The changing patterns of residency training programs.
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Clinical Competence↗
Biomedical subjects
C H Organ
Publications and source records attributed to C H Organ.
Epiploic disorders. Conditions of the epiploic appendages.
Disorders of the epiploic appendages are rarely diagnosed preoperatively and usually result from torsion with subsequent infarction. No diagnostic test or clinical symptoms are pathognomonic of this process, which is a disease of middle age and rarely life-threatening, and the most common preoperative diagnosis is acute appendicitis. An analysis of case information reported in the surgical literature has been combined with our recent experience involving ten cases. Fifty-eight percent of the patients in this collected series were male, and the average age in both sexes was 42 years. The sigmoid colon was the most frequent site of these disorders (41.5%), and acute appendicitis was the most common preoperative diagnosis (37.7%). The treatment is ligation, excision, and occasionally seromuscular inversion. When encountered at exploration, this entity may represent the sole etiology of the abdominal pain if exploration is otherwise negative.
Abdomen↗
Efficacy of a simplified lower gastrointestinal flexible endoscope cleaning method.
Published guidelines from the Center for Disease Control (CDC) "strongly recommended" gas sterilization or 30 minutes of high-level disinfection with either 2 percent glutaraldehyde or 6 percent hydrogen peroxide following each flexible endoscope cleansing for proper care. The guidelines were proposed on the basis of previous CDC studies performed on glutaraldehyde disinfection of respiratory equipment. A prospective study was performed culturing flexible endoscopes following cannulation of the lower gastrointestinal tract and cleansing. A uniform endoscope cleansing method without gas sterilization or high-level disinfection was used between patients. Thirty aerobic and 30 anaerobic RODAC bacterial culturings revealed no obligate anaerobic organism growth and only sparse, aerobic, environmental and cutaneous organism growth. There were no instances of documented or suspected postendoscopy infectious complications. Our results indicate that high-level disinfection and gas sterilization of flexible endoscopes are not necessary to prevent bacterial disease transmission from patient to patient.
Bacteria, Aerobic↗
The interlocking of American surgery. An analysis of surgical leadership in the United States, 1945 through 1985.
To analyze surgical leadership in the United States from 1945 to 1985, 15 positions of influence have been identified. Appointments to these positions have been reviewed by age at appointment, medical school of graduation, site of residency training, solo appointments, and geographic distribution. A weighting scheme was designed to quantify institutional and personal performance. The 460 surgeons involved in this study graduated from 72 medical schools and 68 residency programs. The top ranking medical schools were Harvard, Johns Hopkins, University of Pennsylvania, Washington University in St. Louis, and Northwestern, which together accumulated 48 percent and 47 percent of all points and appointments, respectively. The top ranking residency training programs were Harvard, Johns Hopkins, the Mayo Clinic, Washington University in St. Louis, and the University of Pennsylvania, with Cornell, University of Michigan, Columbia, University of Minnesota, and the University of California in San Francisco occupying the second tier. Personal performances revealed that 40 percent of the top 20 surgeons were located in Southern-based institutions. Since 1965, geographic and institutional diversity has begun to appear in the surgical leadership.
Academies and Institutes↗
Is duodenal ulcer perforation best treated with vagotomy and pyloroplasty?
From 1967 to 1980, 65 patients underwent vagotomy and pyloroplasty for treatment of an acute perforated duodenal ulcer at the University of Oklahoma Health Sciences Center. Their age ranged from 15 to 82 years, with a mean age of 49.6 years. All vagotomies were truncal and pyloroplasties were of the Heineke-Mikulicz variety. The condition of each patient was classified as acute or chronic depending on the duration of symptoms before perforation. The postoperative complication rate and perioperative mortality were higher in the group of patients whose symptoms had been present less than 3 months before perforation. Patients who underwent vagotomy and pyloroplasty more than 24 hours after the onset of symptoms had a higher mortality compared with those who were operated on less than 24 hours from the onset of symptoms. We mainly attributed the perioperative death rate of 11 percent to advanced patient age and associated cardiopulmonary disease. There was no significant difference in the rate of postoperative complications in patients over 60 years of age compared with those under 40 years; hence, age alone does not preclude definitive treatment, such as vagotomy and pyloroplasty. The degree of contamination found at operation did not correlate with a poor postoperative course. There was no significant increase in the mortality in the group with gross contamination. Of the patients available for long-term follow-up, 85 percent remained free of symptoms. These results compare favorably with reports for the elective treatment of duodenal ulcer with vagotomy and pyloroplasty. We conclude that vagotomy and pyloroplasty is acceptable, safe, and ideal for patients with acute perforated duodenal ulcers, except when significant cardiopulmonary disease exists or when the duration of perforation is more than 24 hours.
Acute Disease↗
General surgery and the Humpty Dumpty syndrome. 1984 John Loewenthal lecture.
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Curriculum↗
Long-term results of jejunoileal bypass in the young.
Between 1970 and 1975, 16 adolescent patients with a mean age of 17.8 years underwent jejunoileal bypass for exogenous morbid obesity. Their mean preoperative weight was 273.8 lbs. The total weight loss averaged 48 kg per patient. An extended evaluation process was instituted to determine the effectiveness of this procedure. Six of these parameters were the ponderal index (PI), body mass index, Broca's index, the per cent of ideal weight, complications, and diarrhea as a separate complication. A new formula was introduced to interpret weight loss as the percentage of excess pounds lost (PEPL). Three required reestablishment of normal intestinal continuity. There were no deaths in the group. Fifty and 69 per cent experienced excellent weight loss and postoperative PI respectively; excellent results were obtained in 27.5 per cent in both categories. In contrast, 50 per cent had a weight loss less than 100 lbs and 19 per cent a poor PI postoperatively; 13 per cent experienced poor results by both criteria. Linear growth in all patients continued along a normal curve, and their heights were above the mean.
Adolescent↗
Reflections concerning resident surgical training.
There has been a parallel growth of medical research and quality surgical education during the last 50 years in the United States. Many concerns about our programs are admittedly the by-product of existing societal problems. This address covers specific problems relating to learning, teaching, resident evaluation, discipline, operative supervision, the role of research in the department, the development of a two-tier system of surgical care, and the impact of total patient care on the training of young surgeons.
Clinical Competence↗
Identification and quantification of lower gastrointestinal flexible endoscopic microflora.
After use in 29 patients undergoing mechanical bowel preparation and cleansing by an acceptable, standardized method, flexible colonoscopes and sigmoidoscopes were cultured for identification and enumeration of bacterial organisms that might be transmitted during subsequent endoscopic procedures. Using a unique, new application, RODAC aerobic and anaerobic cultures of the shaft surface showed no evidence of residual fecal contamination, sparse growth of cutaneous and airborne organisms on some instruments, and no aerobic or anaerobic bacterial growth on others. There were no post-endoscopy infectious complications. Our results would indicate that proper cleaning of the flexible endoscope using an acceptable method does prevent bacterial disease transmission from patient to patient.
Bacteria↗
Nutritional support for the geriatric surgical patient.
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Aged↗
Clinical experience with carotid stump pressure and EEG monitoring to determine shunt placement during carotid endarterectomy.
The authors' experience with selective shunting during carotid endarterectomy utilizing electroencephalographic and stump pressure measurements is reported. No postoperative neurological deficits occurred in this group of selectively shunted patients. EEG appeared to offer no significant benefit in the management of the patients. Carotid stump pressures alone were reliable in providing the basis for selective shunting.
Aged↗
Fibroadenoma of the female breast: a critical clinical assessment.
In a study of 70 patients with 75 histologically proven fibroadenomas of the breast, a biphasic peak incidence was recorded, initially in their late 20s to early 30s with a second unexpected peak in their late 40s to early 50s. These lesions averaged 2.8 cm in diameter, two thirds were located in the lateral quadrants of the breast, and 10 percent were multiple. There was a significantly higher incidence among nonwhite than white women when compared to census figures and hospital admission data. The corrected recurrence rate was 17 percent. An inordinately high number of patients under 40 years of age in this series were nonwhite. Family history demonstrates a significantly high incidence of breast disease of all types in first-degree relatives.
Adenofibroma↗
Natural history of hereditary cancer of the breast and colon.
The natural history of 106 patients from eighteen families manifesting hereditary breast cancer syndromes, and 117 affected patients from twenty families manifesting nonpolyposis hereditary colon cancer were evaluated. Findings were compared with the American College of Surgeons (ACS) long-term audits for breast and colon cancer respectively. The cardinal features of hereditary cancer were observed within the study group, including: (1) a significant younger age of onset (49 years, breast; 46 years, colon); (2) an excess of proximal lesions in the hereditary colon series (49%); and (3) an excess of bilaterality in the hereditary breast cancer patients. The clinical stage at presentation was similar for the hereditary and ACS audit patients. Five-year survival was significantly improved (P less than .05) for both hereditary cancer populations as compared to the ACS audits (67% hereditary breast cancer and 52% nonpolyposis hereditary colon cancer). Improved survival in hereditary colon and breast cancer patients may have a bearing on the design of future clinical protocols.
Age Factors↗
Nutritional evaluation of a blenderized diet in five major burn patients.
Five consecutively admitted major burn patients were successfully supported with a high calorie, high protein diet supplemented with a blenderized diet (formula) that was prepared in our hospital. The egg, rice, and milk base formula provided over 60 percent of the average daily caloric requirements essential to their recovery. It was effective in preventing significant weight loss and promoting wound healing and successful skin grafting. The formula is inexpensive, palatable, of high quality protein, and provides a complete feeding when administered daily in conjunction with vitamin and mineral supplements.
Adult↗
Familial cancer in an oncology clinic.
Knowledge of cancer genetics provides the physician with a powerful tool for the recognition of patients who might profit from highly targeted cancer surveillance/management programs. Family history was evaluated by registered nurses on 565 consecutively ascertained patients with verified cancer from Creighton's Oncology Clinic. This initial assessment yielded 199 (35.5%) families with two more family members with cancer (all sites) within an informative nuclear component, which constituted parents, grandparents, aunts/uncles, siblings, and children. One or more of the operational criteria for cancer familiality, namely vertical transmission of cancer, bilaterality, and/or multiple primaries, early age of onset, and three or more site specific cancers, were found on physician review in 171 (30.5%) of the families. This group was referred for comprehensive cancer genetic evaluation consisting of pedigree extension and tumor verification through all second degree, and when possible, third degree relatives. It was determined that approximately 4% of the total clinic population demonstrated findings compatible with hereditary cancer syndromes. Its universal extension in clinical practice is advocated because of the potential yield from meticulous surveillance for cancer of highly targeted organs in such high-risk kindreds, as well as the economy and general case of obtaining detailed family history by registered nurses. The physician is able, therefore, to devote his primary effort toward pedigree analysis and syndrome identification.
Adolescent↗
Supradiaphragmatic right liver lobe and gallbladder.
Descriptions of supradiaphragmatic liver lobules have been previously described in diaphragmatic hernia reviews. A unique case of an otherwise anatomically normal, congenitally positioned right liver lobe and gallbladder in a supradiaphragmatic position with no previous history of trauma was encountered.
Abnormalities, Multiple↗
Jejunoileal bypass. Long-term results.
Between October 1967 and November 1977, the jejunoileal bypass was performed on 177 patients for morbid exogenous obesity. The female--male ratio was 9:1. The mean follow-up period was 3.4 years and their ages ranged from 15 to 58 years. Eighty-five per cent of this patient population base were between the ages of 21 and 49 years, and in 83% the onset of obesity was in childhood. Four parameters were used to assess the effectiveness of this procedure: 1) the ponderal index, 2) the per cent of ideal weight, 3) complications, and 4) diarrhea. Using the ponderal index, 38% of the results were excellent, 20% satisfactory, and 25% poor. When the per cent of ideal weight was used, the results were 24, 27 and 32% respectively. For complications, the results were 55, 23 and 5% and with diarrhea, 53, 22 and 8%. A summary of these mean values was 42.5, 23 and 17.5% for excellent, satisfactory and poor results. There were four deaths in this series, occurring 2--16 months postoperatively, due to sepsis, pulmonary embolism, drug overdose, and liver failure. Of the 28 patients (17%) requiring revision, eight were revised for inadequate weight loss, four for excessive weight loss, 15 for uncontrollable diarrhea, and 11 for metabolic electrolyte problems. In 14% the revision was required for multiple indications. A review of 100 of these patients to determine their response to the procedure revealed that 91% were able to recommend the procedure to other patients and intrepreted their results as being excellent in 51%, good in 36% and fair in 11%. Continued use of this procedure should be deferred pending much needed investigation of the associated complications.
Adolescent↗