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General Surgery

General Surgery IMPORTANT recent developments in general surgery include modification of the approach to the management of severely injured patients. Outcome data have become available for some types of laparoscopic surgery, and medical and surgical resources on the Internet are increasing. Surgery on the Internet The discipline of surgery has rapidly accelerated onto the information superhighway, the Internet. Wang et al,1 describing the Internet as "one of the greatest developments in informational exchange this century," provided an overview of the Internet for physicians, including electronic mail, mailing lists, and the World Wide Web. Richards2,3 described, particularly for the surgeon, the origins of the Internet and the uses of the World Wide Web. Several major surgical societies, including the American College of Surgeons (http://www.facs.org), the American Association for the Surgery of Trauma (http://www.aast.org), and the Eastern Association for the Surgery of Trauma (http://east.org) now have Web sites. These sites include informative articles, practice guidelines, case presentations, and real-time discussion groups. There are online bulletin boards where one can post a question about a case, instantly deliver it to practitioners worldwide, and receive responses within minutes. Numerous journals and listings of surgical residency programs and fellowships are also available online. To enable users to assess the quality of online medical information, core standards for online sources have been proposed.4 These standards include providing complete authorship information with institutional affiliation(s) and relevant credentials, documentation of all content sources, and full disclosure of financial sponsorship and interests. Damage Control Surgery A major advance in recent years has been the application of the damage control approach to complex trauma and general surgery cases.5 Damage control is a paradigm shift in the surgical management of critically injured patients from repairing all injuries at the first operation to a staged approach. It consists of 3 phases. The first phase is immediate exploratory laparotomy for the control of hemorrhage and gross contamination, with rapid, simple closure of the abdomen. The second phase is continued resuscitation in the intensive care unit for correction of acidosis, coagulopathy, and hypothermia. The final phase is definitive repair of all injuries after resuscitation has been completed. Patients with extensive abdominal injuries, including those managed by the damage control approach, are at high risk for increased intra-abdominal pressure and the abdominal compartment syndrome. This syndrome is defined as increased intra-abdominal pressure, increased airway pressures with hypoxia and hypercarbia, and renal dysfunction (oliguria or anuria).6,7 Ivatury et al6 described the profound abdominal and systemic effects of intra-abdominal hypertension. The adverse hemodynamic and respiratory alterations associated with intra-abdominal hypertension act synergistically with inadequate tissue perfusion, the cytokine cascade, and infections to produce organ dysfunction and death. The prevention and early recognition and treatment of intra-abdominal hypertension are clinically important. In a retrospective analysis, Mayberry et al7 studied the effectiveness of prophylactic absorbable mesh prosthesis closure in the prevention of abdominal compartment syndrome in severely injured patients (Figure 1). They obtained information from a trauma registry and from the medical records of 73 consecutive trauma patients treated between 1989 and 1996. Forty-seven patients had their fascia closed with mesh at the initial celiotomy (group 1), and 26 patients had their fascia closed with mesh at a subsequent operation (group 2). The indications for mesh closure in both groups included excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic abdominal wall defect, and planned reoperation. Compared with group 2, there were fewer postoperative complications in group 1, including intra-abdominal abscess/peritonitis (35% vs 4%), necrotizing fasciitis (39% vs 0%), enterocutaneous fistulas (23% vs 11%), and postoperative abdominal compartment syndrome (35% vs 0%). Mortality was similar in the 2 groups. The authors concluded that initial mesh closure is an effective technique in the prevention and treatment of abdominal compartment syndrome. A prospective, randomized controlled trial comparing prophylactic mesh closure with primary closure and postoperative monitoring for intra-abdominal hypertension is needed to determine which method is more beneficial for the management of patients with severe abdominal injuries. Laparoscopic Surgery The role of laparoscopic surgery continues to be defined as data from outcomes research become available. Through a medical record review, Wherry and colleagues8 analyzed the outcomes of laparoscopic cholecystectomies performed at 94 US military hospitals between January 1993 and May 1994. Of 10458 cholecystectomies, 9130 (87%) were performed laparoscopically. This is an increase from the 65.9% rate of cholecystectomies performed laparoscopically between July 1990 and May 1992 when the procedure was being introduced into the military health services system.9 Complete medical records were obtained for 9054 patients who underwent laparoscopic cholecystectomy. The conversion rate to an open procedure was slightly less than 10%. The 30-day postoperative morbidity rate, including bile duct, bowel, and vascular injuries, was 6.09%; the 30-day postoperative mortality rate was 0.13%. A prospective evaluation of 280 laparoscopic fundoplications for the treatment of gastroesophageal reflux performed at a single hospital was conducted by Watson et al.10 They analyzed the complication, reoperation, and open conversion rates and operating times according to both the number of procedures performed at the institution and the number performed by each of 11 surgeons. They observed that the overall risk of adverse outcomes stabilized after approximately 50 laparoscopic procedures had been performed at the institution and after 20 procedures had been performed by an individual surgeon. The authors recommended that experienced supervision be provided during the first 20 laparoscopic fundoplications performed by an individual surgeon. The Clinical Outcomes of Surgical Therapy (COST) Study Group reported the early results of the treatment of colorectal carcinoma with laparoscopic surgery11 prior to the start of a phase 3 prospective randomized study comparing laparoscopic colectomy with open colectomy for colon cancer (protocol INT-0146) sponsored by the National Cancer Institute of the National Institutes of Health.12 They performed a retrospective review of the outcomes of 372 patients with colorectal cancer treated with laparoscopic surgery between October 1991 and August 1994 as reported by 16 of 32 surgeons participating in the National Cancer Institute trial. The 30-day operative mortality was 2%; trocar site or abdominal wall recurrence was observed in 4 patients (1%); and the conversion rate to open colon resection was 15.6%. These early results are comparable with those obtained with open colectomy. The National Cancer Institute randomized controlled trial now in progress will compare the long-term outcomes of laparoscopic and open colectomy for curable colorectal cancer.12 More outcomes research is needed in general surgery. The reports described above, for example, provide useful information for practicing surgeons learning new techniques, for researchers requiring baseline data, for hospital credentialing bodies determining surgical privileges, for physicians referring their patients, and for the general public selecting surgical interventions. References 1. Wang KK, Wong Kee Song LM. The physician and the Internet. Mayo Clin Proc.1997;72:66-71.Google Scholar 2. Richards A. Surgery on the Internet, 1: the origins of the Internet. Ann R Coll Surg Engl.1997;79(suppl):75-77.Google Scholar 3. Richards A. Surgery on the Internet, 2: the World Wide Web. Ann R Coll Surg Engl.1997;79(suppl):109-110.Google Scholar 4. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA.1997;277:1244-1245.Google Scholar 5. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am.1997;77:761-777.Google Scholar 6. Ivatury RR, Diebel L, Porter JM, Simon RJ. Intraabdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am.1997;77:783-800.Google Scholar 7. Mayberry JC, Mullins RJ, Crass RA, Trunkey DD. Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure. Arch Surg.1997;132:957-961.Google Scholar 8. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg.1996;224:145-154.Google Scholar 9. Wherry DC, Rob CG, Marohn MR, Rich NM. An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the Department of Defense. Ann Surg.1994;220:626-634.Google Scholar 10. Watson DI, Baigrie RJ, Jamieson GG. A learning curve for laparoscopic fundoplication: definable, avoidable, or a waste of time? Ann Surg.1996;224:198-203.Google Scholar 11. Fleshman JW, Nelson H, Peters WR.Clinical Outcomes Surgical Therapy (COST) Study Group, et al. Early results of laparoscopic surgery for colorectal cancer: retrospective analysis of 372 patients treated by Clinical Outcomes of Surgical Therapy (COST) Study Group. Dis Colon Rectum.1996;39(suppl):S53-S58.Google Scholar 12. National Cancer Institute. NCI high priority clinical trial—Phase III Randomized Study of Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer. Available at: http://cancernet.nci.nih.gov/cgi-bin/cancer-phy_show?file=pro10431.html. Accessed July 7, 1998. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

General Surgery

Jr, Claude H. Organ,; Porter, John Maurice
JAMA , Volume 280 (6) – Aug 12, 1998
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References (12)

Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.280.6.495
Publisher site
See Article on Publisher Site

Abstract

IMPORTANT recent developments in general surgery include modification of the approach to the management of severely injured patients. Outcome data have become available for some types of laparoscopic surgery, and medical and surgical resources on the Internet are increasing. Surgery on the Internet The discipline of surgery has rapidly accelerated onto the information superhighway, the Internet. Wang et al,1 describing the Internet as "one of the greatest developments in informational exchange this century," provided an overview of the Internet for physicians, including electronic mail, mailing lists, and the World Wide Web. Richards2,3 described, particularly for the surgeon, the origins of the Internet and the uses of the World Wide Web. Several major surgical societies, including the American College of Surgeons (http://www.facs.org), the American Association for the Surgery of Trauma (http://www.aast.org), and the Eastern Association for the Surgery of Trauma (http://east.org) now have Web sites. These sites include informative articles, practice guidelines, case presentations, and real-time discussion groups. There are online bulletin boards where one can post a question about a case, instantly deliver it to practitioners worldwide, and receive responses within minutes. Numerous journals and listings of surgical residency programs and fellowships are also available online. To enable users to assess the quality of online medical information, core standards for online sources have been proposed.4 These standards include providing complete authorship information with institutional affiliation(s) and relevant credentials, documentation of all content sources, and full disclosure of financial sponsorship and interests. Damage Control Surgery A major advance in recent years has been the application of the damage control approach to complex trauma and general surgery cases.5 Damage control is a paradigm shift in the surgical management of critically injured patients from repairing all injuries at the first operation to a staged approach. It consists of 3 phases. The first phase is immediate exploratory laparotomy for the control of hemorrhage and gross contamination, with rapid, simple closure of the abdomen. The second phase is continued resuscitation in the intensive care unit for correction of acidosis, coagulopathy, and hypothermia. The final phase is definitive repair of all injuries after resuscitation has been completed. Patients with extensive abdominal injuries, including those managed by the damage control approach, are at high risk for increased intra-abdominal pressure and the abdominal compartment syndrome. This syndrome is defined as increased intra-abdominal pressure, increased airway pressures with hypoxia and hypercarbia, and renal dysfunction (oliguria or anuria).6,7 Ivatury et al6 described the profound abdominal and systemic effects of intra-abdominal hypertension. The adverse hemodynamic and respiratory alterations associated with intra-abdominal hypertension act synergistically with inadequate tissue perfusion, the cytokine cascade, and infections to produce organ dysfunction and death. The prevention and early recognition and treatment of intra-abdominal hypertension are clinically important. In a retrospective analysis, Mayberry et al7 studied the effectiveness of prophylactic absorbable mesh prosthesis closure in the prevention of abdominal compartment syndrome in severely injured patients (Figure 1). They obtained information from a trauma registry and from the medical records of 73 consecutive trauma patients treated between 1989 and 1996. Forty-seven patients had their fascia closed with mesh at the initial celiotomy (group 1), and 26 patients had their fascia closed with mesh at a subsequent operation (group 2). The indications for mesh closure in both groups included excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic abdominal wall defect, and planned reoperation. Compared with group 2, there were fewer postoperative complications in group 1, including intra-abdominal abscess/peritonitis (35% vs 4%), necrotizing fasciitis (39% vs 0%), enterocutaneous fistulas (23% vs 11%), and postoperative abdominal compartment syndrome (35% vs 0%). Mortality was similar in the 2 groups. The authors concluded that initial mesh closure is an effective technique in the prevention and treatment of abdominal compartment syndrome. A prospective, randomized controlled trial comparing prophylactic mesh closure with primary closure and postoperative monitoring for intra-abdominal hypertension is needed to determine which method is more beneficial for the management of patients with severe abdominal injuries. Laparoscopic Surgery The role of laparoscopic surgery continues to be defined as data from outcomes research become available. Through a medical record review, Wherry and colleagues8 analyzed the outcomes of laparoscopic cholecystectomies performed at 94 US military hospitals between January 1993 and May 1994. Of 10458 cholecystectomies, 9130 (87%) were performed laparoscopically. This is an increase from the 65.9% rate of cholecystectomies performed laparoscopically between July 1990 and May 1992 when the procedure was being introduced into the military health services system.9 Complete medical records were obtained for 9054 patients who underwent laparoscopic cholecystectomy. The conversion rate to an open procedure was slightly less than 10%. The 30-day postoperative morbidity rate, including bile duct, bowel, and vascular injuries, was 6.09%; the 30-day postoperative mortality rate was 0.13%. A prospective evaluation of 280 laparoscopic fundoplications for the treatment of gastroesophageal reflux performed at a single hospital was conducted by Watson et al.10 They analyzed the complication, reoperation, and open conversion rates and operating times according to both the number of procedures performed at the institution and the number performed by each of 11 surgeons. They observed that the overall risk of adverse outcomes stabilized after approximately 50 laparoscopic procedures had been performed at the institution and after 20 procedures had been performed by an individual surgeon. The authors recommended that experienced supervision be provided during the first 20 laparoscopic fundoplications performed by an individual surgeon. The Clinical Outcomes of Surgical Therapy (COST) Study Group reported the early results of the treatment of colorectal carcinoma with laparoscopic surgery11 prior to the start of a phase 3 prospective randomized study comparing laparoscopic colectomy with open colectomy for colon cancer (protocol INT-0146) sponsored by the National Cancer Institute of the National Institutes of Health.12 They performed a retrospective review of the outcomes of 372 patients with colorectal cancer treated with laparoscopic surgery between October 1991 and August 1994 as reported by 16 of 32 surgeons participating in the National Cancer Institute trial. The 30-day operative mortality was 2%; trocar site or abdominal wall recurrence was observed in 4 patients (1%); and the conversion rate to open colon resection was 15.6%. These early results are comparable with those obtained with open colectomy. The National Cancer Institute randomized controlled trial now in progress will compare the long-term outcomes of laparoscopic and open colectomy for curable colorectal cancer.12 More outcomes research is needed in general surgery. The reports described above, for example, provide useful information for practicing surgeons learning new techniques, for researchers requiring baseline data, for hospital credentialing bodies determining surgical privileges, for physicians referring their patients, and for the general public selecting surgical interventions. References 1. Wang KK, Wong Kee Song LM. The physician and the Internet. Mayo Clin Proc.1997;72:66-71.Google Scholar 2. Richards A. Surgery on the Internet, 1: the origins of the Internet. Ann R Coll Surg Engl.1997;79(suppl):75-77.Google Scholar 3. Richards A. Surgery on the Internet, 2: the World Wide Web. Ann R Coll Surg Engl.1997;79(suppl):109-110.Google Scholar 4. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA.1997;277:1244-1245.Google Scholar 5. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am.1997;77:761-777.Google Scholar 6. Ivatury RR, Diebel L, Porter JM, Simon RJ. Intraabdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am.1997;77:783-800.Google Scholar 7. Mayberry JC, Mullins RJ, Crass RA, Trunkey DD. Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure. Arch Surg.1997;132:957-961.Google Scholar 8. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg.1996;224:145-154.Google Scholar 9. Wherry DC, Rob CG, Marohn MR, Rich NM. An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the Department of Defense. Ann Surg.1994;220:626-634.Google Scholar 10. Watson DI, Baigrie RJ, Jamieson GG. A learning curve for laparoscopic fundoplication: definable, avoidable, or a waste of time? Ann Surg.1996;224:198-203.Google Scholar 11. Fleshman JW, Nelson H, Peters WR.Clinical Outcomes Surgical Therapy (COST) Study Group, et al. Early results of laparoscopic surgery for colorectal cancer: retrospective analysis of 372 patients treated by Clinical Outcomes of Surgical Therapy (COST) Study Group. Dis Colon Rectum.1996;39(suppl):S53-S58.Google Scholar 12. National Cancer Institute. NCI high priority clinical trial—Phase III Randomized Study of Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer. Available at: http://cancernet.nci.nih.gov/cgi-bin/cancer-phy_show?file=pro10431.html. Accessed July 7, 1998.

Journal

JAMA – American Medical Association

Published: Aug 12, 1998

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