American Surgeons Research Articles

Aaron A. Cohen-Gadol and Dennis D. Spencer. The Legacy of Harvey Cushing: Profiles of Patient Care

At the turn of the twentieth century, the American surgeon Harvey Cushing (1869-1939) chose to focus his surgical attention on the brain, an organ that had previously proved rather intractable to successful intervention. Over the course of the following decades he made this type of surgery a much safer procedure, reducing the mortality rate from a staggering 50% at the end of the nineteenth century to about 10%. Working first at Johns Hopkins and later at the Peter Bent Brigham hospital in Boston, Cushing established a world-famous school of neurosurgery by training numerous residents and fellows. He also left an extraordinary collection of records and specimens that document his work in surgery: the Cushing Brain Tumor Registry.

John Warren (1753–1815): American surgeon, patriot and Harvard Medical School founder

Dr John Warren was educated in the medical apprenticeship tradition of mid-18th century Boston, Massachusetts. As a surgeon in the American Continental Army he honed not only his surgical but also his teaching skills by providing continuing medical education to his colleagues in Boston's military hospital. Warren became a driving force in post-war Boston medicine. His organizational talents, zeal for science and vision for Massachusetts medicine led to the creation of Harvard Medical School.

Article Commentary: Rib Fracture Fixation: Controversies and Technical Challenges

Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and mortality. The social and economic costs that rib fractures contribute to the health care burden of the United States are therefore significant. But despite this measurable impact on patients' quality of life, current treatment of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports from American centers support an increased application of operative fixation. With this resurgent interest of American surgeons in mind, we review the clinical presentations, potential indications, controversies, and technical challenges unique to rib fracture fixation.

The First Closure of the Persistent Ductus Arteriosus

Congenital heart disease began to be a treatable condition when, in 1938, Robert Edward Gross first successfully ligated a persistent ductus arteriosus. This overview traces the historical development from Munro's first idea of how to close a patent ductus, presented in 1907, to the clinical ligation or division of the ductus. Surgical treatment of the infected ductus began with an unsuccessful attempt by Strieder, but it was not until Tubbs' and Touroff's successful operations that it was actually accomplished.

Ramon Guiteras: Founder of the American Urological Association, Surgeon, Sportsman and Statesman

We conducted an extensive search to learn more about Ramon Guiteras, the founder of the American Urological Association. Scientific publications, newspaper articles, and historical documents and texts were reviewed. Institutions and organizations of which Ramon Guiteras was a member were contacted. Guiteras' career peaked at the turn of the century, just as genitourinary surgery was emerging as an independent field. The American Urological Association began as an organization of the members of Guiteras' clinic with the dream of becoming an inclusive organization for the benefit of all ethical physicians with an interest in the urinary sciences. Guiteras contributed to advances in urological treatments, including improving and helping to bring a method of suprapubic prostatectomy to worldwide attention. He authored numerous scientific articles and a comprehensive, fully illustrated, 2-volume textbook that was widely translated. He pursued adventure through travel and sport, and participated in missions to Cuba and France during President Wilson's term of office. Ramon Guiteras died at age 59 years but his legacy lives on through the American Urological Association, a detailed textbook, contributions to urological instruments and techniques, and a vibrant elementary school in Bristol, Rhode Island that bears his name.

Burnout and Medical Errors Among American Surgeons

To evaluate the relationship between burnout and perceived major medical errors among American surgeons. Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL). Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0-33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0-54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis. Major medical errors reported by surgeons are strongly related to a surgeon's degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

Physician Wellness and Patient Safety

Imagine you are flat on your back on a stretcher, being wheeled into an operating room, and about to undergo a substantial abdominal procedure. You have a choice of 2 equally competent and experienced surgeons. One surgeon suffers from emotional exhaustion, the feeling that “I have nothing left to give,” while the other is fully engaged, and loves the practice of surgery. Which would you choose? The answer is obvious. All surgeons assume that mental distress could influence performance, but no actual data existed to support this assumption until the excellent work, appearing in this month’s Annals of Surgery, by Shanafelt et al, entitled “Burnout and Medical Errors Among American Surgeons.” The authors demonstrate convincingly that mental distress is associated with medical error. It would be difficult for a patient to know whether a surgeon was burned out or depressed, but one would hope that redundant safety net systems, now present in most hospitals, would mitigate against whatever error the burned out surgeon might make. A common example might be insulin dose checking by at least 2 nurses at the bedside, or, from a more surgical perspective, the routine use of a preoperative checklist. Such systems do work to increase patient safety, but here is where Shanafelt et al make their most important point: the practice of surgery might be less amenable to such system based approaches to safety. Indeed, twice as many surgeons having committed a recent medical error felt that the error was due to a “lapse in judgment” by the individual surgeon rather than a system failure (32% vs. 15%). In all, 70% of errors were thought due to individual factors, which, including the judgment problem, also meant burnout or stress, or a lapse in concentration. What an “error in judgment” meant specifically is not clear, but we are surgeons, and one could infer that some, or perhaps most, involved an intraoperative decision or maneuver. Other studies have supported the theory that most errors made by surgeons are technical in nature, or judgments that lead to an inappropriate operation or delayed diagnosis. This category of error seems inherently less correctable by relying on systems of care: surgeons are individuals; the individual makes the decisions and performs the surgery. While not denying that system-based approaches to safety in surgery are important—they certainly are—the work by Shanafelt et al suggest that another very important, and largely overlooked strategy to improve safety in surgery should be directed toward the mental health of the surgeon. It could be argued that making a medical error leads to burnout and depression, rather than the other way around. If this were true a stress reduction strategy aimed at reducing medical error would seem less logical. The study in question is cross sectional in design, and thus sheds no light on this stress–error, chicken, or egg problem. However, it may not matter, because other recent work suggests that the relationship is in fact bi-directional. Sen et al followed 740 interns longitudinally throughout their internship, and saw that higher levels of mental distress (depression) seemed to predispose to error, and that committing an error predisposed to subsequent depression (Sen et al, unpublished data). What seems clear is that a broad strategy to reduce errors could logically be based on attention to both the individual and to the system in which the individual functions. On an individual level one might assume that physical fatigue would be associated with mental fatigue and error, but the Shanafelt data do not support this association. After controlling for different levels of distress using multivariable analysis, no association was found between medical errors and hours worked per week, or number of nights on call per week. So the clue here might be that a work restriction approach might not be the most productive error reduction strategy, because it is actually mental, not physical fatigue that underlies the problem. To be fair, there is another body of work that would disagree. Nevertheless, I think most surgeons are willing to be tired, within reason, if they love what they do. This means that an important direction for the safety-in-surgery effort must involve some level of individual introspection, often done at a midcareer time point, about how we surgeons feel about being surgeons; do we love it or not? My experience, based on a previous survey of several hundred Midwestern surgeons, was that the underpinnings of burnout were an imbalance between work, family, and personal growth and loss of the sense of “meaning” one once had in the practice of surgery. If we have lost either, we need to understand why. Perhaps

Patterns of Antibiotic Prophylaxis Use for Thyroidectomy and Parathyroidectomy: Results of an International Survey of Endocrine Surgeons

Although cervical endocrine operations are classified as clean cases, and prophylactic antibiotics (pABX) are generally not indicated, practice patterns vary. We distributed an Internet-based survey to all members of the American and International Associations for Endocrine Surgeons. As a second component of our study, University of California San Francisco hospital records were queried for all readmissions or reoperations within 30 days after thyroidectomy, parathyroidectomy, or neck dissections between January 1, 1999 and December 30, 2007. Of the 275 endocrine surgeons who responded, 62% "almost never" used pABX and 26.2% administered pABX "almost always." Surgeons' annual caseload (p = 0.21), their experience with past patients who had minor (p = 0.33) or severe (p = 0.83) surgical site infections (SSI) or adverse reactions to antibiotics (p = 0.78) were not associated with their likelihood to prescribe pABX. In the previous 3 years, most surgeons reported treating patients with minor SSIs, and 30% of surgeons treated more than 1 severe SSI. Surgeons who worked in community hospitals were more likely to give pABX than were surgeons in affiliated or university hospitals (49.6% vs 31.8% and 24.5%, respectively (p = 0.04). Unlike European (8.8%) or American surgeons (27.9%), surgeons in Asia were most likely to give pABX "almost always" (58.3%, p = 0.0001). Two-thirds of surgeons would not want antibiotics if they, themselves, needed a cervical operation. Five of the 4,541 patients (0.11%) who underwent cervical operations were readmitted for infectious complications. Infectious complications after endocrine cervical operations are rare and the use of preoperative antibiotics varies widely. Prescribing behavior appears dogmatic in that 90% of surgeons give preoperative antibiotics almost always or almost never.

Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews

For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Explore

Various words derived from the Latin explorare entered the English language from the 15th century onwards, but it was not until the 19th century that explore was used in a medical context. Then, whether the explorer visited unknown regions of the globe or travelled to the interior of the living body, exploration summoned up the heroic virtues of individualism, self-reliance, courage, and muscular strength built on Christian faith.The seeds for this surgical heroism had been sown during the Renaissance when a massive expansion of the exploration of the earth and the body took place. Anatomists, likening the corpse to the earth, compared their task to geographical exploration although they did not use the word. “There are yet, alas!”, wrote the 17th-century natural philosopher Walter Charleton, “Terrae incognitae in the lesser world, as well as the greater, the Island of the Brain, the Isthmus of the Spleen, the streights of the Renes [kidneys]”.At the beginning of the 19th century, modern physical diagnosis—using percussion and auscultation—based on post-mortem analysis was created. Later, this development, along with the use of anaesthesia and asepsis, allowed surgeons to enter the body's cavities. As they did so surgeons recast their earlier identity as butchers—crude, coarse, and beefy—into that of a new professional—both He Man and Gentleman. The surgeon borrowed the identity of a new Victorian hero—the explorer, the pioneer; men who, said Robert Baden-Powell, founder of Scouting, were, “well-muscled males…taming nature in…remote places”. As the American surgeon Frederick Dennis observed: “[There is] no science that calls for greater fearlessness, courage, and nerve than that of surgery”. Just as Captain Randolph Marcy entered the “wholly unexplored and unknown” Red River region of the USA in 1849, so one of the first ovariotomists, Lawson Tait could say that “For my own part, so fearless am I now of abdominal surgery…that in every case…an exploration of the cavity should be made”. Physicians took up the refrain. George Miller Beard, who coined the term neurasthenia, regarded the disease as “the Central Africa of medicine—an unexplored territory into which few men enter.” Something of the heroic explorer still clings to the surgeon, but as with the modern geographical traveller somewhere in that identity the metaphor of teamwork comes into play. Various words derived from the Latin explorare entered the English language from the 15th century onwards, but it was not until the 19th century that explore was used in a medical context. Then, whether the explorer visited unknown regions of the globe or travelled to the interior of the living body, exploration summoned up the heroic virtues of individualism, self-reliance, courage, and muscular strength built on Christian faith. The seeds for this surgical heroism had been sown during the Renaissance when a massive expansion of the exploration of the earth and the body took place. Anatomists, likening the corpse to the earth, compared their task to geographical exploration although they did not use the word. “There are yet, alas!”, wrote the 17th-century natural philosopher Walter Charleton, “Terrae incognitae in the lesser world, as well as the greater, the Island of the Brain, the Isthmus of the Spleen, the streights of the Renes [kidneys]”. At the beginning of the 19th century, modern physical diagnosis—using percussion and auscultation—based on post-mortem analysis was created. Later, this development, along with the use of anaesthesia and asepsis, allowed surgeons to enter the body's cavities. As they did so surgeons recast their earlier identity as butchers—crude, coarse, and beefy—into that of a new professional—both He Man and Gentleman. The surgeon borrowed the identity of a new Victorian hero—the explorer, the pioneer; men who, said Robert Baden-Powell, founder of Scouting, were, “well-muscled males…taming nature in…remote places”. As the American surgeon Frederick Dennis observed: “[There is] no science that calls for greater fearlessness, courage, and nerve than that of surgery”. Just as Captain Randolph Marcy entered the “wholly unexplored and unknown” Red River region of the USA in 1849, so one of the first ovariotomists, Lawson Tait could say that “For my own part, so fearless am I now of abdominal surgery…that in every case…an exploration of the cavity should be made”. Physicians took up the refrain. George Miller Beard, who coined the term neurasthenia, regarded the disease as “the Central Africa of medicine—an unexplored territory into which few men enter.” Something of the heroic explorer still clings to the surgeon, but as with the modern geographical traveller somewhere in that identity the metaphor of teamwork comes into play.

Historical Evolution of Thyroid Surgery: From the Ancient Times to the Dawn of the 21st Century

Thyroid diseases (mainly goiter) have been recognized for more than 3500 years. Knowledge of the nature of these diseases was, of course, limited at that time. Thyroid surgery was conceived by the ancients, but it was limited to rare attempts to remove part of an enlarged thyroid gland in cases of impending death by suffocation or, in very rare cases, of a suppurating thyroid. Like other fields of surgery, thyroid surgery was limited by many problems: the lack of anesthesia and antisepsis, the need for appropriate instruments, mainly artery forceps (many deaths after thyroid surgery were due to severe postoperative hemorrhage or infection). Much of the progress in thyroid surgery occurred in Europe during the second half of the 19th century. During the first half of the 20th century, the evolution of thyroid surgery accelerated significantly, based on the contributions of pioneering European and American surgeons. The present status of thyroid surgery was established during the last quarter of the 20th century, when modern imaging methods and technological advances (including progress in applied molecular biology) brought thyroid surgery into the new millennium.

Meta‐analysis of Survival of Patients with Stage 4 Colorectal Cancer Managed with Resection versus Chemotherapy Alone: Letter to the Editor

In their article Stillwell et al. conclude that, to avoid tumorrelated complications, asymptomatic patients presenting with metastatic colorectal cancer should undergo resection of the primary tumor [1]. While this observation may once have been correct, we believe that recent advances in medical oncology warrant re-examination of this assertion. In the last decade five new chemotherapeutic agents (irinotecan, capecitabine, oxaliplatin, bevacizumab, and cetuximab) have been approved, and a number of effective regimens have been developed, broadening the armamentarium against metastatic colorectal cancer. Clinical trials have demonstrated an increase in median survival in patients with metastatic colorectal cancer from 6–8 months with supportive care alone to more than 20 months with the use of combination chemotherapy [2]. As a result, the view of metastatic colorectal cancer has changed from an acute condition and a certain death sentence to, potentially, a chronic condition, that patients live with but do not die from [2]. Furthermore, complications from an asymptomatic primary tumor being left in situ in a patient with unresectable synchronous metastatic disease receiving newer chemotherapy agents may not be of such concern as suggested in a recent article by Poultsides et al. [3]. In their experience, they managed 233 consecutive patients with synchronous metastatic colorectal cancer and an unresected primary tumor with up-front modern chemotherapy (oxaliplatinor irinotecan-based, triple-drug chemotherapy) between 2000 and 2006. They observed that 213 (89%) patients never required any direct symptomatic management for the intact primary tumor, and the median overall survival for the entire patient cohort was 18 months from the initiation of systemic chemotherapy. The fundamental issue is that comparisons of treatment strategies in the literature have been retrospective and uncontrolled, and they are thus subject to a significant selection bias. Therefore any evaluation is akin to comparing apples and oranges, and to paraphrase a renowned North American surgeon, this makes for an unappetizing fruit salad. Compelling arguments for both approaches can be made, but in the end they are just that ... arguments and not scientific evidence. The Halstedian principles for managing breast cancer were also convincing until welldesigned controlled trials like the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 proved otherwise [4]. The meta-analysis of Stillwell et al. unfortunately raises more questions than it answers, foremost of which is whether the time has come for a randomized trial to determine the optimal treatment strategy for patients with asymptomatic metastatic colorectal cancer in the twentyfirst century. With an estimated 148,000 new cases of colorectal cancer diagnosed in the United States alone each year, and with nearly one-fourth of patients having metastatic disease at diagnosis [5], the numbers certainly suggest so.

Assessment of Emergency and Essential Surgical Providers at the District Hospital in Ghana

Background: Due to substantial geographic and resource-constraints in sub-Saharan Africa, a large amount of emergency and essential surgical care is delivered at the District Hospital level. The present study aimed to document the education and surgical training of surgical providers at the District Hospital Level in Ghana through onsite interviews performed by a combined study team of Ghanaian and American surgeons. Materials and Methods: After institutional review board and governmental approval, the study team visited 10 District hospitals in 10 different regions of Ghana in August 2009.

How Many Plastic Surgeons’ Websites Contain Information Recommended by the ASPS Advertising Code of Ethics?

Websites are rapidly replacing print media as the main medium for American plastic surgeons to advertise their practices to patients, as consumers, in the highly competitive market of plastic surgery. Plastic surgeons may believe exaggerating their advertising messages on their websites will help them compete. These practices also raise concern that their advertising messages may displace information patients, as consumers, need for clinically sound choices. Using the American Society of Plastic Surgeons (ASPS) Advertising Code of Ethics (“Code”) adopted in 2002, we reviewed websites maintained by plastic surgeons to learn whether these websites contained specific items recommended or suggested by the Code. Our preliminary work does not assess whether choosing not to post a given item makes a plastic surgeon more or less ethical in clinical practice. We tested for relationships between items listed with the Code such as specialty board certification, health plans honored or accepted, and practice limitations related to a specific area or field. Additional items queried included the city of practice, presence of a physician photo, practice specialty, and the presence of photo demonstrating a cosmetic effect. Our results show the majority of these websites contain very few of the ASPS recommended items. Moreover, we identified significant relationships between features of the websites and the items recommended for inclusion by the ASPS. We believe more studies are required to learn whether our findings have implications for ethical behavior and patient care.

Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients.

The definition of major bleeding varies between studies on surgical patients, particularly regarding the criteria for surgical wound-related bleeding. This diversity contributes to the difficulties in comparing data between trials. The Scientific and Standardization Committee (SSC), through its subcommittee on Control of Anticoagulation, of the International Society on Thrombosis and Haemostasis has previously published a recommendation for a harmonized definition of major bleeding in non-surgical studies. That definition has been adopted by the European Medicines Agency and is currently used in several non-surgical trials. A preliminary proposal for a parallel definition for surgical studies was presented at the 54(th) Annual Meeting of the SSC in Vienna, July 2008. Based on those discussions and further consultations with European and North American surgeons with experience from clinical trials a definition has been developed that should be applicable to all agents that interfere with hemostasis. The definition and the text that follows have been reviewed and approved by relevant co-chairs of the subcommittee and by the Executive Committee of the SSC. The intention is to seek approval of this definition from the regulatory authorities to enhance its incorporation into future clinical trial protocols.

Burnout and Career Satisfaction Among American Surgeons

To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout. : Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons. Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. Of the approximately 24,922 surgeons sampled, 7905 (32%) returned surveys. Responders had been in practice 18 years, worked 60 hours per week, and were on call 2 nights/wk (median values). Overall, 40% of responding surgeons were burned out, 30% screened positive for symptoms of depression, and 28% had a mental QOL score >1/2 standard deviation below the population norm. Factors independently associated with burnout included younger age, having children, area of specialization, number of nights on call per week, hours worked per week, and having compensation determined entirely based on billing. Only 36% of surgeons felt their work schedule left enough time for personal/family life and only 51% would recommend their children pursue a career as a physician/surgeon. Burnout is common among American surgeons and is the single greatest predictor of surgeons' satisfaction with career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Alexander Fleming, citrated blood and penicillin: paths not pursued and applications delayed

Ninety years ago Alexander Fleming (later to discover penicillin) jointly wrote a description of the use of indirect transfusions of citrated blood at a World War 1 (WW1) base hospital. It was the longest series yet to be published, incorporating what was then a novel procedure for treating war casualties. Returning to civilian life Fleming, a qualified surgeon and bacteriologist, chose a different career path, and not until the wars of the late 1930s were the advances in transfusion in WW1 fully incorporated into the management of trauma and haemorrhage. Like penicillin, the benefits of indirect transfusion were only slowly realised.

Cleft Surgery in Rural Bangladesh: Reflections and Experiences

The authors review their experiences during multiple cleft surgical missions to rural Bangladesh from 2006 to 2008. A significant number of patients who underwent primary palatoplasty or cheiloplasty were of adult age or size. Adult primary cleft lip and palate repair is often more challenging than repair at the standard age of fewer than 2 years. This patient population is rarely seen in the United States, but may be treated more often by American surgeons during surgical missions to the developing world. This report discusses the experiences of the authors' treatment of cleft lips and palates in rural Bangladesh. One hundred forty-six cleft-lip and cleft-palate patients were treated during 3 missions to rural Bangladesh, from 2006 to 2008. Thirty-three (23%) patients were of adult size, and aged 13 to 35 years. One hundred thirteen (77%) patients were aged 12 years or younger. Unilateral cleft lips were repaired with a Millard advancement-rotation technique. Bilateral cleft lips were repaired via the 1-stage procedure advocated by Mulliken and Salyer. Cleft palates were repaired using a 2-finger flap method. Overall, 8 of 146 patients (5.5%) had nonlife-threatening complications (infection or wound dehiscence) requiring subsequent revision surgery. The adult-sized patients had clefts of significantly increased size secondary to patient growth, as well as maxillary expansion transversely and anteriorly. Adult cleft-lip repair required significant soft-tissue dissection to close the cleft adequately, and ensure symmetry to the upper lip and alar bases. However, this procedure sometimes resulted in placement of the lip cicatrix in an anatomically disadvantageous position. In addition, with the increased transverse dimension of the adult cleft palate, tension-free 3-layer closure was difficult. Again, aggressive dissection of the soft tissue was required: the nasal and muscular layers were closed without much tension, but oral closure was often under tension, requiring the assistance of dermal biomaterials to bolster the repair. Patients in the developing world often have limited access to specialized health care, and may not realize that cleft lips and palates can be repaired. As a result, there is an increased incidence of unrepaired clefts in adult-sized individuals in this part of the globe. The American surgeon may encounter these patients during surgical missions. The surgeon should be prepared to repair adult patients with clefts that are significantly enlarged in all 3 dimensions. Closure will require significant soft-tissue dissection as well as the use of biomaterials as needed to repair wide cleft palates.

Von der „mikroskopisch kontrollierten Chirurgie” zur „3D-Histologie” – eine Erfolgsgeschichte

Die ersten Ansätze der „Mikroskopisch kontrollierten Chirurgie” entstanden aus dem histopathologischen Interesse von verschiedenen Chirurgen vor über 150 Jahren. Der entscheidende Wegbereiter der mikroskopisch kontrollierten Chirurgie von Hauttumoren war jedoch der amerikanische Chirurg Frederic Edward Mohs (1919 – 2002) in der Mitte des 20. Jahrhunderts. Mohs führte zunächst eine Fixierung des Gewebes in situ durch, gefolgt von der Exzision und der histopathologischen Aufarbeitung des Tumors. Später wurde die chemische In-situ-Fixierung durch modernere histopathologische Techniken ersetzt, sodass die „Mohs’ surgery” im Prinzip ein histopathologisches Verfahren wurde. Zahlreiche Operateure entwickelten eine Vielzahl von technischen Varianten mit verschiedenen Eigennamen. Das gemeinsame Prinzip umfasst a) die topografische Orientierung und b) Exzision des Hauttumors, c) die dreidimensionale Darstellung der Außenränder und der Basis des Exzidates in Kryostat- oder Paraffinschnitten, d) die histopathologische Beurteilung, ob Tumoranteile angeschnitten wurden, sowie ggf. e) weitere gezielte Nachoperationen, bis tumorfreie Schnittränder vorliegen. Das Konzept, die dreidimensionalen Exzisatschnittränder lückenlos sichtbar zu machen, wird heute bei zahlreichen Tumorentitäten erfolgreich angewandt. Es handelt sich nicht um eine spezielle chirurgische Technik, sondern um ein dreidimensionales histologisches Verfahren. Die Bezeichnung „3D-Histologie” ist treffender, interdisziplinär verständlich und auf andere Fachgebiete übertragbar.

Differences in Prescription of Narcotic Pain Medication After Operative Treatment of Hip and Ankle Fractures in the United States and the Netherlands

Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment. The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment. Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p < 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001). American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures.