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Special Article
July 2001

The Best of the Best—2000

Author Affiliations

From the Department of Surgery, University of California[[ndash]]Davis, East Bay, Oakland.

Arch Surg. 2001;136(7):832-834. doi:10.1001/archsurg.136.7.832

During the year 2000 many innovative and informative articles appeared in surgical and surgical-related journals. After careful consideration, the editors have selected the following 10 articles as presenting the most valuable information for clinical practice. We hope that this list will be helpful to you in staying abreast of significant practice-related innovations.

The articles are presented in random order.

Ng EK, Lam YH, Sung JJ, et al. Eradication ofHelicobacter pyloriPrevents Recurrence of Ulcer After Simple Closure of Duodenal Ulcer Perforation

Ann Surg. 2000;231:153-158.

One of the few indications for ulcer surgery that remains is the perforated ulcer. The role of Helicobacter pylori in ulcer recurrence after simple closure of a perforation has been unclear, and therefore, this randomized prospective trial of antihelicobacter therapy with a control group receiving a 4-week course of omeprazole is of great value. Of the 51 patients assigned to the treatment group, 5% had a relapse at the 1-year follow-up as opposed to 38% of the control group. Treatment consisted of a 1-week regimen of oral bismuth subcitrate, tetracycline, and metronidazole, in addition to omeprazole. Thus, within the limits of this study, it would seem prudent to pursue a conservative operative approach to the perforated ulcer, knowing that most patients can be spared ulcer recurrence by eradication of H pylori.

Braun S, Pantel K, Müller P, et al. Cytokeratin-Positive Cells in the Bone Marrow and Survival of Patients With Stage I, II, or III Breast Cancer

N Engl J Med. 2000;342:525-533.

While we are very aware of micrometastases and macrometastases in the sentinel and other axillary nodes and their influence on prognosis, this article documents the significant presence of occult metastases in the bone marrow of breast cancer patients (stage I, II, and III). The presence of these cells in the bone marrow was unrelated to the presence or absence of lymph node metastases and was an independent predictor of the risk of death (4-year follow-up) of cancer after adjustment for the use of systemic adjuvant chemotherapy. This finding supports the routine performance of bone marrow aspiration as part of the prognostic evaluation of a patient with any stage of breast cancer.

Luijendijk RW, Hop WC, van den Tol MP, et al. A Comparison of Suture Repair With Mesh Repair for Incisional Hernia

N Engl J Med. 2000;343:392-398.

In this multicenter trial, 200 patients were prospectively randomized to undergo either suture repair or mesh repair of a primary or first recurrent hernia less than 6 cm in length or width through a vertical midline incision of the abdominal wall. The 3-year cumulative rates of recurrence among patients who had suture repair and among those who had mesh repair were 43% and 24%, respectively, for primary hernia, and 58% and 20% for repair of a first recurrence. Size did not affect the rate of recurrence. Thus, mesh repair seemed to be a superior technique.

Shapiro AM, Lakey JR, Ryan EA, et al. Islet Transplantation in Seven Patients With Type 1 Diabetes Mellitus Using a Glucocorticoid-Free Immunosuppressive Regimen

N Engl J Med. 2000;343: 230–238.

Seven consecutive patients with type I diabetes and a history of severe hypoglycemia and metabolic instability underwent islet transplantation (mean mass of 11 547 islet equivalents per kilogram of body weight) by way of a percutaneous transhepatic portal embolization. Mean follow-up was approximately 1 year and to date all patients have maintained insulin independence with excellent metabolic control when glucocorticoid-free immunosuppression is combined with the infusion of an adequate islet mass.

De Meester SR, De Meester TR. Columnar Mucosa and Intestinal Metaplasia of the Esophagus

Ann Surg. 2000;231: 303-321.

To clarify current concepts regarding etiology, diagnosis, and treatment of intestinal metaplasia of the esophagus and gastric cardia, this review encompasses the literature published between 1950 and 1999. Cardiac mucosa is the precursor of intestinal metaplasia of the esophagus and both develop as a consequence of gastroesophageal reflux. Even a short length of intestinal metaplasia is premalignant; the presence of dysplasia indicates progression on the path to adenocarcinoma. Antireflux operations may halt progression. The presence of high-grade dysplasia is frequently associated with an unrecognized focus of adenocarcinoma. Esophagectomy removes the diseased esophagus and can be curative if only the mucosa is involved. Invasion beyond the mucosa with a high likelihood of lymph node metastases requires an extended operation with lymphadenectomy. Although controversy about the definition and best treatment of Barrett esophagus continues, new molecular insights, coupled with careful patient follow-up, should help to clarify our understanding of these concepts.

Ivy ME, Atweh NA, Palmer J, et al. Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Burn Patients

J Trauma. 2000;49:387-391.

Studying a small but important number of severely burned patients, it was noted that 7 of 10 developed intra-abdominal hypertension, 2 requiring decompression (both with 80% body surface area burns and abdominal compartment syndrome). It was concluded that intra-abdominal hypertension occurs commonly in patients with major burns and abdominal compartment syndrome is seen regularly in patients with burns covering more than 70% of the body surface. Bladder pressure measurement is recommended for infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm of water. Intra-abdominal hypertension usually responds to conservative therapy while abdominal compartment syndrome warrants surgical decompression.

The Acute Respiratory Distress Syndrome Network. Ventilation With Lower Tidal Volumes as Compared With Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome

N Engl J Med. 2000;342:1301-1308.

To determine whether ventilation with lower than conventional (10-15 mL/kg of body weight) tidal volumes would improve the clinical outcome in patients with acute lung injury and acute respiratory distress syndrome, a multicenter, randomized trial was undertaken to compare patients receiving an initial tidal volume of 12 mL/kg and an airway pressure (plateau pressure) of 50 cm of water or less with patients receiving an initial tidal volume of 6 mL/kg and a plateau pressure of 30 cm of water or less. Two outcomes were recorded death before discharge home and number of days without ventilator use from day 1 to day 28. Eight hundred sixty-one patients were involved before the trial was stopped because mortality was lower in the group treated with lower tidal volumes (31% vs 40%), and the number of days without ventilator support was greater (12 vs 10; P = .0007). A clear improvement in management was achieved with lowered tidal volumes.

Franklin GA, Boaz PW, Spain DA, et al. Prehospital Hypotension as a Valid Indicator of Trauma Team Activation

J Trauma. 2000;48:1034-1039.

To ensure proper use of resources, a database was created for all injured patients (burns excluded; 83% blunt injury) at a level I trauma center, which included prehospital hypotension recorded in approximately two thirds of patients. Of this group (n = 4437), 791 had documented prehospital hypotension, which persisted in the emergency department (ED) in 299 (193 were dead on arrival [DOA] or near death), 492 had normal ED systolic pressures, and 130 developed ED hypotension after normal systolic pressure in the field. Even though most of the patients with non-DOA status (492/598) were stable on arrival to the ED, nearly 50% required operative intervention and an additional 25% required intensive care admission. This dramatically speaks to the need to activate the trauma team for early involvement with these patients.

Büchler MW, Gloor B, Müller CA, et al. Acute Necrotizing Pancreatitis: Treatment Strategy According to the Status of Infection

Ann Surg. 2000;232:619-626.

To determine a rationale for observational and/or surgical treatment for patients with necrotizing pancreatitis, a prospective single-center trial was completed, involving 204 consecutive patients with acute pancreatitis. Necrotizing disease was found in 86 (42%), disease was sterile in 57 (66%), and 29 (34%) had infection, detected by fine-needle aspiration following dynamic computed tomography of the pancreatic area. All patients with necrosis received early antibiotic treatment (imipenem/cilastatin). Fine-needle aspiration exhibited a 96% sensitivity for detecting pancreatitis infection. The mortality rate with sterile necrosis managed without operation was 1.8%, whereas the rate for infected necrosis was 24% with operation. These results support the nonsurgical management of patients with sterile necrosis. For patients with infected necrosis, representing a high-risk group, surgical treatment seems preferable.

Rixen D, Siegel JH. Metabolic Correlates of Oxygen Debt Predict Posttrauma Early Acute Respiratory Distress Syndrome and the Related Cytokine Response

J Trauma. 2000;49:392-403.

Eighty patients with multiple trauma during their intensive care courses (ISS = 28, 36% deaths) were studied and categorized as having acute respiratory distress syndrome (ARDS) or not at the time of sampling for arterial base excess and lactate as correlates of oxygen debt and enzyme-linked immunoabsorbent assay–measured mixed venous cytokines (daily collection). Twenty-nine patients developed ARDS, 17 in the early period, and 12 later. Patients who subsequently developed ARDS had evidence of ischemic acidosis during or within the first 24 hours after hospitalization. In early ARDS, ischemia was followed by higher values of interleukin (IL)-6 and IL-8. These data suggest that the maximum posttrauma oxygen debt (quantified by the ischemia correlates of negative base excess and lactate) is a critical primary determinate of the fulminant autoinflammatory early ARDS response conveyed by the host's endogenous cytokine mediators. Thus, this is a possible guide to determine the adequacy of resuscitation.

Many fine articles are not included in this selection and are deserving of your attention. Those presented represent, to us, the most informative, organized, and innovative of the clinical literature of the past year.

Corresponding author: Gerald W. Peskin, MD, Associate Editor, Archives of Surgery, 1411 E 31st Street, Oakland, CA 94602 (e-mail: archivesofsurgery@worldnet.att.net).