The Best of the Best—1998

Abstract

I n an attempt to highlight those articles published in 1998 that contributed most to the better understanding of the practice of clinical surgery, we solicited opinions from a range of surgeons familiar with the literature of their area of expertise. From their thoughtful suggestions, we have distilled this list of “The Best of the Best—1998.” Overall, the articles that have advanced our clinical expertise have been predominantly in the area of critical care. Our hope is that this list will be helpful to you in staying abreast of significant practice-related innovations. Gould SA, Moore EE, Hoyt DB, et al. The First Randomized Trial of Human Polymerized Hemoglobin as a Blood Substitute in Acute Trauma and Emergent Surgery. J Am Coll Surg. 1998;187:113-122. In a randomized trial of 44 trauma patients (ages 19-75 years, with a mean Injury Severity Score of 21), human polymerized hemoglobin, a universally compatible, disease-free, oxygen-carrying resuscitative fluid, was administered to 21 patients and red cell transfusion was used as the treatment for 23 patients. There were no serious or unexpected adverse events related to the polymerized hemoglobin (given in doses up to 6 U). Although 40% of the total circulating hemoglobin was in the plasma of the polymerized hemoglobin infusion group, the total hemoglobin was not different between the groups. Thus, polymerized hemoglobin appears to be safe in replacing acute blood loss and can be a useful blood substitute. After 30 years of investigation, stroma-free polymerized hemoglobin has found its way into the clinical armamentarium. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-Performed Ultrasound for the Assessment of Truncal Injuries. Ann Surg. 1998;228: 557-567. The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid test that sequentially surveys the pericardial region for hemopericardium and then the right and left upper abdominal quadrants and pelvis for hemoperitoneum in patients with potential truncal injuries. In this report, the examination was performed in 1540 patients (1227 with blunt injury, 313 with penetrating injury) with only 16 false-negative results and 4 false-positive results, for a sensitivity of 83.3% and a specificity of 99.7%. It was most sensitive and specific for the evaluation of patients with blunt abdominal trauma. This ultrasonographic technique should be the initial diagnostic modality for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate, thus leading to immediate surgical intervention when positive in all patients with precordial wounds and in patients with blunt torso trauma who are hypotensive (blood pressure #90 mm Hg). Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK. Rectal Cancer: The Basingstoke Experience of Total Mesorectal Excision, 1978-1997. Arch Surg. 1998; 133:894-899. From a district hospital and referral center in England comes a study of 519 surgical patients with proven adenocarcinoma of the rectum treated by anterior resection (n = 465, with 407 patients having total mesorectal excision under direct vision), abdominoperineal resection (n = 37), Hartmann procedure (n = 10), local excision (n = 4), and laparotomy only (n = 3). Ten percent of the patients received preoperative radiotherapy. Follow-up revealed a cancer-specific survival of all surgically treated patients of 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% at 5 years and 8% at 10 years. In 405 “curative resections,” the local recurrence rate was 3% at 5 years and 4% at 10 years and disease-free survival was 80% at 5 years and 78% at 10 years. Thus, by the technique of mesorectal excision, 2 of 3 patients with rectal cancer can be cured by surgical therapy alone (all stages) and in those undergoing “curative resection,” 4 of 5 patients can experience longterm, disease-free survival. Although total mesorectal excision, as practiced, doubles the operating time, adds to the expense of operation, and is a challenge to surgical skill, it appears to be well worth the effort. Ivatury RR, Porter JM, Simon RJ, Islam S, John R, Stahl WM. Intra-abdominal Hypertension After LifeThreateningPenetratingAbdominalTrauma:Prophylaxis, Incidence, and Clinical Relevance to Gastric Mucosal pH and Abdominal Compartment Syndrome. J Trauma. 1998;44:1016-1023. Intra-abdominal hypertension is frequent after major abdominal trauma. To define the incidence, prophylaxis, and treatment of this phenomenon and its relevance to gut mucosal pH, multiorgan dysfunction syndrome, and the abdominal compartment syndrome, 70 patients with life-threatening penetrating abdominal trauma were monitored at a level I trauma center. Intra-abdominal pressure was estimated by measuring bladder pressure, and gut mucosal pH was evaluated by gastric tonometry every 4 to 6 hours. Intra-abdominal pressure greater than 25 cm of water was treated by bedside or operating room laparotomy. Two groups were compared: patients with loosely applied abdominal wall mesh closure and those