the outcome for elderly patients with appendicitis? A retrospective analysis of appendectomy using CT and the laparoscopic approach did not lower the morbidity or mortality rate among the elderly. Emphasis was placed on earlier consideration of the diagnosis in older patients with abdominal pain, followed by prompt surgical consultation and operation. In reviewing the article's discussion, it is apparent that CT can help in determining alternative diagnoses.

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Second, how to deal with the pancreatic stump when the pancreatic duct is small and the residual organ is soft is a problem all pancreatic surgeons consider. Suzuki et al present their algorithm based on 50 consecutive pancreatoduodenectomies, with different procedures used prospectively according to pancreatic texture and duct size (aided by fibrin glue). Behrman's invited critique puts this information into perspective.

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Third, when is the best time for wound excision and grafting in severely burned children? Xiao-Wu et al found that delays in excision were associated with longer hospitalization and delayed wound closure as well as increased rates of invasive wound infection and sepsis. Early excision (within 48 hours) is optimal. Our reviewers warn us of the potential harm of early operative intervention.

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To answer the age-old question, "Can you improve the status of an asymptomatic patient?" Sheldon et al analyzed 74 consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism using the Medical Outcomes Study Short-Form Health Survey (SF-36) as a basis for comparison preoperatively and 1-year postoperatively. They found that surgical treatment, regardless of the preoperative symptoms, was associated with durable, statistically significant improvements in health-related quality of life, whether the operative intervention was bilateral neck exploration, unilateral neck exploration, or a minimally invasive 1-gland exploration. Although one can bicker about the interpretation of asymptomatic, it is difficult to ignore these results.

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Sackett et al have surveyed the members of the International Association of Endocrine Surgeons and have had enough feedback to make the following statements. First, the number of parathyroidectomies performed worldwide increased more than 4-fold in the 20 years from 1980 through 2000 and the average number per endocrine surgeon increased to 45 annually, with more than half of the surgeons using minimally invasive techniques. Second, the most common approach is the focused technique with a small incision, either central or lateral, followed by endoscopic gland retrieval. Third, techniques used to ensure completeness of resection include a quick intraoperative intact parathyroid hormone assay, a same-day intact parathyroid hormone assay, and the nuclear probe.

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In a series of more than 200 consecutive patients with gastroesophageal reflux disease undergoing a fundoplication, preoperative and postoperative testing was conducted. Only a few patients in the postoperative symptomatic group had abnormal DeMeester scores. Thus, symptomatic assessment appears to be a poor predictor of true pathological reflux in these patients.

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