International Journal of Surgery 16 (2015) 129e130

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Editor's perspectives e April 2015 Everyone has heroes. If you do not have at least one hero you should have. By definition a hero is a person who is admired or idealized for courage, outstanding achievements or noble qualities. He is regarded as a model or the ideal person. I have written he because heroes are masculine; I will turn to heroines in due course. It would be amiss of me not to mention my father at the start-an ideal model as a surgeon. Totally committed and an excellent technical surgeon; I wish I was half as competent. Heroes can be from the past or present. Of course Hippocrates, Galen, Albucasis and Maimonides would have to be mentioned from the distant past. My first real hero in medicine from the past, however, is Versalius. He certainly fits the definition having the courage to dissect the human body in the 16th century and beautifully draw the correct anatomy of humans which had previously been based on Galen's dissection of animals. In the same century Ambroise Pare, a French barber surgeon, was the father of modern scientific surgery doing a trial on the battlefield between boiling oil and an ointment made of egg yolk, oil of roses and turpentine on amputation stumps. This led to his famous saying “I bandaged him and God healed him”. In the next century a physician, William Harvey, is a hero. Other medical men, but not surgeons, who I admire were Jenner who introduced vaccinations, Moreton the first to use ether as a general anaesthetic and Fleming, a bacteriologist who realized the properties of penicillin. Other surgical heroes from the 18th century were Percival Pott, the Hunter brothers and Astley Cooper. The dawn of modern day surgery followed the introduction of general anaesthesia and, thanks to Lister, antisepsis. This allowed Billroth to perform the first successful partial gastrectomy and Langenbuch the first cholecystectomy. Turning to the 20th century I admire Alexis Carrell and Harvey Cushing but above all Muhe who despite being shunned by his German colleagues performed the first laparoscopic cholecystectomy in 1985. It is the surgeons who taught me and with whom I brushed shoulders that are my real heroes. I count my lucky stars that my clinical studies were undertaken at Westminster Hospital, London, where I was so fortunate as to be a student under Harold Ellis, the most accomplished teacher of surgery anywhere. He became a surrogate father to me and guided me through good and bad times always supportive and still is in many ways. He stands out for his wisdom, abilities to make the difficult simple and his humour. Gerald “Charlie” Westbury, a brilliant diagnostician and amazingly skillful surgeon taught me not only surgical oncology but compassion. Roy Calne imbued me with the science of surgery as did my times with Murray Brennan. Aubrey Yorke Mason and GB Ong taught me technical skills and post operative care. My last hero, Joe Petelin, taught me how to perform a laparoscopic cholecystectomy in a shoe box back in November 1989. An unsung hero he perfected this new minimally invasive surgery and was a great mentor. 1743-9191/© 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

So these are my medical heroes. Are there any heroines who can serve as role models for our female surgeons. Women were not allowed to practise surgery even in the 19th century but Dr. James Barry, who was a woman, was an army surgeon then and his secret not discovered until her death. However she paved the way for later in that century Elizabeth Garrett became the first woman on the medical register in the UK. The first lady surgeon to pass the FRCS examination was Eleanor Davies-Colley. In the USA, Dr. Jonasson paved the way forward. The first female surgeon to be elected to the Council of The Royal College of Surgeons of England was Phyllis George with whom I worked when I was the Penrose-May Tutor. And now we have in the 21st century the first lady President of that College, Clare Marx, who was a colleague of mine at St. Mary's Hospital, London. What a role model and therefore heroine she is to the increasing number of female surgeons in training. All of us have a little bit of our heroes and heroines inside us having picked up a few of their great attributes. We would be lesser people without them. This issue has a wide range of topics demonstrating we are truly a Journal of Surgery in General. That we are international goes without saying with 5 of the articles coming from China, 2 from the UK, 2 from France, 2 from Turkey 2 from Australia and 1 from each of the following countries- Taiwan, Korea, USA, Finland, Poland, Italy, Eire, Germany and Egypt-22 in total. As usual I am surprised to receive yet another paper on appendicitis. A retrospective study on the effect of surgical experience on the macroscopic diagnosis shows that in Australia operator experience does not affect the accuracy of the intra-operative assessment of the appendix. The authors recommend appendicectomy if clinically indicated regardless of its appearance. This is true especially in females as the false negative rate is higher. We include a best evidence topic which also is from Australia reviewing partial adrenalectomy. 65 studies were selected with 1224 patients. It can obviate the need for steroid replacement in the majority of patients and local recurrence rates are infrequent. The papers from China cover 5 different specialties. There is a meta-analysis on intramedullary versus plates in the treatment of distal tibial fractures. 16 studies with 1140 patients were analysed and it would seem that intramedullary nailing has a lower incidence of surgical infection but with a higher risk of non-union. The next paper concerns post operative portal vein thrombosis in cirrhotic patients. In a retrospective study of 116 patients the authors found that a spleno-renal shunt with devascularization was the best surgical option to inhibit the occurrence and development of post-operative portal vein thrombosis and also improves liver function. Turning to gynaecology another retrospective study in 147 patients undergoing various laparoscopic procedures with either cholecystectomy or appendicectomy was safe even in obese


Editorial / International Journal of Surgery 16 (2015) 129e130

women. Yet another retrospective analysis of 18 patients with abdominal and pelvic desmoplastic small round cell tumours demonstrated that surgery can significantly improve survival outcomes in these highly aggressive malignancies that can infringe on many organs. Radiotherapy was unhelpful. The last paper from China is a retrospective study as well analyzing the prognostic factors of endovascular therapy in 59 patients with acute anterior circulation stroke. Multi modal treatment may be suitable for patients with severe admission NIHSS (Health Stroke Scale Score) and a higher patency rate than intra-arterial thrombolysis. Vessel recannalization was the only predictor for favourable outcome. We include two experimental studies. The first from the USA looks at two energy sources used on cerebral tissue in pigs. Standard bipolar electric cautery was compared to a new ferromagnetic induction device. The latter caused less adjacent tissue damage based on quantitative radiology and quantitative histology analysis. The second article from Taiwan compares a SILS approach versus VATS for lung resection in dogs. Comparing haemodynamics and the inflammatory response there were no differences. All females undergoing colorectal resection and male patients undergoing colonic resection may have their urethral catheters removed at 48 h irrespective of the use of post operative epidural anaesthesia. However, males undergoing rectal surgery are at risk of developing post operative urinary retention. Whilst discussing epidural anaesthesia, following cytoreductive surgery with peritonectomy in a retrospective study of 101 patients the mean time for such analgesia was 5 days. It ensured adequate pain relief, was well tolerated but hypotension was common especially during the first 3 days. From Finland there is a paper on whether there is more than one approach to evaluate the variability of surgeons’ performance. 7 surgeons operated on rotator cuff tears in 742 patients. The bottom line was that variability in performance within a group of surgeons performing a specific type of surgery cannot be generalized to include the performance of all surgeons doing the same type of surgery without additional statistical analyses. Polish surgeons have shown that intra-operative monitoring of cerebral Near Infra-Red Spectroscopy oximetry leads to better post operative cognitive performance compared to those patients undergoing lumbar spondylosis surgery than those not monitored. From France the authors found if they bend the tip of an elastic stable intra-medullary nail to 180 before burying it avoids skin irritation and additional procedures. We include 2 papers from Turkey. One is a retrospective study of 236 patients comparing the modified Limberg flap with a modified elliptical rotation flap in the treatment of pilonidal sinus. Both flaps seemed equally effective. The second paper is also a retrospective analysis of 399 patients having staging surgery for gynaeclogical malignancies. 36 (9%) developed chylous ascites. There was a strong association between the number of para-aortic lymph nodes harvested. Drainage was effective treatment. Invagination of the pancreatico-jejunal anastomosis is easier to perform than a duct to mucosa anastomosis when performing pancreaticoduodenectomy especially if the duct is small. Invagination in a randomized controlled trial carried out in Egypt showed that this method was not associated with a lower rate of post operative fistula but it was associated with a decreased severity of such a fistula as well

as steatorrhoea. Also it was quicker to perform. It is good to include an endocrine paper. From Germany is a retrospective study looking at 43 patients with metastatic differentiated thyroid cancer. There was no difference in the sensitivity of rhTSH or thyroid hormone withdrawal for the group of patients when using I 131 whole body scans to identify metastases. The follow up of colorectal cancer using CEA levels is contentious. An article from the UK states that CEA is a predictor of recurrence, resectability and survival following resection of colorectal cancer. There is a short diagnostic interval with a raised CEA of approximately 4 weeks. Whilst discussing colorectal cancer there is a paper from Korea on factors affecting the selection of these patients to have minimally invasive surgery. Old age and surgeon factors were barriers to the choice of the laparoscopic approach. Short term results and oncological outcomes were the same for open and laparoscopic operations. The time to tolerable diet and hospital stay were decreased in the laparoscopic patients. The Brompton Harefield Infection Score effectively predicts surgical site infection risk and may help with risk stratification in relation to public reporting and reimbursement as well as targeted preventative strategies in patients undergoing coronary artery bypass grafting it is reported from the UK. Finally we publish an editorial on the proper reload selection during laparoscopic sleeve gastrectomy. Linear cutting stapling devices are intended for transection, resection and/or creation of anastomoses. The French authors suggest that one should consider using a thicker staple load, such as a black one, with thicker tissue as encountered in bariatric surgery. This is a longer than usual editorial to make up, for what will probably be a very short one next month as I shall be in China, Cambodia, Vietnam and Laos. Ethical approval None required. Funding None. Author contribution None. Conflicts of interest None. Guarantor None. R. David Rosin, Professor University of the West Indies, Department of Surgery, Cavehill Campus, West Indies, Bridgetown, Barbados E-mail address: [email protected]

Editor's perspectives – April 2015.

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