Chair Of Surgery Research Articles

The legacy of Ladislau Steiner (1920–2013): the neurosurgeon who won the heart of the world

There are not many things one can say when the tragic moment of losing a friend and a mentor comes. Professor Ladislau Steiner was, first of all, more than just a friend and a mentor. He was a man fromwhich all of us, those who knew him, had a lot to learn both professionally and in what regards life conceptions, appreciating true value, simply talking to a patient, holding a speech, and so on. As time passed, Professor Steiner became our role model; he became a symbol of virtue and commitment to medicine. Like all great neurosurgeons, although he is no longer physically amongst us, his spirit is above, watching (Image 1). Born on the 26th of August 1920 in one of Transylvania’s iconic fortress cities—the city of Fagaras (Image 2)— Professor Ladislau Steiner was part of the team that invented and promoted Gamma Knife Radiosurgery. He lived his talelike childhood not far from the famous monastery of Sambata which was erected by the martyr Constantin Brancoveanu as a symbol of Orthodox Christianity in Transylvania. His proper upbringing and education made him stand out as a bright and hard-working student ever since his admission in high school which he graduated top of his class. Soon after high school, the future doctor L. Steiner gets admitted at the King Ferdinand University, Medical School in Cluj-Napoca. At the time, the medical school was renowned for the elite group of professors which were active in all the fields of medicine. For example, the chair of anatomy was Professor Victor Papilian (1888–1956), at histology was Professor A.Miskolcy (1894–1978), at internal medicine was Professor Iuliu Hatieganu (1885–1959) (after which the university was later baptized), and last but not the least, the chair of surgery was Professor Iacob Iacobovici (1879–1959), one of the most famous surgeons in Eastern Europe at the time. Using the advantages such an exquisite academic environment had to offer, the young Ladislau Steiner manages to publish a few studies concerning conditional reflexes during experimental traumatic brain injuries and the modifications of the CSF during schizophrenia and epilepsy. His early works proved that the young medical student had a special set of skills needed for research and deep understanding of neurosurgery. His early certified neurosurgical activity arrived during the pioneering age of the Cluj-Napoca clinic of neurosurgery, at the time of which there still were countries in Europe that did not have an autonomous neurosurgical unit. His first mentor, Prof. Stefan T. Iacob (1920–1975), managed to keep young Ladislau interested in neurosurgery, while at the same time helping him get the bigger picture in international medicine. It was in Cluj where Ladislau learned that success is obtained only through commitment and hard work. Eager for knowledge, Ladislau gets admitted to a short stage of neurosurgery in the clinic of Prof. Constantin Arseni (1912–1994) in Bucharest in 1960 and soon afterwards leaves together with his wife Melita for a short period of time to Prof. Friedrich Weickmann’s clinic in Berlin Buch. Through a fortunate twist of events, Ladislau and his wife Melita manage to leave the Soviet Bloc through checkpoint D. A. Nica Department of Neurosurgery, St. Pantelimon Emergency University Hospital, Bucharest, Romania

Anesthesia Scholarship, Research, and Publication

Anesthesia Scholarship, Research, and Publication

Surgical treatment of dentoalveolar injury in the anterior region of maxilla

Traumatic injuries of teeth and alveolar bone are common in oral surgery departments. Maxillary incisors are the most frequently injured teeth. The right diagnosis is crucial for proper treatment method. Time elapsed between the accident occurrence and emergency treatment plays an important role. The aim of our research work was to present a case of a 25-year old female patient referred to Chair and Department of Oral Surgery, Medical University of Lublin who sustained dentoalveolar trauma of the maxillary anterior region including alveolar process fracture, extrusive luxation of all maxillary incisors, apical root fracture and lacerated upper lip. The surgical treatment consisted of repositioning the displaced teeth and alveolar bone fracture. The fracture was stabilized with the use of orthodontic brackets and orthodontic wire. PRP was used to promote bone healing after apicoectomy during second stage of surgical management.

Professor Ronald W. Busuttil: my opinion about the national program for diseased organ donation in China.

Prof. Busuttil (Figure 1) previously served as the Co-Chairman of the International Congress on immunosuppression and is past President for the American Society of Transplant Surgeons as well as past-President of the International Liver Transplant Society. Dr. Ronald W. Busuttil is currently Distinguished Professor and Executive Chairman of the UCLA Department of Surgery and holds the William P. Longmire, Jr. Chair in Surgery.

Current state of treatment of acute acromioclavicular joint injuries in Germany: is there a difference between specialists and non-specialists? A survey of German trauma and orthopaedic departments.

The purpose of this study was to evaluate currently preferred treatment strategies as well as the acceptance of new arthroscopic techniques among German orthopaedic surgeons. We assumed that surgeons specialized in shoulder surgery and arthroscopy would treat acute acromioclavicular joint dislocations different to non-specialized surgeons. Seven hundred and ninety-six orthopaedic and/or trauma departments were found through the German hospital directory of 2012. Corresponding websites were searched for the email address of the chair of shoulder surgery (if applicable) or the department. Seven hundred forty-six emails with the request for study participation including a link to an online survey of 36 questions were sent. In 60 emails, the recipient was unknown. Two hundred and three (30 %) surgeons participated in the survey. one hundred and one were members of the AGA (German-speaking Society for Arthroscopy and Joint-Surgery) and/or of the DVSE (German Association of Shoulder and Elbow Surgery) and regarded as specialists, while 102 were non-members and regarded as non-specialists. According to the treatment of Rockwood I/II and IV-VI injuries, no significant differences were found. Seventy-four % of non-specialists and 67 % of specialists preferred surgical treatment for Rockwood III injuries (P = 0.046). Non-specialists would use the hook plate in 56 % followed by the TightRope in 16 %; specialists would use the TightRope in 38 % followed by the hook plate in 32 % (P = 0.004). The majority of German orthopaedic and trauma surgeons advise surgical treatment for Rockwood III injuries. Specialists recommend surgery less often. Non-specialists prefer the hook plate, whereas specialists prefer the arthroscopic TightRope technique. Observational survey, Level IV.

Editorial introductions

Current Opinion in Otolaryngology & Head and Neck Surgery was launched in 1993. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of otolaryngology and head and neck surgery are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jacqui E. AllenJacqui E. AllenJacqui E. Allen, MBChB, FRACS is a Consultant Otolaryngologist in the Department of Otolaryngology – Head and Neck Surgery at North Shore Hospital, Auckland, New Zealand and an Honorary Senior Lecturer in the Department of Surgery at the University of Auckland, New Zealand. Dr Allen's practice includes voice, laryngology with complex airway management, dysphagia and head and neck cancer. She earned her medical degree from the University of Auckland Medical School and completed ORL residency in New Zealand, followed by a fellowship at the University of California, Davis, USA, in the Voice and Swallowing Centre. She is a member of the New Zealand Society of Otolaryngologists Head and Neck Surgeons, the RACS Academy of Surgical Educators and a Fellow of the Royal Australasian College of Surgeons. Dr Allen's research interests include airway stenosis, cough and reflux, and novel dysphagia management. Her publications have appeared in journals such as Laryngoscope, Otolaryngology Head and Neck Surgery, Head and Neck and Dysphagia. Lisa BuckmillerLisa BuckmillerDr Lisa Buckmiller is a Pediatric Otolaryngologist at the Children's Hospital of San Antonio, Texas, USA. Dr Buckmiller completed her undergraduate training in molecular biology and biochemistry at the University of California, Santa Cruz, USA, and went on to do her medical training at the University of California, Irvine College of Medicine, USA, and her residency in otolaryngology at the University of California, Davis, USA in Sacramento. She then accomplished her fellowship training in pediatric otolaryngology at Arkansas Children's Hospital, USA, and continued on as faculty from 2002–2012. Dr Buckmiller directed two multidisciplinary teams, including the Cleft Lip and Palate Team as well as the Vascular Anomalies Team while on faculty at Arkansas Children's Hospital. In 2005, she was awarded the Benjamin and Milton Endowed Chair in Pediatric Facial Plastic and Reconstructive Surgery for her work to better the lives of children with facial deformities. She also is dedicated to serving overseas on medical missions several times a year and performs surgeries for both cleft lip and palate as well as hemangiomas and vascular malformations on these trips. She is board certified and is an active member of the: American Academy of Otolaryngology; International Society for the Study of Vascular Anomalies; American Cleft Palate Association; and the American Society of Pediatric Otolaryngology. Dr Buckmiller's research interests are in the areas of vascular anomalies as well as treatment of velopharyngeal insufficiency and primary rhinoplasty for cleft patients.

Chemoradiotherapy and colorectal cancer

Dr Julio Garcia-Aguilar is the Chief of Colorectal Surgery and the Stuart HQ Quan Chair in Colorectal Surgery at Memorial Sloan-Kettering Cancer Center (NY, USA). A native of Spain, Dr Garcia-Aguilar received his MD at the Universidad Complutense in Madrid and subsequently completed fellowships at Harvard Medical School (MA, USA) and the University of Minnesota (MN, USA). From 2002–2008, he was Chief of Colon and Rectal Surgery at the University of California, San Francisco (CA, USA). From 2008 to 2012, he was the Chair of the Department of Surgery at City of Hope in Los Angeles (CA, USA). An acknowledged leader in the field of surgical oncology, he lectures nationally and internationally, and has won numerous professional awards. Dr Garcia-Aguilar is an expert in minimally invasive laparoscopic and robotic techniques for performing colon and rectal surgery. He has led National Cancer Institute-sponsored clinical and translational studies aimed at improving the quality of life of patients with rectal cancer by developing less morbid therapies, performing smaller operations and identifying individuals who might benefit from nonoperative management of their disease, potentially avoiding surgery altogether through sufficient elimination of tumors using radiation therapy and chemotherapy. He has served on the editorial boards of several journals and is past President of the American Society of Colon and Rectal Surgeons Research Foundation.

Minimally invasive mitral valve surgery.

This issue of the Annals of Cardiothoracic Surgery is devoted to Minimally Invasive Mitral Valve Surgery. It is our tremendous honor to introduce our Guest Editors, Professor Friedrich Mohr and Professor Martin Misfeld, of the Leipzig Heart Center in Germany. The Leipzig Heart Center has a reputation for pioneering robotic and video-assisted mitral valve surgery and has the world’s largest series in video-assisted mitral valve surgery. Professor Mohr performed the world’s first robotic mitral valve repair with Professor Alain Carpentier in 1998. His contributions to the field have been extraordinary; the institution that he created and leads has completed around 4,300 port-access mitral procedures, with over half performed by Professor Mohr himself. Professor Mohr trained at the University of Bonn and the University of Berlin in Germany, then at the University of New South Wales in Australia before taking up residency in Bonn. But it was, in fact, in Poland where he first caught the cardiac surgery bug, while undertaking an elective in Gdansk with Professor Miroslawa Narkiewicz. There he saw one of the first cardiac operations performed in Poland, an atrial septal defect repair, and from that moment his fascination with cardiovascular surgery was born. He began working in cardiac surgery but then took some advice that was to equip him with a set of unique skills that has differentiated him from other cardiac surgeons to this day. The advice given to Professor Mohr was to work in cardiology. He therefore went to Los Angeles and did a fellowship in laser angioplasty and angioscopy. This ability to interact with both cardiac surgeons and cardiologists has defined major parts of his career, including the creation of Heart Teams in his pioneering work with TAVI and also vital collaborations in the SYNTAX, EXCEL and PARTNER Trials. During his early career in the USA, Professor Mohr often went to the Texas Heart Centre during his vacations to watch Professor Denton Cooley. The smooth control and technical dexterity of the operations he watched continue to provide a source of inspiration for him to this very day. He returned to Germany and took up an Associate Professorship in Goettingen. In 1994, he was offered a full chair in surgery in a new unit called the Leipzig Heart Center. Shortly after starting there, he was offered other more prestigious positions, which he turned down. ‘People told me that I was crazy. Why did I want to work in this unit in Eastern Germany when I could work in one of the top units in Western Germany? But I had a vision to set up a unit as great as the Texas Heart Center which is the reason that I stayed’. He has certainly achieved and possibly surpassed this vision, with many now regarding the Leipzig Heart Center to be the greatest heart surgery centre in the world. Pioneering surgeons such as Randy Chitwood, Michael Mack and Randy Wolf all came to learn from his unit before setting up their own programs. The center employs more than 1,400 staff including over 20 senior surgeons and 60 surgeons in training, performing over 6,000 operations per year. Remarkably, 1 in 6 senior surgeons in Germany are trained in Leipzig! Professor Misfeld is the Professor of Cardiac Surgery and Associate Chief of the Leipzig Heart Center. After graduating from the University of Hamburg with a Medical License Certificate, he undertook training at the Curschmann-Clinic and cardiothoracic specialist training at the Medical University of Luebeck, Germany. In recognition of his exceptional surgical performance and extensive research into the vasoactive behavior of aortic valve structures, he has been endowed with the prestigious titles of “Medical Specialist for Cardiac Surgery,” “Habilitation” and “Venia legend”. Professor Misfeld also holds the positions of Associate Professor of Cardiothoracic Surgery at the University of Sydney, Honorary Visiting Medical Officer at Royal North Shore Hospital, Sydney, and Leading Senior Cardiac Surgeon and Head of Minimally Invasive Cardiac Surgery in the Department of Cardiac and Thoracic Disease at the University of Schleswig-Holstein, Germany. Thus it is with great pleasure that we invite you to read and enjoy this very special edition of the Annals of Cardiothoracic Surgery. We hope you will also enjoy the interview with Professor Friedrich Mohr (Video 1) and the insights provided by our contributors into the operation that they have pioneered. We thank all of our eminent contributors for their tireless work and extraordinary contributions to the field of minimally-invasive mitral valve surgery. Video 1 Foreword.

The Influence of Dispositional Optimism on Decision Regret to Undergo Major Breast Reconstructive Surgery

INTRODUCTION: Optimism improves patient reported outcomes in breast cancer survivors, however, it is not known if optimism influences a patient’s regret following major reconstructive breast surgery. We examined the relationship between dispositional optimism, major complications and decision regret in patients undergoing microsurgical breast reconstruction. METHODS: A consecutive series of 290 patients with a minimum of one-year follow-up after microsurgical breast reconstruction were surveyed. The two independent variables were: 1) dispositional optimism measured by the Life Orientation Test-Revised(LOT-R) and 2) major complications. The primary outcome was the Decision Regret Scale, a validated instrument in breast reconstruction. A multivariate regression analysis determined the relationship between the independent variables, confounders and decision regret. RESULTS: Of the 181 respondents, 63% reported no regret after breast reconstruction, 26% had mild regret and 11% moderate to severe regret. On the multivariate analysis, major complications did not have a significant effect on decision regret, and the impact of dispositional optimism was not significant in Caucasian women. However, there was a significant effect in non-Caucasian women with greater optimism who had significantly lower levels of mild regret 0.72(0.50-0.95) and lower levels of moderate to severe regret 0.67 (CI 0.28-0.97). CONCLUSION: This is the first paper to identify a vulnerable subgroup of non-Caucasian patients with low dispositional optimism who may be at risk for developing regret after microsurgical breast reconstruction. Possible strategies to ameliorate regret may involve addressing cultural and language barriers, setting realistic expectations for surgical outcomes, and providing more supports during the pre-operative decision-making phase. DISCLOSURES: Dr. Zhong is supported by an American Society of Clinical Oncology, Conquer Cancer Foundation Career Development Award. Dr. Hofer is supported by the Wharton Chair in Plastic and Reconstructive Surgery at the University Health Network. Doctors Hofer, Metcalfe and Zhong are supported by grant funding from the Canadian Breast Cancer Foundation and the Canadian Institutes of Health Research. The remaining authors do not have a financial interest to declare. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

American Society of Breast Surgeons presidential address: treatment by chance.

In a prior Presidential Address I talked of how important it was to have an attitude of gratitude. I still maintain this and am grateful for all the opportunity that life and the American Society of Breast Surgeons have afforded me. Mentors. Mentors come in many forms and sometimes are lifelong and span continents. In terms of my initial surgery and research training, J.J. Marshal, PhD, Edward M. Copeland, MD, Kirby I. Bland, MD, Charles Badgwell, MD, Farhat Moazam, MBBS, Tim Flynn, MD, and Wiley ‘‘Chip’’ Souba, ScD, MD have contributed greatly to my training not only in surgery but in the laboratory in which I spent four of my years. During that training my fellow residents were a constant stimulus to know more, do more, create more, and write more. Beyond those initial years others have afforded more opportunities and advised me on organizational paths to achieving my goals including but not limited to Ted Copeland, MD and Kirby Bland, MD, Charles Balch, MD, Dr. Fabrizio Michelassi, MD, Shirley Graves, PhD, Carlos Pelligrini, MD, David P. Winchester, MD, Jack Hollenbeck, MD, Mel Silverstein, MD, Art Lerner, MD, and Vic Zannis, MD. Legislative. I have had the good fortune to be involved in writing six different laws to upgrade the care of breast patients in Arkansas and am grateful for the legislative savvy and work of Josetta Wilkins, PhD and Cherry Duckett. Surgical Colleagues. I am grateful to all the Surgery Department at University of Arkansas for Medical Sciences and my Division, Kent Westbrook, MD, Ronda HenryTillman, Cristiano Boneti, MD, Daniela Ochoa, MD, Anne Mancino, MD, Maureen McCarthy, RN OCN, and Laura Adkins, MPh, Fellows in Diseases of the Breast, and all the nurses and scrubs in the operating room as well as all the members of our multidisciplinary team. Research Colleagues. Thanks to Soheila Korourian, MD, Issam Makhoul, MD, Larry Suva, PhD, ‘‘Tears for Life,’’ Steve Harms, MD, YiHong Kaufmann, PhD and Valentina Todorova, PhD, Laura Adkins, MS and Maureen McCarthy, RN, OCN, Susan Kadlubar, PhD and ‘‘Spit for the Cure,’’ Sharp Malak, MD, MPH, Fellows including long-time research partner Isabel Rubio, MD, and contributors and partners in the ABLATE multicenter trial and ARM. More importantly thanks to the more than 25,000 pioneers (patients) who gave of themselves for our breast cancer research at the Winthrop P. Rockefeller Institute. Education. My partners in education have been my Breast Cancer Challenge Organizing Committee from Kansas, Oklahoma, Missouri, and Arkansas including our Program Chair this year, Julie Margenthaler, MD, and Committee Chairs and Members who went through a GREAT planning process this year. Thanks to Jane and all her posse for her inordinate leadership as our executive director and workforce. Family. Finally, thanks to my ultimate supporters and facilitators Sam, Spencer, Sade, and to those who have adopted me into their family. There are so many more to thank, so forgive me if I did not include your name but know I appreciate all your efforts on behalf of myself and the mission of the American Society of Breast Surgeons. The title of my address is ‘‘Treatment by Chance.’’ I have taken the title of this talk from an article my former Chair of Surgery at Arkansas Kent Westbrook, MD, who wrote more than 30 years ago about the disparity of care at a time when the debate of the safety of mastectomy versus breast conservation was still raging. In speaking with then President of the American College of Surgeons, Dr. Patti Neumann, she reiterated that what is happening today is no Society of Surgical Oncology 2013

The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey

To what extent do the management of endometriosis and the symptoms that remain after treatment affect the quality of life in women with the disease? Many women with endometriosis had impaired quality of life and continued to suffer from endometriosis-associated symptoms even though their endometriosis has been managed in tertiary care centres. The existing literature indicates that quality of life and work productivity is reduced in women with endometriosis. However, most studies have small sample sizes, are treatment related or examine newly diagnosed patients only. A cross-sectional questionnaire-based survey among 931 women with endometriosis treated in 12 tertiary care centres in 10 countries. Women diagnosed with endometriosis who had at least one contact related to endometriosis-associated symptoms during 2008 with a participating centre were enrolled into the study. The study investigated the effect of endometriosis on education, work and social wellbeing, endometriosis-associated symptoms and health-related quality of life, by using questions obtained from the World Endometriosis Research Foundation (WERF) GSWH instrument (designed and validated for the WERF Global Study on Women's Health) and the Short Form 36 version 2 (SF-36v2). Of 3216 women invited to participate in the study, 1450 (45%) provided informed consent and out of these, 931 (931/3216 = 29%) returned the questionnaires. Endometriosis had affected work in 51% of the women and affected relationships in 50% of the women at some time during their life. Dysmenorrhoea was reported by 59%, dyspareunia by 56% and chronic pelvic pain by 60% of women. Quality of life was decreased in all eight dimensions of the SF-36v2 compared with norm-based scores from a general US population (all P < 0.01). Multivariate regression analysis showed that number of co-morbidities, chronic pain and dyspareunia had an independent negative effect on both the physical and mental component of the SF-36v2. The fact that women were enrolled in tertiary care centres could lead to a possible over-representation of women with moderate-to-severe endometriosis, because the participating centres typically treat more complex and referred cases of endometriosis. The response rate was relatively low. Since there was no Institute Review Board approval to do a non-responder investigation on basic characteristics, some uncertainty remains regarding the representativeness of the investigated population. This international multicentre survey represents a large group of women with endometriosis, in all phases of the disease, which increases the generalizability of the data. Women still suffer from frequent symptoms, despite tertiary care management, in particular chronic pain and dyspareunia. As a result their quality of life is significantly decreased. A patient-centred approach with extensive collaboration across disciplines, such as pain specialists, psychologists, sexologists and social workers, may be a valuable strategy to improve the long-term care of women with endometriosis. The WERF EndoCost study is funded by the World Endometriosis Research Foundation (WERF) through grants received from Bayer Schering Pharma AG, Takeda Italia Farmaceutici SpA, Pfizer Ltd and the European Society of Human Reproduction and Embryology. The sponsors did not have a role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript. L.H. is the chief executive and T.D. was a board member of WERF at the time of funding. T.D. holds the Merck-Serono Chair in Reproductive Medicine and Surgery, and the Ferring Chair in Reproductive Medicine at the Katholieke Universiteit Leuven in Belgium and has served as consultant/research collaborator for Merck-Serono, Schering-Plough, Astellas and Arresto.

Embrace the Challenge

In this issue, Kastor discusses the challenges and responsibilities of a contemporary chair of medicine as described in interviews of 44 chairs. As a chair of surgery at the University of North Carolina at Chapel Hill for 17 years, the author of this commentary uses his own experiences to reflect on how the insights presented in Kastor's commentary can apply to department chairs in other specialties. Elements from Kastor's commentary, as well as additional observations from the author's tenure, may be sources of advice to future chairs of any department. The author concludes that, despite a changing health care environment and other significant leadership challenges, being a department chair is a rewarding job with many opportunities to pursue worthwhile objectives.

External validation of the endometriosis fertility index (EFI) staging system for predicting non-ART pregnancy after endometriosis surgery

Can the ability of the endometriosis fertility index (EFI) to predict non-assisted reproductive technology (ART) pregnancy after endometriosis surgery be confirmed by an external validation study? The significant relationship between the EFI score and the time to non-ART pregnancy observed in our study represents an external validation of this scoring system. The EFI was previously developed and tested prospectively in a single center, but up to now no external validation has been published. Our data provide validation of the EFI in an external fertility unit on a robust scientific basis, to identify couples with a good prognosis for spontaneous conception who can therefore defer ART treatment, regardless of their revised American Fertility Society (rAFS) endometriosis staging. Retrospective cohort study where the EFI was calculated based on history and detailed surgical findings, and related to pregnancy outcome in 233 women attempting non-ART conception immediately after surgery; all data used for EFI calculation and analysis of reproductive outcome had been collected prospectively as part of another study. The EFI score was calculated (score 0-10) for 233 women with all rAFS endometriosis stages (minimal-mild, n = 75; moderate-severe, n = 158) after endometriosis surgery (1 September 2006-30 September 2010) in a university hospital-based reproductive medicine unit with combined expertise in reproductive surgery and medically assisted reproduction. All participants attempted non-ART conception immediately after surgery by natural intercourse, ovulation induction with timed intercourse or intrauterine insemination (with or without ovulation induction or controlled ovarian stimulation). All analyses were performed for three different definitions of pregnancy [overall (any HCG >25 IU/l), clinical and ongoing >20 weeks]. Six groups were distinguished (EFI scores 1-3, 4, 5, 6, 7+8, 9+10), and Kaplan-Meier (K-M) estimates for cumulative pregnancy rate were calculated. Subjects were censored when they were lost to follow-up, had subsequent surgery for endometriosis, started ovarian suppression or underwent ART. As K-M estimates might overestimate the actual event rate, cumulative incidence estimates treating ART as competing event were also calculated. Cox regression analysis was used to assess the performance of EFI and constituting variables. Performance of the score (prediction, discrimination) was quantified with the following methods: mean squared error of prediction (Brier score), areas under the receiver-operating curve and global concordance index C(τ). There was a highly significant relationship between the EFI and the time to non-ART pregnancy (cumulative overall pregnancy rate, P = 0.0004), with the K-M estimate of cumulative overall pregnancy rate at 12 months after surgery equal to 45.5% [95% confidence interval (CI) 39.47-49.87]-ranging from 16.67% (95% CI 5.01-47.65) for EFI scores 0-3, to 62.55% (95% CI 55.18-69.94) for EFI scores 9-10. For each increase of 1 point in the EFI score, the relative risk of becoming pregnant increased by 31% (95% CI 16-47%; i.e. hazard ratio 1.31). The 'least function score'-which assesses the tubal/ovarian function at conclusion of surgery-was found to be the most important contributor to the total EFI score among all the other variables (age, duration of infertility, prior pregnancy, AFS endometriosis lesion and total score). The EFI score had a moderate performance in the prediction of the pregnancy rate. Indeed, the decrease in prediction error was rather small, as shown by the decrease in Brier score from 0.213 to 0.198, and low estimates for R&sup2; (13%) and C(τ) (0.629). As the EFI was validated externally in our own European population after initial testing by Adamson and Pasta (Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010;94:1609-1615) in an American population, it appears that the EFI can be used clinically to counsel infertile endometriosis patients receiving reproductive surgery in specialized centers about their post-operative conception options. This research was supported by funds obtained via the Clinical Research Fund of the University Hospitals Leuven, Belgium, via the Ferring Chair in Reproductive Medicine and Surgery, and the Serono Chair in Reproductive Medicine granted to the Leuven University Fertility Center. The authors have no conflicts of interest to declare.

Professor L.e. Hughes: a legend in academic surgery who contributed immensely to Indian surgery.

Prof. L.E. Hughes decorated the chair in surgery at the University Hospital of Wales in Welsh National School of Medicine at Cardiff, UK between 1971 and 1992 (Fig. 1). We, the privileged surgeons, who received training in surgical science and skills under his patronage are very strongly drawn to express our feeling and the indelible marks he has left in our lives. Fig. 1 Professor Leslie E. Hughes, FRCS, DS, Professor of Surgery 1971–1992 There are skills which subside with the person completing his journey in this world, but Prof. Leslie E. Hughes is immortal because the surgical skills which he imparted are growing steadily and encompassing the barriers of nationalities and social boundaries. Prof. L.E. Hughes had the singular characteristic of teaching by his shear actions that started in the OPD when he first met the patients. There was no ambiguity in his discussions about the management either with the patient or the trainees. He gave full and graded responsibility to the trainees much earlier than was the norm elsewhere that instilled a sense of responsibility and dedication to the work assigned to the trainees. He had this wonderful nack of assuaging the requirements of trainees; therefore, he involved the trainees in research which was wonderfully designed in such a way that it first assessed the aptitude of a trainee and his/her capacity to apply his/her mind for more serious research. Ward rounds were like going through a pious religious ceremony. No point was missed. The rectal examination was a norm rather than exception. He took as much time as was necessary to go not only round the patient, but around his all other attributes. This gave a tremendous insight to Prof. Hughes in understanding the patient’s requirement concerning his treatment. We do not remember any patient whose diagnosis was missed or who went unsatisfied from the ward. Prof. Hughes expressed extreme care for the well-being of the patients as well as the trainees.

Interview: Metabolic/bariatric surgery

Attended Columbia College (Valedictorian, 1954) and the College of Physicians and Surgeons of Columbia University. He studied under Drs Wangensteen and Varco at the University of Minnesota (USA). He is Professor of Surgery and Biomedical Engineering at the University of Minnesota, and was the first Owen H and Sarah Davidson Wangensteen Chair in Experimental Surgery at the University of Minnesota. Dr Buchwald served as President of the International Federation for the Surgery of Obesity (IFSO), American Society for Metabolic/Bariatric Surgery (ASMBS), Central Surgical Association, International Study Group for Implantable Insulin Delivery Devices and the Owen H Wangensteen Society. He was principal investigator of the Program on the Surgical Control of the Hyperlipidemias (POSCH), the first randomized clinical trial to demonstrate, in 1990, that cholesterol lowering via the partial ileal bypass resulted in reductions in myocardial infarctions, angina pectoris and peripheral vascular disease; arteriographic...

The Canadian general surgery resident: defining current challenges for surgical leadership

Surgery training programs in Canada and the United States have recognized the need to modify current models of training and education. The shifting demographic of surgery trainees, lifestyle issues and an increased trend toward subspecialization are the major influences. To guide these important educational initiatives, a contemporary profile of Canadian general surgery residents and their impressions of training in Canada is required. We developed and distributed a questionnaire to residents in each Canadian general surgery training program, and residents responded during dedicated teaching time. In all, 186 surveys were returned for analysis (62% response rate). The average age of Canadian general surgery residents is 30 years, 38% are women, 41% are married, 18% have dependants younger than 18 years and 41% plan to add to or start a family during residency. Most (87%) residents plan to pursue postgraduate education. On completion of training, 74% of residents plan to stay in Canada and 49% want to practice in an academic setting. Almost half (42%) of residents identify a poor balance between work and personal life during residency. Forty-seven percent of respondents have appropriate access to mentorship, whereas 37% describe suitable access to career guidance and 40% identify the availability of appropriate social supports. Just over half (54%) believe the stress level during residency is manageable. This survey provides a profile of contemporary Canadian general surgery residents. Important challenges within the residency system are identified. Program directors and chairs of surgery are encouraged to recognize these challenges and intervene where appropriate.

My Addiction: The Artificial Kidney, The Rise and Fall of Dialysis

My Addiction: The Artificial Kidney, The Rise and Fall of Dialysis

Percutaneous ultrasound-guided drainage of the biliary tree in palliative treatment of mechanical jaundice: 17 years of experience.

IntroductionAdvanced malignant tumours involving the head of the pancreas, gallbladder or extrahepatic bile ducts usually lead to the development of cholestasis. In such cases improvement of the quality of life of patients can be achieved with the decompression of jaundice. Endoscopic implantation of self-expanding or (seldom) rigid plastic stents into the biliary tree constitutes the most common technique allowing for restoration of bile duct patency. In some patients however the use of such a procedure is technically impossible. In this particular group percutaneous drainage of the biliary tree can constitute the only method of management.AimPresentation of our experience with the use of percutaneous ultrasound-guided drainage of the biliary tree in patients with mechanical jaundice resulting from malignant tumours.Material and methodsThere were 852 patients with mechanical jaundice resulting from malignant neoplasms treated in the 2nd Chair of Surgery of Jagiellonian University Medical College from January 1994 to December 2010. In 199 of them jaundice was decompressed by means of open – radical or palliative – surgical operations. In 539 patients endoscopic treatment was implemented while in 114 of them percutaneous ultrasound-guided drainage was performed.ResultsIn 5 patients percutaneous drainage was introduced to prepare them for radical surgical treatment, while in the remaining 109 it constituted the definitive way of management. The average hospitalization time for women was 6.5 days (range: 1-22 days) and proved to be twice as short as in men – 12.2 days (range: 1-38 days). The duration of percutaneous drainage prior to surgical treatment averaged 7.2 days (range: 6-10 days). Mean volume of the bile drained during the first day was 370 ml (range: 10-1300 ml), increased to 450 ml (range: 100-1150 ml) during the second day and reached 780 ml (range: 80-1600 ml) during the third day. Mean bilirubin level before the drainage was 320-23 µmol/l (range: 658-130.7 µmol/l) and decreased by half before discharge or before the operation, reaching on average 181.87 µmol/l (range: 14.5-343 µmol/l).ConclusionsComplications of the percutaneous ultrasound-guided technique were found sporadically and resulted from leakage of the bile into the peritoneum.

Die „Akiurgischen Abbildungen“ von Ernst Blasius (1802–1875)

The work ”Akiurgische Abbildungen” (surgical illustrations) by the surgeon Ernst Blasius from Halle compiles the surgical equipment of the nineteenth century in a unique guide. Not only does it illustrate the enormous number of more than 3,000 instruments, it also impresses with its accuracy. Additionally, each instrument is explained in detail by indications and function.During the 33 years in his position as the Chair of surgery at the Friedrichs University in Halle, Blasius left behind an amazing life’s work and also trained many subsequently famous doctors. He collected the surgical and ophthalmological knowledge of his time in several textbooks. Especially their aspects concerning vascular surgery are emphasized in part II of this article.Derived from the ligature of arteries, operations on blood vessels as described by Blasius were performed in almost all topographies of the human body. However, they were carried out more or less close to the body surface. Established in France and England these operations had been utilized for almost 100 years before Blasius’ time and hence originate from a period prior to narcosis. It is thus surprising that Blasius delivers no more information about the development of vascular surgery after the introduction of narcosis.

Valete et Bona Fortuna

Editor Address for reprints: Basil A. Pruitt, Jr., MD, FACS, FCCM, Clinical Professor, Dr. Ferdinand P. Herff Chair in Surgery, The University of Texas Health Science Center at San Antonio, 7330 Floyd Curl Drive, San Antonio, Texas 78229-3900; email: [email protected].