International Journal of Surgery 14 (2015) 105e106

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Editor's perspectives e February 2015 No country in the world in the 21st century can afford medical treatment for all conditions free at the point of delivery. The United Kingdom National Health Service (NHS) introduced in 1948 was formed on the back of the William Beveridge report published in December 1942, during the 2nd World War, which addressed ‘Social Insurance and Allied Services’. This report was influential in founding the welfare state in the UK. An economist, Beveridge identified the five giant evils in society, namely SQUALOR, IGNORANCE, WANT, IDLENESS and DISEASE. When Aneurin Bevan opened the Park Hospital in Manchester on the 5th July 1948, the first hospital providing free services for all at the point of delivery, free health care became available to all and paid for out of taxation. A mere four years later prescription charges were introduced. The writing was on the wall even thenthe country could not afford all services free. The founders of the NHS believed that the nation would become healthier and therefore the costs would not increase. Antibiotics were dealing with infections, vaccines were reducing childhood illnesses and surgery, such as it was at that time such as repairing hernias, was putting people back to work. They had no conception of the explosion that would occur in medical care over the second half of the 20th century, nor did they foresee that people would live for many years more than the usual three score years and ten. Intricate heart and brain surgery were to become routine, joint replacements for the ageing population, transplantation, minimal access surgery, navigational surgery, robotic surgery, vascular surgery and advanced cancer surgery were all to become common place. All are very expensive as are the modern treatments of chronic diseases such as dialysis for renal failure, stenting and expensive chemotherapeutic agents. Diagnoses were improved with the introduction of much improved imaging devices such as Ultra-Sound, flexible endoscopy, CT scanning, MRI scans, PET scans and radionuclide scans. These investigations hugely increased the numbers of patients now able to receive the new modalities of treatment. In the field of cancer treatment, expensive chemotherapy drugs, linear accelerator radiotherapy machines and the cyber knife are also now a matter of routine. These are all most welcome additions but come at an enormous cost. Also these new advances have helped people to live longer with the average expectancy of a man in the western world extended by 12 years and that of a woman by seventeen years. It is said that people spend more on health in their last few years that in their previous lifetime. The result of all these advances is that no country in the world can afford free health to everyone at the point of delivery. Also, it has been shown that free health is often abused by the public. So is there an answer? Rationing of health care already happens in most Health Care Systems with some treatments being denied as unnecessary. In the UK there is often what is termed “post-code” 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

medicine meaning some health care areas can afford more than others such as the drug, haceptin. This is not what the founders of the NHS envisaged. Therefore if the Health Service is to work public/private co-operation is essential. The other huge problem in all health services is the increasing emergency work to the detriment of elective work. I will have to address this problem in my editorial in the next issue. There are no papers on these issues upon which to comment but there are 18 fascinating articles. Let me start with an important negative study from the Netherlands on sentinel lymph node (SLN) localization with contrast enhanced ultra-sound and an implanted I-125 seed in breast cancer patients.14 patients with 15 lesions were examined. The authors concluded from this prospective study that it is not a viable alternative to standard SLN procedures as they only found a 60% success rate. A second paper on SLNs comes from Japan in a study on the T staging and positive SLN ratio being useful factors in predicting non-SLNs in breast cancer patients with macro-metastasis in the SLN. They carried out a retrospective study, studying 420 patients in whom 61 had positive macro-metastasis in the SLN. In these patients T stage and the SLN ratio were useful in predicting non-SLN metastases. Whilst mentioning breast cancer there is a third paper on the potential role of oestrogen receptor b2 as a tumour marker. The Korean authors suggest there is a role for this as an independent prognostic marker. It has been sometime since we included a paper on surgical site infections (SSI). In this issue we include two; the first from Germany looked at metabolism gene signatures and SSIs following abdominal surgery. Altered expression of metabolism genes in subcutaneous tissues might constitute a risk factor for post-operative abdominal SSI. In the other retrospective study on the treatment of SSI in patients with peripheral vascular arterial disease, the Dutch authors identified 40 patients of whom 60% had superficial SSIs. In these patients they had a 92% success rate in healing these infections with antibiotics and drainage. However this only healed 25% of the remainder with deep SSIs. They review the treatment. Abdominal adhesions still prove popular for experimental research. From Turkey there is a study on the use of Bromelain, a pineapple extract, to prevent adhesion formation. The authors state that Bromelain acting through its barrier, anti-inflammatory, antioxidant and proteolytic effects maybe a suitable agent to prevent intra-abdominal adhesions, as in the rat it has no adverse effects on wound healing and does not increase bleeding tendencies. A clinical first experience with the radial reload tri-staple technology in low rectal surgery is reported from the Netherlands. A questionnaire was used by 33 surgeons using the device. They confirmed that it facilitates low stapling in both open and laparoscopic procedures with good visibility and the possibility to create adequate distal margins.


Editorial / International Journal of Surgery 14 (2015) 105e106

From Singapore we publish a paper on the management of 332 patients over 5 years with perforated peptic ulcers. The authors conclude that emergency surgery has a very low morbidity and that the Mannheim peritonitis index was the only scoring system that predicted all complications. There is a literature review on the use of chewing gum to prevent post-operative ileus. 7 out of 12 RCTs concluded chewing gum decreased post-operative ileus but there appeared to be minimal difference in reducing time to passing flatus or the first stool and no difference in length of hospital stay or in the complication rate. It would seem to be of little benefit. Morbid obesity is now a worldwide problem. From Italy we publish an article in which the lipid profile changes were compared after 2 different types of bariatric surgery-sleeve gastrectomy and mini-gastric bypass. Ultimately there was similar efficacy in improvements in the lipid profile for each procedure. From Portugal there is a paper reporting that CT scan appears to measure 2 important markers of the Metabolic Syndrome in morbidly obese patients-visceral adiposity and hepatic fatty infiltration. Both of these increase the risk for the presence of the Metabolic Syndrome. Whilst mentioning CT scanning it appears that 2-phase low dose scanning is as effective as 4D for identifying enlarged parathyroid glands not definitely identified using MIB imaging and UltraSound. The American authors point out this leads to decreased radiation exposure. I enjoyed reading the Italian paper on the use of simultaneous Delorme's procedure with inter-sphincteric prosthetic implant for rectal prolapse despite there only being 3 patients. We do not have many gynaecology papers so it is a pleasure to include from the USA an article on the survival impact of cytoreduction to microscopic disease for advanced stage cancer of the uterine body. It appears to improve the R0 resection rates and overall survival in all types of uterine cancer. Likewise we do not publish an abundance of cardiac papers so it is equally pleasing to add in this issue the review of the miniaturized extracorporeal circulation approach versus off-pump coronary bypass grafting. Authors from the COMET group analyzed 7 RCTs which included 271 patients treated off-pump and 279 using the mini-EC circuit. The results were comparable. The last three papers are on laparoscopic surgery related subjects. The first from Korea shows that a single port laparoscopic reversal of Hartmann's operations is feasible and safe. Only 23 cases

were included in this retrospective study but there were no intraoperative complications. The second paper addresses the use of 3D simulation to enhance surgical skills acquisition in standardized laparoscopic tasks. It came as no surprise that novices reached proficiency sooner than compared to those training on 2D simulators. Finally we include a cross-over study of the effect of coffee consumption on simulated laparoscopic skills. 31 novices were tested following drinking decaffeinated coffee or with 2 different doses of caffeine added. There was no difference in accuracy but caffeine had a negative effect on task economy. I found this of interest as I have always found I operate better after a mug of coffee! Once again I have learned much from reading all the enclosed articles. A good spread from across the globe. Keep these articles pouring in as they make our Journal so comprehensive and interesting. Ethical approval None required. Funding None. Author contribution None. Conflicts of interest None. Guarantor None. R. David Rosin, Professor University of the West Indies, Barbados E-mail address: [email protected]

Editor's perspectives - February 2015.

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