Surgical Treatment Of Disease Research Articles

Physician Reimbursement for General Surgical Procedures in the Last Century: 1906−2006

The last century has seen revolutionary changes in health-care delivery and treatment of surgical diseases. Equally dramatic has been the changes in health-care economics, including the creation of the Medicare and Medicaid programs in 1965. To better characterize the impact to surgical billing, we have undertaken an analysis of physician fees for common general surgical procedures during the past century. Five common general surgical procedures were analyzed--inguinal herniorrhaphy, appendectomy, cholecystectomy, thyroidectomy, and repair of abdominal aortic aneurysm. Data for physician fees and reimbursement were obtained from the Illinois Medical Blue Book, the University of Iowa Department of Surgery, and the Centers for Medicare and Medicaid Services. The Consumer Price Index was used to convert all data to 2006 dollars. Trends for billed charges of common surgical procedures during the last century have decreased by an average annual rate of approximately 3.5%. Reimbursement during the past 15 years demonstrates continued decreases for repair of abdominal aortic aneurysm (4.7%), thyroidectomy (3.3%), and cholecystectomy (2.9%), and reimbursement for inguinal herniorrhaphy has been flat and for appendectomy has increased slightly (0.9%). The combined annual decrease in reimbursement for the group of 5 surgical procedures during the past 15 years is 1.4%. By comparison, the average annual change in the price of an automobile during the past century has seen a 1.25% increase. Interestingly, milk prices have had a similar trend as surgical procedures with an average annual decline of 1.5% during the last 15 years, which has been attributed to government support (creating a surplus) and increased productivity. There has been a substantial decline in payments for general surgical procedures during the past century. The influences of government regulations and increased productivity are likely to continue to apply downward pressure on surgical reimbursement.

Diagnosis and treatment of surgical diseases of the spinal cord and its membranes. By Charles A. Elsberg, M.D., F.A.C.S., Professor of Clinical Surgery at New York University Pp. 330, with 153 illustrations, 3 in colours. 1916. Philadelphia and London W. B. Saunders Co. 21s. net

Diagnosis and treatment of surgical diseases of the spinal cord and its membranes. By Charles A. Elsberg, M.D., F.A.C.S., Professor of Clinical Surgery at New York University Pp. 330, with 153 illustrations, 3 in colours. 1916. Philadelphia and London W. B. Saunders Co. 21s. net

Hand-assisted laparoscopic colectomy: rational evolution for diverticulitis.

Laparoscopic technique has proved to be a revolutionary advance in the surgical treatment of disease. However, limits exist regarding its application to colorectal resection as evidenced by the higher conversion rate and longer learning curve seen with colectomy. Conversion remains a complex issue related to multiple factors. One of the factors, inflammatory disease such as diverticulitis, exposes limitations of laparoscopic technique, specifically the absence of tactile sensation and use of one's hand as a surgical instrument. Nonetheless, the clinical benefits of smaller incisions, decreased pain, decreased ileus, and reduced hospitalization and disability make laparoscopic colectomy a compelling surgical option for the treatment of diverticulitis. Hand-assisted technique offers surgeons a practical and rational innovation for conventional laparoscopic colectomy and offers promise for improved feasibility and efficacy for the treatment of diverticulitis.

HPV16-associated tumours: therapy of surgical minimal residual disease with dendritic cell-based vaccines.

Dendritic cell (DC)-based vaccines are being intensively investigated for the treatment of a variety of human neoplasms. However, little attention has until now been paid to the use of DC-based vaccines for immunotherapy of tumour residua after surgery. In this communication, an animal model mimicking human HPV16-associated neoplasms was employed to examine the effect of DC-based vaccines for the treatment of surgical minimal residual tumour disease. Mice were subcutaneously inoculated with syngeneic TC-1 tumour cells of HPV16 origin. When the tumours reached approximately 1 cm in diameter, they were surgically removed and the operated mice were injected into the site of the operation with bone marrow-derived DC, which were either pulsed with TC-1 cell lysates or co-cultured with irradiated TC-1 cells. It has been found that the growth of TC-1 tumour recurrences in the mice treated with these vaccines was substantially suppressed, as compared to the operated-only controls. The phenotypic analysis of the spleen cells has shown that the percentage of CD3+ cells was diminished in the operated-only and vaccinated mice carrying recurrent tumours, in comparison with healthy control mice and with operated tumour-free mice. Moreover, accumulation of immature myeloid cells (CD11b+/Gr-1+) was observed in spleens of the tumour-bearing mice. These findings indicate that the immune system of the tumour-bearing individuals was compromised, as compared to that of normal individuals or tumour regressors. To our knowledge, this is the first report that has demonstrated the positive effect of local administration of the DC-based, HPV16 E6/E7 oncoprotein-containing, tumour lysate-loaded vaccines in the treatment of surgical minimal residual tumour disease.

Acceptance of Medical Hypnosis by Oral and Maxillofacial Patients

Prognosis in surgical treatment of diseases of the oral and maxillofacial region under local anesthesia is quite commonly restricted by compliance by the patient. An alternative approach, medical hypnosis, has not been used in oral and maxillofacial surgery to any significant degree. As such, hypnosis treatment also depends to a great extent on the cooperation of the patient, and it would seem advisable to collect information concerning the individual motivation for accepting such a treatment option. The questionnaire consisted of 21 questions and was handed out to patients of the department. A total of 310 questionnaires were evaluated statistically, and the result shows a high level of acceptance of medical hypnosis by patients being treated surgically in the oral and maxillofacial region. The authors conclude that the effectiveness of this treatment option should be examined in clinical studies.

The role of genetics in the surgical management of familial endocrinopathy syndromes.

Our knowledge of genetics has increased dramatically in recent decades and this has led to important changes in the medical and surgical management of hereditary endocrine diseases. Genetic screening for disease-causing mutations can identify carriers at young ages, which has enabled earlier diagnosis and surgical intervention. For example prophylactic thyroidectomy is now routine in patients with multiple endocrine neoplasia type 2 (MEN2). Appropriately timed surgical intervention will minimize disease-specific morbidity and mortality, but the diagnosis and surgical treatment of disease in presymptomatic patients is much more complex than in symptomatic patients with measurable disease. Surgeons must remain conversant with the developments in genetic technology and the established role for genetic counselors in the multidisciplinary management of hereditary endocrine syndromes. In this article we briefly review the clinically relevant information and indications for genetic testing for the most common hereditary endocrine syndromes including multiple endocrine neoplasia type 1 (MEN1), MEN2, von Hippel-Lindau syndrome (VHL), and hereditary paraganglioma syndrome. We also use several case descriptions to illustrate the impact of genetic counseling on the management of familial cancer. Finally we provide several key genetic counseling resources available for the proper identification and expeditious referral of patients at risk for these familial endocrine syndromes. MULTIPLE ENDOCRINE NEOPLASIA TYPE 1 MEN1 is an autosomal dominant disease that demonstrates nearly complete penetrance in the form of various combinations of endocrine tumors involving the parathyroid glands, pancreatic islet cells and duodenum, and pituitary gland (Table 1). Hyperparathyroidism (HPT) is the most prevalent (90% to 97%) and is usually the first manifestation, typically appearing between the ages of 20 and 25 years but sometimes as late as the fifth decade of life. Anterior pituitary gland tumors in patients with MEN1 are less common (33%) and may be nonfunctioning or may secrete hormones such as prolactin. Tumors of the pancreatic islet cells and duodenum (pancreatic endocrine tumors, PETs) occur in as many as 30% to 80% of patients. Some PETs are nonfunctioning, but many secrete one or more pancreatic hormones. With earlier diagnosis and control of hormone-associated complications such as ZollingerEllison syndrome, metastatic neuroendocrine tumors of the pancreas are now the leading cause of disease-specific mortality in patients with MEN1. Because PETs in MEN1 patients are multifocal and distributed throughout the pancreas, their proper management remains poorly defined. This issue was summarized in a recent consensus statement in which it was concluded that surgical treatment for MEN1-related PETs is controversial except for patients with hypoglycemia secondary to insulinoma syndrome in whom pancreatic resection is indicated. There is currently no consensus on the timing and extent of surgical treatment for gastrinoma and nonfunctioning PETs in patients with MEN1. Less prevalent tumors associated with MEN1 include adrenocortical tumors, lipomas, and foregut carcinoid tumors. Foregut carcinoids are found in 2% to 8% of patients with MEN1, but bronchial carcinoids are more common in women and thymic carcinoids are more common in men. The malignant potential of carcinoids, particularly thymic carcinoids, has led to recent No competing interests declared.

Interventions in pseudophakic rhegmatogenous retinal detachment

With refinement of vitrectomy techniques over the past 30 years, the treatment of rhegmatogenous retinal detachment (RRD) has transitioned from the almost exclusive use of extraocular techniques to the present time in which intraocular interventions are available and, in some practices, enjoy almost exclusive use for primary repair of RRD. Except for those situations in which a retinal detachment is associated with obvious immediate complications related to the cataract surgery, the considerations for the treatment of pseudophakic RRD are quite similar to those of phakic RRD. The current options are: use of an extraocular buckling device, vitrectomy-related procedures, intraocular gas injection with associated retinopexy, and combinations of these. Disagreement on the ideal intervention for pseudophakic retinal detachment is not uncommon and particularly so in those RRDs which lie somewhere in the spectrum between complex and simple. As is so often the case in the surgical treatment of disease, there may not be one ideal technique for a particular type of RRD; but knowledge of alternatives logically increases the likelihood of a successful result. The goal of this paper is to outline the clinical factors shown to be of importance in deciding which technique will have the greatest chance at not only achieving retinal re-attachment but also in optimizing long-term vision.

The microsurgical transoral decompression for treatment of diseases and injuries of the craniocervical junction

Besides the microsurgical ventral decompression for treatment of cervical disc prolapses, combined with an intercorporal fusion using an autologous bone graft from the iliac crest and a plate osteosynthesis, the microsurgical, transoral approach to the craniocervical junction has proven to be an effective procedure for adequate indications. Even for surgical treatment of diseases and injuries of the craniocervical junction ventral, anterolateral, lateral and dorsal approaches are applicable alone or in combination. The special anatomic and functional conditions of this region, however, obviously require that the indicational criteria for the various approaches differ from those selected for the other cervical segments. The postoperative complication risk requires that particulary critical consideration be given to the question of isolated transoral interventions. The same holds true for the question as the necessity for additional ventral stabilisation in combined dorsoventral interventions. This report is about 20 patients who underwent transoral decompression, about the indications and the procedure typical problems.

Microsurgical transoral decompression in diseases of and injuries to the cranio-cervical junction

Besides the microsurgical ventral decompression for treatment of cervical disc prolapses, combined with an intercorporal fusion using an autologous bone graft from the iliac crest and a plate osteosynthesis, the microsurgical, transoral approach to the craniocervical junction has proven to be an effective procedure for adequate indications. Even for surgical treatment of diseases and injuries of the craniocervical junction ventral, anterolateral, lateral and dorsal approaches are applicable alone or in combination. The special anatomic and functional conditions of this region, however, obviously require that the indicational criteria for the various approaches differ from those selected for the other cervical segments. The postoperative complication risk requires that particulary critical consideration be given to the question of isolated transoral interventions. The same holds true for the question as the necessity for additional ventral stabilisation in combined dorsoventral interventions. This report is about 20 patients who underwent transoral decompression, about the indications and the procedure typical problems.

Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease.

The medicolegal impact of adverse events in surgical endocrine disease has not been described previously. This study was undertaken to determine the causes, costs, and outcomes of endocrine malpractice litigation. Jury verdict reports from the U.S. civil court system from 1985 through 1991 were reviewed. Sixty-two malpractice cases were identified from 21 states. The 62 cases were classified into three categories, totaling 63 adverse events: (1) complications (n = 34, 54%) from thyroid (n = 32, 51%) or parathyroid (n = 2, 3%) surgery; (2) delayed diagnosis (n = 22, 35%) of thyroid cancer (n = 11, 18%), adrenal tumors (n = 9, 14%), and hyperparathyroidism (n = 2, 3%); and (3) medical morbidity (n = 7, 11%) from radioactive iodine (n = 5, 8%) or from propylthiouracil (n = 2, 3%). Surgical injuries, mostly recurrent nerve injuries by general surgeons, accounted for the greatest number of cases and the highest cost of litigation. Medical malpractice involving endocrine disease results in expensive litigation, a result of serious harm. Technical misadventures account for most cases, followed closely by delays in diagnosis. These data may aid design of risk prevention strategies in endocrine disease.

Summary of study groups proceedings

1) Pediatric neurosurgery is the theory and art of surgical treatment of diseases of the child’s nervous system. 2) Pediatric neurosurgery should continue the develop as a specialty of neurosurgery, and this should be facilitated by organized neurosurgery. 3) Pediatric neurosurgery should be practiced in a pediatric environment, by a pediatric neurosurgeon. 4) Given the many variations in number, density and distribution of population in different countries, the general goal should be to concentrate pediatric neurosurgery patients either in a pediatric service of a general hospital, or in a children’s hospital. Also, given the many different economic and social realities in the European countries, it is stressed that the goal is not that of devising one module to be adopted and followed by all countries, but each health delivery system should find an individual way to implement this principle with criteria that will work in its specific conditions, according to the existing situation and and its feasible developments. 5) Though a comprehensive definition of pediatric neurosurgeon cannot be reached, there is agreement that a pediatric neurosurgeon is either a neurosurgeon whose activities, including training and clinical practice, are exclusively or primarily aimed at the treatment of neurosurgical afflictions of children; or a general neurosurgeon whose interests comprise such patients, and whose education and training are considered satisfactory to perform operations in this field properly. 6) Geographic and population realities may not permit complete professional dedication to pediatric neurosurgery, since it appears that a fully dedicated pediatric neurosurgeon requires a population of 3 million people for an adequate flow of case material. Consequently, it may not be uncommon for pediatric neurosurgery to be practiced by a general neurosurgeon. In these circumstances, such general neurosurgeons must be educated in pediatric neurosurgery principles, and keep abreast of pediatric neurosurgical progress. 7) It is not necessary, and in some cases it may not even be advisable, that pediatric neurosurgeons limit their activities to the pediatric field; yet, conversely, it is considered indispensable that all children with surgical afflictions of the CNS be seen by a neurosurgeon with proper pediatric expertise. Although it is recognized that the pediatric neurologist and the pediatric surgeon may familiarize themselves with the general principles of management of these afflictions, it is true that they have neither the educational preparation nor the full commitment that proper care of these children requires. 8) It is considered necessary for the pediatric neurosurgeon to work in a pediatric environment and to have access to the full range of pediatric specialists. The attitude, the behavior, and the perspectives of the pediatric neurosurgeon should be such as to recognize and welcome the participation and management decisions of other pediatric specialists. 9) Certain disease entities — craniofacial anomalies, spina bifida, epilepsy — should be treated in designated pediatric centers with special facilities and an adequate case load to permit excellence and efficiency. 10) Other disease entities — CNS tumors, dysraphism, hydrocephalus — requiring a multi-disciplinary approach, should be managed by a team of pediatric specialists, including the pediatric neurosurgeon. 11) The proper practice of pediatric neurosurgery requires full and free access to a dedicated operating room with state-of-the-art instrumentation and equipment, specifically geared to pediatric operations. 12) Modernization is recommended; however, the frequently outstanding results of centers with limited technical facilities and excellent organization must not be overlooked. 13) Great interest and a true sense of responsibility were expressed in developing and standardizing the attitude and means of communicating with the child and the family in an emotionally secure environment. The availability of accommodations for the parents within the hospital area is considered essential. 14) No conclusive recommendations were reached regarding a curriculum for the education of a pediatric neurosurgeon: this material is left for a future Symposium. Similarly, no other criteria were provided for research, either clinical or experimental, nor for epidemiologic studies or disease classifications. However, at least for the present, the importance of national and international societies as instruments of education is recognized.

Inflammatory Bowel Disease Revisited: Surgery Today and Tomorrow

Both topical and systemic medical therapy are helpful in controlling the symptoms in patients with ulcerative colitis. However, no drug therapy is known to influence the natural history of Crohn's disease. Surgical management is often required for the complications of acute colitis unresponsive to medical treatment and for socially incapacitating diarrhoea and urgency due to ulcerative colitis. The gold standard of such surgical treatment is a panproctocolectomy with end ileostomy. In young patients with a good anal sphincter, total colectomy with the formation of an ileal pouch-to-anus anastomosis obliterates the disease and usually results in satisfactory continence. There appears to be no prospect of using gut transplantation in the management of this disease. In the absence of curative medical treatment for Crohn's disease surgical intervention is often needed to control the complications of Crohn's disease. The initial complication that makes the disease symptomatic is stenosis from the healing of asymptomatic ulcers. If strictures can be detected early, they can be treated before secondary complications such as abscess or fistula occur. Some success is being achieved with balloon dilatation of strictures. For the first presentation of ileo-caecal Crohn's disease limited resection offers good long-term cure without the need for continued medical therapy. For recurrent and multiple strictures strictureplasty offers a safe alternative to extensive resection.

Teaching surgical endoscopy of the gastrointestinal tract.

Surgical endoscopy, or the utilization of endoscopic techniques in the diagnosis and treatment of surgical disease, is an integral part of the practice of modern gastrointestinal surgery and the training of surgical residents. In addition to information crucial to preoperative evaluation and postoperative surveillance, endoscopy offers alternative therapeutic and complementary intraoperative options. Surgical endoscopy can be taught as part of an integrated residency experience, a separate endoscopy rotation, a postresidency fellowship, or an individually-arranged preceptorship. Each method of teaching has relative advantages and disadvantages. The 3 surgical endoscopy training programs with which the authors have been associated include an integrated experience, a separate endoscopy rotation followed by an integrated experience, and a preceptorship followed by an integrated experience.

Surgical Treatment of Diseases of the Nail

Nail disorders and diseases are common enough that the primary care physician should be familiar with and capable of performing surgical procedures necessary to treat them. The anatomy of the nail should be well understood. The physician should have access to specialized instruments that are necessary for proper nail surgery and should be familiar with the various techniques of anesthesia and postoperative care that will lead to the best result. Finally, the physician needs to be aware of those instances when a nail disorder is best treated conservatively or when a better result can be obtained with the proper surgical procedure.

A new surgical treatment of moyamoya disease in children: A preliminary report

A new operative method, encephalo-duro-arterio-synangiosis, for the surgical treatment of pediatric moyamoya disease has been developed. The rationale of the operation is to help promote the natural tendency of this disease to develop cerebrovascular collaterals. The method is to transplant a scalp artery with a strip of galea, leaving the distal as well as the proximal arteries intact, to a narrow linear dural opening made under an osteoplastic craniotomy. A representative case is described and the operative procedure is outlined. Our new method is compared with other surgical treatments of this disease.

Value and reason for routine rectosigmoidoscopy (author's transl)

Routine rectosigmoidoscopy was undertaken in 700 patients under surgical treatment for disease in other parts of the body. Pathological changes were found in 39 patients (5.6%): 24 with adenomatous polyps, 5 with adenopapillary polyps, 7 with infiltrating growing "carcinomatous" polyps without involvement of the muscularis mucosae, and three with carcinoma. The polyps were removed with an electric loop or haemoclip in 28, by transanal submucous excision in eight. One of the carcinoma cases was treated by resection, the other two by abdominoperineal rectal resection. The results indicate that routine rectosigmoidoscopy is of value.

Experience in the surgical treatment of diseases of the thyroid gland.

Over a 7-yr period from January 1967 to January 1974, 141 patients underwent thyroid surgery for various pathology at the Bexar County Hospital - University of Texas Medical School at San Antonio. Of these, 113 patients underwent subtotal thyroidectomy for benign diseases, including 28 of thyrotoxic patients who underwent subtotal thyroidectomy as definitive treatment. In this group of patients special interest and emphasis was placed in the preoperative and intraoperative management of the difficult and complicated hyperthyroid patient. Preoperative treatment was accomplished by the utilization of multiple drug combinations - including antithyroid drugs, adrenergic blocking agents, and iodine - which resulted in significant decrease in preparation time for surgery. Furthermore, this short intensive preoperative management of complicated hyperthyroid patients allowed satisfactory correction of their problems with little or no morbidity which otherwise would have been extremely difficult if not impossible to resolve. At operation, 28 patients were diagnosed to have malignant disease; 23 underwent total thyroidectomy and the other 5 had subtotal thyroidectomy. In addition to total or subtotal thyroidectomy, 23 patients had either classical or modified radical neck dissection including 9 patients who had bilateral neck dissection. The various surgical techniques utilized, the rationale for rapid preoperative preparation of complicated hyperthyroid patients, morbidity, and long-term follow-up are discussed.

Massive resection for ileitis: twelve-year follow-up of two patients.

Surgical treatment of disease of the ileum sometimes involves removal of adjacent segments of jejunum and colon so extensive as to jeopardize the patient's postoperative nutritional balance. In the cases here reported two patients were studied 12 years after unusually extensive intestinal resections. One weighs 158 lb. (71.7 kg.) and is working full time although he lacks parts of the sigmoid and descending colon, the right half of the transverse colon, all of the ascending colon with cecum, all of the ileum, and all but about 60 cm. of the jejunum. The other retains about 45 cm. of jejunum and lacks the ileum, ascending colon with cecum, and half of the transverse colon; he weighs 142 lb. (64.4 kg.) and works as a truck driver. Both men compensate for poor water-absorption by a large daily intake of beverages and liquid foods, but they tolerate carbohydrates, proteins, and fats equally well. Their dietary habits and nutritional status show that they have made good adjustments to their handicap.

Indications for Surgical Treatment of Diseases of the Biliary Tract

Indications for Surgical Treatment of Diseases of the Biliary Tract

Surgical Treatment of Disease of Horseshoe Kidneys

Surgical Treatment of Disease of Horseshoe Kidneys