James M. McGreevy

A preliminary measurement of the surgical personality

BACKGROUND We used the Revised NEO Personality Inventory (Psychological Resources, Inc.) to test for a distinct surgical personality. METHODS The NEO-PI-R is a compilation of 240 statements. Subjects agree or disagree with the statements, generating a score in five personality traits according to the five factor theory: neuroticism (N), extraversion (E), openness (O), agreeableness (A), and conscientiousness (C). Each score is compared with that for the general population. RESULTS Twenty-four male and 15 female surgical residents voluntarily took the inventory. Compared to the general population, males scored lower in N (p <0.05), higher in E (P <0.001), O (P <0.05) and C (p <0.001), and average in A (no significant difference). Females scored average in N and A (no significant difference), and higher in E (p <0.001), O (P <0.05), and C (P <0.001). CONCLUSIONS The similarity of trait variance from the general population in both male and female surgical residents supports the concept of a surgical personality.

Detailed comparison of regional and general anesthesia for carotid endarterectomy

Abstract Forty-one variables were examined in 75 patients who underwent carotid endarterectomy to determine if significant differences were present between 45 patients who had general anesthesia and 30 patients who had regional anesthesia. The two groups were similar in terms of age, existing medical illnesses, neurologic presentation, and angiographic severity of the carotid lesions. There were no differences between the two groups for operative time, anesthesia time, blood loss, maximum or minimum blood pressures, postoperative hemodynamic data, or the requirement for or duration of intravenous pressor or antihypertensive medications. One patient in the regional group had a postoperative neurologic deficit which resolved in 1 month. Three patients in the general group had cardiovascular complications. Postoperative hospital stay was significantly longer in the general anesthesia group (5.6 to 3.2 days, p = 0.003). Regional and general anesthesia produce similar perioperative hemodynamic and surgical outcomes, but regional anesthesia results in a shorter hospital stay and less cardiovascular morbidity in this high risk population.

Minimally invasive lymphatic mapping using fluorescently labeled vitamin B12

BACKGROUND We examined the usefulness of a new agent in the mapping and dissection of inguinal lymph nodes in the pig. Cy5-cobalamin bioconjugate is blue under visible light and fluoresces brilliant red with laser stimulation. The wavelength of the emitted red light is sufficiently long that it is visible through blood, subcutaneous fat, and fascia. Currently available surgical techniques of minimally invasive dissection are well suited for using fluorescent detection in a dark operating field with minimal modification of an existing Hopkins surgical telescope. MATERIALS AND METHODS We tested this concept in the live post-adolescent, female, nonlactating pig (30 kg). We insufflated the subcutaneous tissue over the groin and inserted three ports (1 x 10 mm and 2 x 5 mm) for dissection. We injected the Cy5-cobalamin bioconjugate in a dermal location on the hind limb. A HeNe laser stimulated the CobalaFluor in the lymphatics and the emitted fluorescence passed through a holographic notch filter to a three-chip camera. RESULTS Under white light, the lymphatic trunks and the sentinel node were visualized within minutes of injection. Both the lymphatic trunks and the node fluoresced bright red under stimulation with red laser light. CONCLUSIONS These preliminary studies establish the potential usefulness of this new agent in lymphatic mapping. This novel technology might be useful in visualizing cancers that spread to regional lymph nodes. This technique has the potential to map the lymphatic drainage and to identify the presence of malignant cells in that drainage with currently available minimally invasive technology.

Effect of delayed operation for bleeding esophageal varices on child's class and indices of liver function

The charts of 38 patients managed with a period of intensive medical treatment (mean 7 days) prior to portosystemic shunting were examined. We found that the operative delay did not improve the Childs class or the indices of liver function. The operative mortality rates in these patients were 0 in Childs A patients, 13 percent in Childs B patients, and 50 percent in Childs C patients. Based on these findings, we began to operate on patients with bleeding esophageal varices as soon as they stabilized. The charts of 10 consecutive Childs C patients operated on without a period of intensive medical management (mean 3 days) were reviewed and compared with the charts of 8 Childs C patients with delayed operation. The two groups of patients were similar. We recommend that patients who need a shunt should be operated on as soon as possible after bleeding has ceased.

Selective nonoperative management of patients referred with abnormal mammograms

Screening mammography provides a means of detecting clinically occult breast carcinoma, but the question of whether all abnormal mammograms require biopsy remains unanswered. We retrospectively reviewed records of 214 women referred over an 8-year period for abnormal mammograms. They were selectively assigned to biopsy or mammographic follow-up based on specific mammographic criteria. Of 114 women initially observed mammographically, 2 were later found by biopsy to have carcinoma. Initial assignment to mammographic observation delayed the recommendation for biopsy 3 and 12 months, respectively, in these patients, but no effect on outcome was documented. Because they have benign lesions by clinical and mammographic criteria, 102 women (53%) have been spared biopsy; they continue to be monitored closely. We believe these data support the use of a selective approach to biopsy based on specific mammographic criteria.

Groin hernia and surgical truth

BACKGROUND Surgeons have used many methods to repair groin hernia since 1889. In that year, both Halsted and Bassini described the first effective operation. All operative solutions to groin hernia since then have used a suture repair. The differences have been related to the anatomic structures that are joined by the sutures. Recently, laparoscopy has forced most surgeons to question their approach to groin hernia. Common questions are: Is laparoscopy superior? When should mesh be used? Which of the many available techniques give superior results? DATA SOURCES This review presents an opinion-based review of the classical and recent literature. In addition, this review considers the manner in which surgeons search for answers to such questions. CONCLUSION The result of this search, for the author, is an acceptance of the mesh plug repair as superior to all others currently available.

Screening mammography: a surgeon's strategy for dealing with abnormal mammographic findings

Screening mammography is a valuable tool in the detection of breast cancer at an early stage. Large numbers of patients are being referred to surgeons for biopsies on the basis of mammographic abnormalities alone. As mammograms are complex studies and the findings often subtle, variation in terms of interpretation and recommendations for biopsy can leave the surgeon in a difficult position. We have reported a systematic method for evaluating patients and mammograms. Eighty-eight patients were referred to a single surgeon solely for an abnormal mammographic finding. Physical examination was repeated and the mammogram reviewed with a single consulting radiologist using specific criteria to define a mammographic abnormality. Through this evaluation, biopsy was avoided in 42 of 88 patients, with follow-up mammograms and physical examinations finding no suspicion of malignancy. By becoming educated in regard to mammographic abnormalities, establishing specific criteria with a consistent radiologist, and following patients carefully who are not biopsied, the surgeon can deal effectively with screening mammography.

Chloride transport in bullfrog gastric mucosa

Omeprazole uncouples histamine-stimulated hydrogen and chloride secretion in the frog gastric mucosa. This uncoupling results in a large increase in PD and Isc due to the unmasking of an electrogenic Cl- flux. Using a selective anoxia technique, we have attempted to define the cellular origin of this electrogenic Cl- flux. Sixteen bullfrog gastric mucosae were mounted in Ussing chambers. Under short-circuit conditions, PD, Isc, R, and unidirectional 36Cl flux were determined every 15 min. Acid secretion (10(-5) M histamine) was measured by hand titration (0.1 N NaOH). With both sides of the mucosae oxygenated, the addition of omeprazole (10(-4) M) resulted in cessation of H+ secretion and the unveiling of an electrogenic Cl- flux. Subsequent serosal anoxia (5% CO2-95% N2 nutrient side/30% O2 secretory side) resulted in a drop in JClnet associated with an appropriate fall in Isc. These changes were reversible with reoxygenation: (Table: see text). Bullfrog gastric mucosae which are partially oxygenated on the secretory side only (serosal anoxia) do not secrete acid in response to histamine. Therefore, the JClnet which is inhibited in these experiments by serosal anoxia may originate in the gastric glands approximately equal to 3.0 mu eq/cm2 X hr). The JClnet which remains during serosal anoxia may originate in the surface epithelial cells (approximately equal to 1.0 mu eq/cm2 X hr).

Uptake and distribution of fluorescently labeled cobalamin in neoplastic and healthy breast tissue

Fluorescent analogs of cobalamin (vitamin B12) have been developed as diagnostic markers of cancer cells. These compounds are recognized by transcobalamin, a cobalamin transport protein, with high affinity, as shown by surface plasmon resonance. The cellular sequestration and gross distribution of fluorescent cobalamin bioconjugates in breast tissue is being examined by epifluorescence microscopy. The distribution of each compound is being evaluated in proliferative and non-proliferative tissue, i.e. normal tissue and breast carcinoma. The results of preliminary studies suggest that fluorescent analogs of cobalamin may be a useful tool in therapeutic breast operations to define tumor margins and to distinguish neoplastic breast tissue from healthy breast tissue.

Outcomes Evaluation for Operative and Nonoperative Management of the Abnormal Mammogram

BACKGROUND This study reviewed the outcome of women with an abnormal mammogram and no mass (n = 194). METHODS Patients were immediately biopsied (34%) or followed up mammographically (66%). Information was collected prospectively over a 13-year period. RESULTS Eight of those initially biopsied (12%) proved to be cancer. Of the remaining 129 patients, 20 were lost to follow-up, leaving 109 for further review. Thirty of these patients ultimately came to biopsy, with 5 (17%) proving to be cancer. Of those followed up mammographically and not biopsied, the majority (92%) of lesions either remained unchanged or resolved. The average follow-up time is 53 months. Biopsy was avoided in 51%. Of the 179 patients with follow-up information, 40 (23%) developed new lesions. Fourteen of these lesions have been biopsied, and 36% were cancer. CONCLUSIONS Most mammographic lesions resolve or remain unchanged. Women who have a lesion on mammography are at increased risk for further mammographic abnormalities.