Changing Role Of Surgery Research Articles

PTU-124 Development of a specialist anti-reflux service

Introduction Surgical management of anatomical and functional failure of the lower oesophageal sphincter is becoming increasingly complex with advances in diagnostics, eg. high-resolution manometry (HRM), and further therapeutic options such as magnetic-bead sphincter augmentation (MSA).1With the increasing incidence in functional bowel / motility disorders which may create worse surgical outcomes, there is a need for specialisation in this field. We report on the development of a specialist anti-reflux service including the changing role of surgery and the increasing importance of physiology investigations. Method Data was retrieved from a prospective databases maintained by the clinical measurements and surgical departments to identify patients undergoing physiology investigations and surgical intervention over a 5 year period 2010–2014, since the start of the specialist service. Surgical data was cross-referenced against hospital coding data. Results Following introduction of a specialist anti-reflux clinic there has been a sustained rise in new referrals to the clinic (Figure 1)and patients treated surgically. Recent years have also seen a trend to increasing use of second generation physiology investigations such aswireless pH monitoring and HRM, as well as a rise in the total number of investigations (Figure 2). A peak in the upward trend was associated with the introduction of MSA, with subsequent divergence of MSA and fundoplication reflecting the relative popularity of these procedures (Figure 3). There was no significant change in the frequency of complex para-oesophageal hernia repair over the same period. Conclusion Introduction of a specialist anti-reflux service has led to a rise in the number of physiology investigation requested and patients treated operatively. Magnetic-bead sphincter augmentation appears to be a more acceptable alternative for patients than traditional fundoplication. Guidance and service requirements need to be developed including the identification of standards and quality indicators in the field of anti-reflux surgery to optimise patient outcomes in a field where an increased range of investigation and management expertise are required. Disclosure of interest None Declared. Reference Bonavina, et al. Ther Adv Gastroenterol. 2013;6(4):261–8

The evolving identity, capacity, and capability of the future surgeon

Technology has transformed surgery more within the last 30 years than the previous 2000 years of human history combined. These innovations have changed not only how the surgeon practices but have also altered the very essence of what it is to be a surgeon in the modern era. Beyond the industrial revolution, today׳s information revolution allows patients access to an abundance of easily accessible, unfiltered information which they can use to evaluate their surgical treatment, and truly participate in their personal care. We are entering yet another revolution specifically affecting surgeons, where the traditional surgical tools of our craft are becoming “smart.” Intelligence in surgical tools and connectivity based on sensory data, processing, and analysis are enabling and enhancing a surgeon׳s capacity and capability. Given the tempo of change, within one generation the traditional role and identity of a surgeon will be fully transformed. In this article, the impact of the information revolution, technological advances combined with smart connectivity on the changing role of surgery will be considered.

Oligometastatic NSCLC: the changing role of surgery.

There is a very limited role for pulmonary resection in the management of NSCLC that has already metastasized systemically. Well selected individuals who present with limited metastatic disease (oligometastases) to a single organ may be considered for resection or an alternative local therapy to both the lung and the extrapulmonary site in rare instances where a thorough metastatic evaluation fails to reveal other foci of disease. This evaluation must include a negative mediastinoscopy.

The changing role of surgery in the current era of head and neck oncology

As in all fields of scientific endeavor, the nature and role of surgery for treatment of neoplastic disease in the head and neck has evolved since the publication of the first textbook on head and neck surgery by Levi Cooper Lane in 1896 [1]. After the discovery that ionizing radiation could destroy malignant tissue, this modality became a preferred treatment for head and neck cancer because it avoided the massive tissue ablation, infection and other morbidities associated with extirpation of head and neck tumors in the pre-antibiotic era. The initial promise of radiation treatment proved to be disappointing, and by the mid 20th century, ablative surgery with en bloc resection of tumors including wide margins of surrounding normal tissue and the draining lymph node basin could be performed with relative safety and became the preferred standard either as initial treatment or for treatment of irradiation failure [2]. The introduction of megavoltage radiotherapy units in the 1950s and subsequent continuous advances in the fields of radiotherapy technology, radiobiology and drug design led to increased use of irradiation and systemic therapy over time [3]. This paper was written by members of the International Head and Neck Scientific Group (www.IHNSG.com).

The Changing Role of Surgery in Contemporary Head and Neck Oncology

The Changing Role of Surgery in Contemporary Head and Neck Oncology Surgery has been considered the historic mainstay of therapy for patients with advanced squamous cancer of the head and neck. This approach has been modified with the recognition that combining chemotherapy with irradiation therapy is effective in controlling cancer in some patients with advanced disease. The enthusiasm for nonoperative intervention with CRT has resulted in worldwide recognition of the fact that treatment-related toxicity associated with chemoradiation can be severe in over 40% of patients.

The changing role of surgery for sclerosing cholangitis.

Primary sclerosing cholangitis is a chronic cholestatic disease that may ultimately progress to hepatic parenchymal dysfunction and death from premature liver failure. Symptomatic patients should undergo radiological evaluation to exclude secondary causes of cholangitis and to evaluate the extent and location of biliary ductal disease. A percutaneous liver biopsy is advisable in any patient with clinical or biochemical evidence of cirrhosis. Patients with diffuse ductal involvement should initially receive medical treatment, preferably in a center conducting prospective clinical trials. Liver transplantation should be considered the initial procedure in primary sclerosing cholangitis patients with diffuse ductal involvement, complications of cirrhosis or deteriorating liver function. Nontransplant procedures should be restricted to symptomatic patients with a dominant extrahepatic stricture. In properly selected patients, effective and durable palliation of symptoms can be anticipated with biliary enteric drainage. Many currently available techniques obviate the need for longterm transanastomotic stenting, thus minimizing the risk of recurrent cholangitis and the need for repeated tube changes. These patients may also be candidates for percutaneous or endoscopic balloon cholangioplasty. Liver transplantation should also be considered in patients with a dominant stricture and histologic evidence of biliary cirrhosis or hepatic deterioration following a nontransplant procedure.

The changing role of surgery in the management of rhabdomyosarcoma: B. Conolly, A. Staines, A. O'Meara, et al. Eur J Pediatr Surg 2:90–93, (April), 1992

The changing role of surgery in the management of rhabdomyosarcoma: B. Conolly, A. Staines, A. O'Meara, et al. Eur J Pediatr Surg 2:90–93, (April), 1992

The changing role of surgery in the management of rhabdomyosarcoma.

A retrospective analysis was performed of 56 patients presenting to Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland, over a 25 year period with a diagnosis of rhabdomyosarcoma, in an effort to assess the changing role of surgery in the management of this disease. There were 38 males and 18 females; the age range at presentation was from birth to 13 years with a median of three years. Head and neck tumors occurred most frequently (23) followed by pelvic (14), paratesticular (6), extremities (6), gastrointestinal (4) and thoracic (3). Prior to 1971 there were no survivors while a doubling of survival has been observed within the past decade (31% to 63%). The minimum period of follow-up was four years. Surgical intervention ranged from total primary excision (20) to biopsy only (21) with total or subtotal resection performed electively in 15. Surgical evaluations, including examinations under anesthesia, staging laparotomy and second look laparotomy were also invaluable in assessing disease status. The incorporation of multiagent chemotherapy together with more selective use of radiotherapy has enabled a more conservative role to be adopted by the surgical oncologist thereby minimizing longterm sequelae.

The changing role of surgery in the treatment of primary liver cancer

For decades, the role of surgery in the treatment of primary liver cancer (PLC) was important but limited. However, a comparison of pathologically proven PLC during the three periods 1958-1966, 1967-1975, and 1976-1984 revealed that as a result of alpha fetoprotein (AFP) serosurvey, changing concepts in surgical oncology, and introduction of new surgical modalities, the role of surgery has become greater. The increasing proportion of subclinical PLC (0, 7.2, and 21.2%) has favored the increasing series resection rate (16.1, 34.7, and 39.6%) and palliative surgery (13.7, 17.0, and 29.8%). The results indicated that early resection, reoperation for subclinical recurrence, resection of huge PLC in stages, and combination of palliative surgery other than resection might be responsible for the increasing 5-year survival rate (1.7, 7.1, and 19.5%) in the entire series.

The changing role of surgery in the treatment of breast cancer

Approaches to the treatment of early breast cancer are undergoing changes and close scrutiny to be sure that they do not alter the chances curing the disease. Radical mastectomy has been replaced by modified mastectomy in almost all patients. In selected patients with small tumors, excision and radiation therapy is now being compared with modified mastectomy. The results of these trials will require a few more years for final evaluation. If excision and radiation therapy proves to be successful, it will provide a large scale incentive for early detection of breast cancer, particularly through self-examination. In the past, women who “did everything right” and found a small lump received a mastectomy. In the future, there may be a very real reward for the woman who finds a small tumor.

The changing role of surgery for pulmonary metastases

From 1960 to 1977, 663 resections for pulmonary metastases were performed in 448 patients, 202 with a sarcoma and 246 with a carcinoma. The majority of the patients (70%) had wedge resection or segmentectomy. Operative mortality was 1.0% (7 patients in 663 thoracotomies). With the increased effectiveness of chemotherapy in some specific areas--osteogenic sarcoma and carcinoma of the testis, breast, and colon--the role of surgery is changing. Surgery is now indicated to establish the histology of a solitary lesion, resect metastases unresponsive to chemotherapy, and to reclassify lesions that stabilize but do not disappear totally with chemotherapy.