Moshe Schein

One Hundred Citation Classics in General Surgical Journals

AbstractThe number of times an article is cited in scientific journals reflects its impact on a specific biomedical field or specialty and reflects the impact of the authors’ creativity. Our objective was to identify and analyze the characteristics of the 100 most frequently cited articles published in journals dedicated to general surgery and its close subspecialties. Using the database (1945–1995) of the Science Citation Index of the Institute for Scientific Information, 1500 articles cited 100 times and more were identified and the top 100 articles selected for further analysis. The 100 articles were published between 1931 and 1990, with more than two-thirds of them published after 1960. The mean number of citations per article was 405, (range 278–1013). Altogether, 84 of the articles originated from North America (USA 78, Canada 6) and the UK (12). New York State led the list of U.S. states with 14, and Harvard and Columbia University led the list of institutions with 6 articles each. The 100 articles were published in 10 surgical journals led by theAnnals of Surgery (n = 40), followed bySurgery (n = 15), Archives of Surgery (n = 12), Surgery, Gynecology and Obstetrics (n = 11), and British Journal of Surgery (n = 10). A total of 80 of the articles reported clinical experiences, 6 were clinical review articles, and 14 dealt with basic science. Eighteen articles reported a new surgical technique and six a prosthetic device. Gastrointestinal surgery and trauma and critical care led the list of the surgical fields, each with 25 articles, followed by vascular surgery (n = 15). Thirty-four persons authored two or more of the top-cited articles. This list of the top-cited papers identifies seminal contributions and their originators, facilitating the understanding and discourse of modern surgical history and offering surgeons hints about what makes a contribution a top-cited classic. To produce such a classic the surgeon and his or her group must come up with a clinical or nonclinical innovation, observation, or discovery that has a long-standing effect on the way we practice—be it operative or nonoperative. Based on our findings, to be well cited such a contribution should be published in the English language in a high-impact journal. Moreover, it is more likely to resonant loudly if it originates from a North American or British ivory tower.n

Abdominal wall endometriomas

BACKGROUNDnThe diagnosis of abdominal wall endometriomas is often confused with other surgical conditions.nnnMETHODSnA retrospective study was made of 12 patients presenting with an abdominal wall mass, which proved to be endometrioma.nnnRESULTSnOf a total of 297 patients of endometriosis treated in our hospital over a 7-year period, 12 (4%) had isolated abdominal wall endometriomas. Their mean age was 29.4 years. The presenting symptoms were abdominal mass (n = 12), cyclical (n = 5) or noncyclic pain (n = 7), dyspareunia and dysmenorrhea (n = 1). All patients had a history of gynecologic operations and presented, after an average of 1.9 years, with a tender mass (average 4 cm) at the previous incision site. Preoperative diagnosis was correct in 4 patients (33%) who presented with a cyclically painful abdominal mass. The others were diagnosed as incisional hernia (n = 4), abdominal wall tumor (n = 2), and inguinal hernia (n = 2). All patients underwent wide excision of their endometrioma; 2 required polytetrafluoroethylene patch grafting for the resulting fascial defect. The diagnosis was confirmed at frozen section or conventional histological examination in all patients. At follow-up, ranging from 4 months to 3 years, there was no recurrence of endometrioma.nnnCONCLUSIONSnScar endometrioma commonly presents as an abdominal mass with noncyclical symptoms. Imaging techniques are nonspecific and needle biopsy may confirm the diagnosis. Wide excision is the treatment of choice for abdominal wall endometrioma as well as for recurrent lesions.

Current Practices in Left-Sided Colonic Emergencies

Background: The paradigms in the surgical management of obstruction and perforation of the left colon – once considered absolute contraindications to primary resection and anastomosis – are changing. The aim of this survey was to poll American Gastrointestinal surgeons on their current approach to left colonic emergencies. Methods: A questionnaire was sent to 500 US-based surgeons, randomly selected members from the membership list of the Society for Surgery of the Alimentary Tract. It surveyed the surgeons on how they would approach ‘good-risk’ and ‘poor-risk’ patients with left colonic obstruction or perforation. Results: 215 (43%) surgeons responded to the questionnaire; 180 fully completed questionnaires (36%) were analyzed. Sigmoid obstruction: 96 responders (53%) selected a one-stage procedure in ‘good-risk’ patients; 78 preferred sigmoid resection with (n = 46) or without (n = 32) ‘on-table’ colonic lavage and 18 opted for a subtotal colectomy and ileo-rectal anastomosis. Most (94%) responders preferred a staged procedure in ‘high-risk’ patients: a Hartmann resection (n = 120) or a transverse colostomy (n = 46). Sigmoid diverticular perforation: only one third of the responders recommended a one-stage procedure in ‘good-risk’ patients: 58 would perform a sigmoidectomy with (n = 19) or without (n = 39) ‘on-table’ colonic lavage; only two opted for subtotal colectomy with ileo-rectal anastomosis. In ‘high-risk’ patients most surgeons opted for a Hartmann’s (88%) procedure or a diverting colostomy (7%). Conclusions: This survey suggests that a half and one-third of the responders would perform a one-stage resection and anastomosis in ‘good-risk’ patients with left colonic obstruction and perforation, respectively. In ‘poor-risk’ patients most responders would still opt for a staged procedure.

Source Control for Surgical Infections

The concept of source control encompasses all of the physical interventions, surgical and otherwise, that are used to treat infection. Although source control is one of the most important aspects of the treatment of serious infection, it has received relatively little attention. It is the topic of this overview, which draws heavily on a book we edited recently: Source Control: A Guide to the Management of Surgical Infection (Springer-Verlag, 2002). The first section focuses on general considerations: historical perspective, scientific basis, and surgical principles of source control. The second section highlights specific considerations of source control in various situations.

Delayed Post-Operative Pneumoperitoneum

We present a case of post-operative pneumoperitoneum (PP), which persisted for eight weeks. Postoperative retained air is the most common cause of PP. It does not require a surgical intervention and thus is defined as a ‘non-surgical PP’. The etiological factors contributing to the duration of the postoperative PP are controversial but the longest time described in the literature is 24 days. We review the relevant literature and discuss factors contributing to the duration of postoperative PP.

Duodenal atresia associated with proximal jejunal perforations: a case report and review of the literature

Duodenal atresia is associated with Downs syndrome, malrotation, and congenital cardiac defects. Idiopathic intestinal perforations in a newborn, which are not associated with necrotizing enterocolitis (NEC), have been described. The authors report on a full-term neonate who had multiple perforations of the proximal jejunum distal to duodenal atresia. To the best of the authors knowledge, the combination of idiopathic intestinal perforation and duodenal atresia has not been reported previously.

Colonoscopy-Assisted ‘Trephine’ Sigmoid Colostomy

Fecal diversion is often required to treat complex traumatic, malignant or inflammatory anorectal conditions. In such circumstances, the formation of a proximal, ‘trephine’ sigmoid colostomy would avoid the need for, and the associated morbidity of, a formal laparotomy. We describe a technique which combines intraoperative colonoscopy with a diverting, ‘trephine’ sigmoid colostomy, thereby helping the surgeon to identify the correct loop of bowel, to avoid inadvertent maturing of the wrong end of the divided colon, and to exclude intracolonic lesions.

New 'surgical innovation' as a revolution.

Accessible online at: www.karger.com/journals/dsu What promoted this brief commentary is the great enthusiasm with which surgeons welcomed the use of circular stapler in the management of hemorrhoids. Clearly, many thousands of patients were subjected to this procedure, worldwide, before the emergence of solid scientific evidence to document its shortand long-term advantages, efficacy, and safety. Let me thus reflect on surgeons’ attitude to any new ‘surgical innovation’. Surgeons – as all human beings – express a few limited patterns of attitude. One could compare a surgical ‘innovation’ to a political revolution (e.g., the French, the October in Russia, or that of the National Socialists in Germany during the 1930s). To simplify matters, let me identify six main patterns of attitude. The ‘revolution’ in our case will be the ‘anal stapling procedure’ (ASP), also known as PPH (procedure for prolapsed hemorrhoids) [1, 2].

The AIDS Patient

• The general principles of source control are applicable to the HIV/AIDS patient; however, a thorough understanding of the natural history and spectrum of HIV disease is essential. The pathology may or may not be related to HIV status. • Abdominal complaints are extremely common in the HIV population and clinical evaluation is often difficult. Serial clinical evaluation and frequent use of the CT scan are essential to prevent nontherapeutic interventions. • Early diagnosis and prompt intervention are essential for non-HIV-related surgical disorders such as acute appendicitis and cholecystitis. Surgical intervention is also essential for complications of opportunistic infections such as cytomegalovirus (CMV) perforation. The morbidity and mortality of surgical procedures depends on the stage of the HIV disease and the nature of pathology. • Surgical interventions should not be denied to this population because of the risk of occupational transmission and the fear of high complication rates. Relief of symptoms and improvement in quality of life are the chief considerations.