Southwestern Surgical Congress Research Articles

The Southwestern Surgical Congress: a seal of approval

I’d like to talk today about the Southwestern Surgical Congress, a subject that is quite dear to my heart. I intend to focus on what the Southwestern Surgical Congress is doing today and what I believe are the options for the future. Surgical societies, in general, are facing issues of decreased membership and decreased meeting attendance. But there are forces on the horizon which may allow regional surgical societies to provide new value to their members.

The regional surgical society and physician advocacy

The role of regional surgical societies in American Surgery is being reexamined. Specialty societies have expanded and proliferated, reflecting the importance of advanced surgical skills and knowledge in current surgical practice. Regional surgical societies bring together surgeons from defined geographical areas, presumably reflecting common practice, political and social issues from that specific area. While regional societies have had an ongoing role in surgical education, their continued viability will depend, in part, on their ability to serve as an advocate for their physician members. To advocate means to represent one’s views in another audience. Regional surgical societies serve as advocates for their members to national surgical organizations, such as the American College of Surgeons and the American Board of Surgery. This mechanism is already in place through representations by these societies in these two organizations and communication with their leadership. However, the ability of regional societies to serve as advocates for their surgeon members and, by extension, for their patients to other audiences is less clear and certainly less structured. Given the unique characteristics of a regional society’s members, there may be great value in being an advocate to various regulatory bodies and legislative groups at both the local and national level. This is usually where decisions are made that greatly influence delivery of patient care. Another, less well defined role of regional societies is to serve as an advocate for their members to the public and the patients for whom the members care. A better understanding by these constituents of the nature of surgical practice and ongoing changes in the delivery of medical care might greatly improve physician-patient interactions with resultant improved care. The Southwestern Surgical Congress during its recent strategic planning process, identified advocacy as an important role for the organization and has made plans to expand this activity. An advocacy council has been created which includes the representative to the American College of Surgeons and several at large members. Responsibilities of this council will include ongoing solicitation of important issues and concerns of the members, improved communication via its website, electronic mail, and editorials, such as this, and identifying medical and political figures who might contribute to our annual meeting. These activities should lead to other strategies to expand and improve the role of this regional society as an advocate for its surgeon-members. Am J Surg. 2000;180:396. From the Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska. Requests for reprints should be addressed to Jon S. Thompson, MD, Professor and Vice Chair, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, Nebraska 68198-3280. Presented at the 52nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, April 9–12, 2000. SCIENTIFIC PAPER

Surgical progress and understanding in the treatment of the melanoma epidemic

Surgical progress and understanding in the treatment of the melanoma epidemic

The general, general surgeon

It is a tremendous honor for me to present the Thomas G. Orr Memorial Lecture at the Southwestern Surgical Congress this year. I am particularly grateful to President McCollum and his wife, Sally. Dr. Orr served with distinction as the chairman of the Department of Surgery at the University of Kansas and was the second president of the Southwestern Surgical Association. It occurs to me that Dr. Orr really personified all that is good about our discipline and our profession of general surgery. Dr. Orr was a consummate clinical surgeon. He exhibited the kind of compassion for his patients and their families that reflects great credit upon our discipline. He recognized his responsibility to give back to his community. And he was actively involved in training his successors and instilling within them the kind of rigorous self-criticism that is characteristic of general surgeons—the kind of continuous self-review that makes us perform better and better. In the next 45 minutes I propose to review with you: (a) who we are as general, general surgeons; (b) what our influence and opportunities are concerning the evolution of surgical instrumentation; (c) our responsibilities relative to continued quality assurance and self-review; (d) trends in our training of general surgeons and our responsibilities of maintaining a cohesive discipline of general, general surgery; and finally (e) our almost unique, and gratifying rewarding, opportunity as general surgeons to create sustaining value.

Tribute to 50 years and a look forward

Welcome to the 50th Annual Meeting and anniversary celebration of the Southwestern Surgical Congress. This is a historic meeting! Earlier this morning, highlights of the contributions of the Congress have been very eloquently presented. I think we can all agree that the scientific contributions of the Southwestern Surgical Congress during our previous 49 meetings have been significant. It seems proper and fitting as part of our 50th anniversary celebration to review some of the historical aspects of our Congress. Three previous presidents, Dr. Howard D. Cogswell in 1961, Dr. John A. Growdon in 1967, and Dr. Albert J. Kukral in 1982, presented historical aspects of the Southwestern Surgical Congress as their Presidential Address. In 1985, Dr. Claude H. Organ edited a review of the history of the Southwestern Surgical Congress from 1948 to 1985. I just received The American Journal of Surgery supplement to the March issue honoring our 50th anniversary. Our thanks to the editors, Dr. Feliciano, and Dr. Organ for a fine job. Dr. Organ has updated the history through the present. I may repeat some of his effort, but many of you may have not read it, and perhaps I can offer some additional interesting information. History is often defined in part by the individuals involved at the time. For example, in considering the history of World War II, the names Eisenhower, MacArthur, Marshall, Patton, and others come to mind. So it was with the Southwestern Surgical Congress. Much of our history involves the impact and contributions of many individuals. I intend to illustrate the history of the Southwestern Surgical Congress by noting the participation of several such individuals. Over 50 years ago, three surgeons had a particularly prominent role in the formation and organization of the Southwestern Surgical Congress. Dr. Walter G. Stuck was an orthopedic surgeon in San Antonio. He was born in 1905 and reared in Jonesboro, Arkansas. After graduating from Emory University, he completed his medical education at Washington University in St. Louis and served his internship at the University of Michigan Hospital. He served as a Fellow at the Mayo Clinic and received his Master of Science in orthopedic surgery. When he settled in San Antonio to practice, he became a leader and a talented investigator. He collaborated on pioneering work on the internal fixation of fractures and the introduction of nonactive metals, such as vitallium, into the field of orthopedics. His book, The Internal Fixation of Fractures, is considered a classic in its field. Before World War II, he had arranged for the papers from the Texas Surgical Society to be published in The Southern Surgeon, which was owned by the Southeastern Surgical Congress. During this time, he had developed many friendships with surgeons in that region. In 1947, Dr. Stuck attended the annual meeting of the Southeastern Surgical Congress in Hollywood Beach, Florida, where Dr. Frank K. Boland, Jr., of Atlanta first suggested the possibility of a sister organization in the Southwestern part of the United States. The following year, in April 1948, Dr. Stuck was a speaker at the Southeastern Surgical Congress in Miami and he visited at length with Dr. B. T. Beasley and Dr. R. L. Sanders. They emphasized the need for a regional surgical society in the southwestern part of the United States, and together they began formulating plans for a regional surgical society. Dr. Ben T. Beasley was born in 1884 in rural Georgia and was a graduate of the College of Physicians and Surgeons (Emory) in Atlanta. He practiced surgery in Atlanta with a special interest in gynecology. Dr. Beasley was a surgeon Charles H. McCollum, MD

50 Years of Vascular Surgery at the Southwestern Surgical Congress: Evolution of a New Specialty

The inaugural meeting of the Southwestern Surgical Congress in Houston, Texas, in September of 1949 barely predated the modern era of vascular surgery. The Southwestern Surgical Congress, with an avowed purpose ‘‘to stimulate and promote the progress of surgery in the states comprising the organization,” has played a prominent role in disseminating new knowledge, techniques, and technology in the field of vascular surgery. Many of the pioneers in vascular surgery resided in the territory of the Southwestern Surgical Congress and were not only members, but also contributed to its scientific publications. Another characteristic of the Southwestern Surgical Congress, that of contributions of scientific publications by both “town and gown,” has been well exemplified in the vascular arena during the first half century of its existence. We will look at the development of the field of vascular surgery through the eyes of the publications of the Southwestern Surgical Congress in 2 periods. The initial years provided us with the techniques, technology, and early experiences leading to a solid understanding of the repair of blood vessels. The second era started around the later years of the Vietnam conflict when many young, experienced, vascular surgeons returned to their communities with new skills in operating on all segments of the vascular tree. Speaking at the Midwest Vascular Society in Chicago in

50 Years of General Surgery at the Southwestern Surgical Congress

The proceedings of the Southwestern Surgical Congress (SWSC) clearly document the breadth and development of the specialty of general surgery over the last 50 years. Even excluding the areas of abdominal surgery, thoracic and cardiac surgery, vascular surgery, breast/endocrine/oncologic surgery, and trauma/burns/surgical critical care reviewed elsewhere in this supplement, the modern history of general surgery can be traced through the programs from 1949 to the present. Because of the variety of topics presented, the 6 general areas to be reviewed herein are as follows: Diagnosis, operation, response to operation, postoperative management and complications, surgical infections, and special addresses.

50 Years of Trauma, Burns, and Surgical Critical Care at the Southwestern Surgical Congress

50 Years of Trauma, Burns, and Surgical Critical Care at the Southwestern Surgical Congress

The History of the Southwestern Surgical Congress: 1949–1998 Introduction

The first thought of organizing the Southwestern Surgical Congress originated in a discussion between Drs. B.T. Beasley of Atlanta, Georgia; R. L. Sanders of Memphis, Tennessee; and Walter Stuck of San Antonio, Texas during the 1948 meeting of the Southeastern Surgical Congress in Hollywood, Florida. They emphasized that the Southwest was the only area in the United States not represented by a regional surgical organization. Drs. Beasley and Sanders encouraged Dr. Stuck to explore the feasibility of developing such an organization.

50 Years of Abdominal Surgery at the Southwestern Surgical Congress: Common Problems and Uncommon Surgeons

Abdominal surgery has maintained a prominent position in the proceedings of the Southwestern Surgical Congress (SWSC) since its inception. The focus of the Congress has been primarily on the common surgical problems of interest to clinical surgeons, but key advances in the field have also been highlighted. Some of the most well-known and respected surgeons in the various areas of abdominal surgery have presented at the annual meetings (Table I). A surgeon who deserves special recognition is Dr. Edgar J. Poth of Galveston, Texas. Dr. Poth was the 15th president and participated at >18 presentations spanning 20 meetings on a variety of topics in gastrointestinal surgery. The Edgar J. Poth Lectureship was initiated in 1975 and has been the forum for many of the updates in abdominal surgery that followed.

50 Years of Thoracic and Cardiac Surgery at the Southwestern Surgical Congress: From Tuberculosis to the Artificial Heart

50 Years of Thoracic and Cardiac Surgery at the Southwestern Surgical Congress: From Tuberculosis to the Artificial Heart

50 Years of Breast, Endocrine, and Oncologic Surgery at the Southwestern Surgical Congress: Earlier Diagnosis and Improved Outcomes

The proceedings of the Southwestern Surgical Congress (SWSC) over the last 50 years have contained .200 presentations related to the field of breast, endocrine, and oncologic surgery. Of these, I have selected 62 for review. A review of the proceedings revealed that in most areas the papers mirrored the evolution of American surgery over the last half century. The breast presentations, beginning in the early 1960s, challenged the rationale of the Halstedian approach to breast cancer and reported comparable results with less disfiguring procedures. In the field of endocrine surgery, as surgeons began embracing newer techniques in diagnosis (fine needle aspiration [FNA], abdominal computed tomography [CT], and flow cytometry), earlier diagnoses and more information on prognosis became available. The papers related to melanoma presented a persuasive argument away from wider radical resections and amputation to operations with smaller margins, with no discernible effect on survival figures. In the area of abdominal oncologic surgery, the most striking trend seemed to be an increasingly aggressive operative approach to pancreatic cancer at the same time as operative mortality rates fell from .30% to ,5%.

The Role of The Southwestern Surgical Congress in the Future

The Role of The Southwestern Surgical Congress in the Future

Why use clinical pathways rather than practice guidelines?

Financial pressures from managed care organizations, the government, and other "stakeholders" have resulted in the production of practice guidelines and clinical pathways. Clinical pathways involve all segments of a health care system and may prove to be more beneficial and less hazardous to patients and health care providers. A historical narrative describing the development of clinical pathways by the Southwestern Surgical Congress (SWSC) and the Southeastern Surgical Congress (SESC) is made. The motivations, the benefits, and the hazards of both clinical pathways and practice guidelines are discussed. Clinical pathways have proven to reduce length of stay (LOS), complications, and cost, and provide increased patient satisfaction whereas practice guidelines from some specialties show improved quality of care when compared with nonspecialists. However, many practice guidelines are developed by specialists on "best practice" standards, and few have documented studies proving their effectiveness. Eleven clinical pathways were developed by the SWSC and the SESC and are in the process of revision and study for efficacy. They will be disseminated in the American Surgeon and on the SWSC web site for review and comment. In 1998, both congresses hope to publish the efficacy of selected pathways by describing their effect on LOS and charge for those diagnostic-related groups.

General surgeons in the world of gatekeepers

Iam extremely honored to be speaking before my friends about some issues that are of critical interest to each of us, issues that we must tackle both individually and together if the role of the general surgeon in today’s society is to retain its significance. Since our meeting in Tucson last year, a great change has taken place in this country’s medical profession. Twelve months ago, doctors in the United States were carefully preparing themselves for the interface with government and the proposed health care reform. But that reform never happened. Since President Clinton’s so-called managed competition disappeared, it has been replaced with unbelievable speed by the appearance of new managed-care entities all over the country. Sometimes we are probably tempted to think that the difficulties our profession faces today are unique, the result of a government that has changed. But history tells us otherwise. The government has long been involved in our work, and only in the more recent generations has that relationship become more adversarial. Thirty-six years ago, in 1958, my father, Ken Sawyer, stood before this very organization and delivered his presidential address.’ The fact that he did that is another reason why I’m honored to be here before you all today. But more important, the core of his message was not all that different from what you will hear from me over the next few minutes. The title of his 1958 address was “Eternal Vigilance,” and it centered on the need to be organized and work together in the face of governmental changes affecting our calling as surgeons. For him, it was the threat of socialized medicine. For us, it is the threat of managed competition and managed care. Before I get into those topics and where we should consider taking ourselves in the future in light of them, however, I think it is appropriate to touch on a couple of historical footnotes about the Southwestern Surgical Congress, and its important role in organized medicine in this country. Nearly half a century ago, in 1948, three surgeons-Dr. B.T. Beasley of Atlanta, Dr. R.L. Saunders of Memphis, and Dr. Walter Stuck from here in San Antoni-attended the meeting of the Southeastern Surgical Congress in Hollywood, Florida. There, they acknowledged that the Southwest was

Colorectal cancer in patients under 30 years of age

The Southwestern Surgical Congress (SWSC) recently initiated a registry of unusual cases. The registry was created to collect information on patients with uncommon conditions treated by members of the Congress. The registry is intended to be a source of clinical information for the members, as well as a tool for the conduct of retrospective and prospective clinical and epidemiologic studies. As the first project, we collected data on patients with colorectal cancer who were 30 years of age or less at the time of diagnosis. Letters were sent to all members of the SWSC soliciting information about such patients. Data collection sheets were subsequently mailed to those who responded to the letter. The data sheets asked for demographic data, as well as pertinent anamnestic, clinical, and staging information. Operative reports, pathology reports, and paraffin-embedded tissue blocks were also requested. Twenty-four members contributed a total of 55 patients to the registry. There were 23 males (age range: 14 to 30 years) and 32 females (age range: 16 to 30 years). In 37 patients, factors assumed to predispose to colorectal cancer were identified. The most common predisposing factor was smoking. There were 12 right colon tumors, 24 left colon tumors, and 11 rectal tumors. According to the TNM classification, 6 patients had stage I disease, 15 patients had stage II disease, 17 patients had stage III disease, and 17 patients had stage IV disease. Tissue blocks from tumor and adjacent bowel will be examined to address the issue of a possible genetic predisposition for cancer at the molecular level, in these young patients. We will also assess the independent influence of age on prognosis by comparing the actuarial survival and recurrence rates in patients from the registry with data from older patients who are matched for the presence of other known prognostic factors. The Unusual Case Registry will provide the members of the Congress with a valuable database of clinical information. Furthermore, this method of compilation will facilitate the collection of relatively large patient samples over a short period of time. This will greatly facilitate the conduct of original and relevant collaborative prospective studies of uncommon diseases within the framework of the SWSC.

Thoracic outlet syndromes: Update 1987

It is a great honor to be invited to deliver the 13th Annual Edgar J. Poth Lecture to the Southwestern Surgical Congress. This lecture was originated by the Congress to honor one of its most distinguished members. Doctor Poth was born in Seguin, Texas on February 1,1899. He received his bachelor’s degree from the University of Texas, his doctorate in physical chemistry from the University of California with a dissertation in atomic physics, and his medical degree from Johns Hopkins University in 1931. He then served his internship, surgical residency, and faculty appointment at Stanford University Medical Center in San Francisco until 1939 when he was appointed chief of the department of surgery at the University of Arkansas. In 1943, Dr. Poth was named professor of surgery at the University of Texas in Galveston, and became chief of the division of general surgery there in 1962. In 1964, he was named the first Ashbell Smith Professor of Surgery of the University of Texas, and he still holds that title today, emeritus. Dr. Poth has been an active member of the Southwestern Surgical Congress, serving as chairman of the planning committee that established the Sponsored Resident Program, and was elected president of the Congress in 1963. During four decades of active research, he made numerous contributions in the fields of pathophysiology of intestinal obstruction, peptic ulcer disease, and antibiotic bowel preparation. He was principally responsible for introducing succinylsulfathiazole (Sulfasuxidine@) as the original bowel preparation for colon surgery, and he was the first to maintain a dog on extracorporeal circulation in the early 1930s. He was elected governor of the American College of

Newer antibiotics for the surgeon

It is an honor for me to have been asked by Dr. Ronald Elkins and the Program Committee to deliver the 21st Annual Thomas G. Orr Memorial Lecture. Dr. Orr was born in 1834 and was an Alpha Omega Alpha graduate of Johns Hopkins University in 1910. Among his many ,accomplishments, he was a founding member of the American Board of Surgery, president of the Western Surgical Association, the second president of the Southwestern Surgical Congress, and president of the American Surgical Association. For 25 years, he was professor and chairman of the department of surgery at the University of Kansas, where he was also professor of bacteriology. As professor of bacteriology, I am sure that Dr. Orr would be amazed today to see the number and spectrum of newer antibiotics. A survey of 1 million hospital admissions to 338 hospitals determined that 42 percent were surgical admissions; however, these patients accounted far 71 percent of nosocomial infections [I]. The annual cost of nosocomial infections exceeds 1.5 billion dollars [2]. Preoperative antibiotics are usually administered to patients undergoing elective operations after arrival in the operating room. Animal studies demonstrate that wound infections are related to the time from contamination of a wound or incision until the administration of an antibiotic. The longer the delay from contamination until antibiotic administration, the greater the inflammatory response [3]. Several factors must be considered when comparing newer antibiotics, including pharmacologic properties, cost, in vitro activity, toxicity, and clinical efficacy. The longer the half-life, the less frequent the dosing. Less frequent administration means decreased cost due to less nursing and pharmacy time required to mix and administer the antibiotic, using fewer intravenous infusions. A true

Critical decisions in the management of hepatic trauma

It is a great honor to present the 10th Annual Edgar J. Poth Lecture to the Southwestern Surgical Congress. Befitting this 10th anniversary, I would like to briefly outline Dr. Poth’s distinguished career. Born in Seguin, Texas on February 1, 1899, Dr. Poth earned his undergraduate degree at the University of Texas in Austin and his doctorate in physical chemistry at the University of California. He completed medical school at Johns Hopkins University and returned west for surgical training at Stanford University. Dr. Poth joined the University of Texas in Galveston in 1942. Over the ensuing two decades, as director of surgical research, he made important contributions to various aspects of peptic ulcer disease, intestinal obstruction, and bowel antisepsis. Indeed, his pioneering work with sulfonamides and later, neomycin is the basis for the operative colon preparation in use today. In 1964, Dr. Poth was awarded the Ashbel Smith Professorship in Surgery and has remained in that capacity since. His contributions to the Southwestern Surgical Congress are no less noteworthy. Serving in numerous capacities, perhaps his most gratifying accomplishments have been chairing the committee that established the Sponsored Residents’ Program and serving as our Society’s president in 1963. To Dr. Edgar J. Poth, I dedicate this lecture entitled, “Critical Decisions in the Management of Hepatic Trauma.” The liver is the most commonly injured organ following abdominal trauma. Although the basic principles in management (control of hemorrhage,, removal of devitalized tissue, and perihepatic drainage) have been well established [l-5], the optimal techniques to achieve them remain controversial. I will review the decision points in management of acute hepatic trauma and characterize the prevailing trends in operative treatment today.

The pathophysiology of acute renal failure

It is an honor and a pleasure to deliver the 16th Annual Thomas G. Orr Memorial Lecture to the Southwestern Surgical Congress. Unlike some of you in this audience, I never had the privilege of knowing this great man personally, since his death occurred when I was a mere 17 year old boy in high school. Rather, I have come to know this extraordinary surgical teacher, like other great teachers, from his numerous surgical contributions, papers, and books, and the stories and legends which still abound about Dr. Orr at the University of Kansas Medical Center. Dr. Orr served as the Chairman of the Department of Surgery at the University of Kansas Medical Center for 25 years, and all of us who have subsequently joined the surgical ranks in this University still live in his shadow. He did everything a great surgeon and teacher could be expected to do. In addition to his busy clinical practice, he authored in excess of 200 surgical publications, single-handedly published two surgical textbooks, and was the President of seven surgical organizations, including our Southwestern Surgical Congress, the Western Surgical Society, and the American Surgical Association [I]. Those who knew Dr. Orr best did not describe him as being an overly charismatic or flashy individual. Rather, such terms as loyal, honest, compassionate, dedicated, ingenious, and honorable were used to characterize this man. Dr. Ralph Major, a cohort of Dr. Orr’s in medical school who subsequently served as the Chairman of Medicine during Dr. Orr’s tenure at the University of Kansas, probablJ, best summed up Dr. Orr’s goals in surgery when he stated, “Physicians and surgeons have been described as belonging to one of three groups-those who look on their professions solely as a business, those who see it as an experimental science, and those who regard it as a mission” [2]. According to Dr. Major,