ORIGINAL ARTICLES
RECENT ADVANCES IN GENERAL SURGERY’ ERICM. NANSON Department of Surgery, School of Medicine, Auckland, New Zealand In order to give an overview of recent advances i n geqeral surgery, It is necessary to define: ( i ) what is general surgery; (11) what is recent; and (lil) what constitutes an advance. General surgery appears t o have entered an era of conservatism. This Is particularly evident i n the surgery o f breast cancer, peptic ulceration, varicose velns, liver trauma, portal hypertension, upper gastrointestinal bleeding, and hiatal hernia. Controlled clinical trials In surgery have become popular. T h e following are considered to be advances: parenteral nutrition, suction drafnage, control o f Gram-negative sepsis, bypass surgery f o r pathological obesity, and a dlscriminatory approach to transplant surgery.
IT is a difficult assignment to discuss recent advances in general surgery because of three questions : (1) What is general surgery?-This is hard to define in the modern era, and like shifting sands, is subject to change, but broadly speaking, general surgery covers the surgery of the head and neck, breasts, abdomen, some endocrine glands, and most soft tissue lesions. (2) What is recent? - As 1977 is the jubilee year of the Royal Australasian College of Surgeons, it might be pardonable to consider a span of 50 years, but that is too long. One year, 1976, is too short. I t would therefore seem reasonable to take a span of five to ten years. (3) What is an advance?-This is probably the hardest question, to answer, especially after reading Medical Nemesis, by Ivan Ilich. All things new are not necessarily advances, and in surgery, as in many human endeavours, fashions and fads come and go. It could be agreed, however, that certain discoveries and developments have been advances, such as
armsthesia, asepsis, antibiotics, and open heart surgery. These have changed the face of surgery. But often it is necessary to wait several years to decide whether something new is a real advance. As with history, the perspective of time may be needed. Thus gastric freezing for duodenal ulcer and hyperbaric oxygen are examples of temporary surgical bandwagons. Rather than discuss a list of major or minor developments in the research, or the clinical or technical aspects of surgery, it is proposed to look at the changing thought and attitudes in general surgery, and to illustrate these with specific examples.
Presented at the 50th Jubilee General Scientific Meeting of the Royal Australasian College of Surgeons, Melbourne, May 1977. Reprints: Professor Eric M. Nanson, address as above.
THERETURNTO THE ERAOF CONSERVATISM It would appear that surgery is returning to an era of conservatism. This is particularly evident in the surgery of breast cancer. It is now recognized that many cancers, and breast cancer in particular, are systemic diseases, and the outcome depends on the battle between the invasive disease and the host’s resistance. Therefore major extirpative operations such as the radical mastectomy of Halstead, and the supraradical operation of Urban, are now pmsk. Simple mastectomy, extended simple or modified radical mastectomy, or even “lumpec-
438
Ausz N.Z.J. SURG.,VOL.47 - No. 4, AUGUST, 1977
ADVANCES I N GENERAL SURGERY
tomy”, are now generally used for breast cancer. The acknowledged aim of surgery is to control the local d i s e a s e t h e control of the systemic disease now depends more on adjuvant chemotherapy with or without boosting of the patient’s immune mechanisms. Thus the results of Bonadonna e t alii (1976) with cyclophosphamide, Methotrexate and fluorouracil, and the National Surgical Adjuvant Breast Project Study with L-PAM (1975)) must receive very serious consideration. The measurement of estrogen receptors on the breast tumour tissue removed, together with the urinary discriminant or Miller ratio, may prove useful as predictive factors for manipulation of the hormonal environment. Hypophysectomy and adrenalectomy are now rarely used for metastatic disease. Thus the principle is for surgery to eradicate the bulk of the tumour mass, and for systemic chemotherapy to take care of distant micrometastasis. This is because most cancers are already well advanced biologically by the time they manifest themselves to the patient and the doctor. I n this context, the Japanese (Yamada, 1975) are to be commended for their ability to diagnose early intramucosal carcinoma of the stomach by radiological and endoscopic methods and, by surgery, to achieve a 97% five-year survival rate in these early lesions. However, the worldwide use of screening programmes to detect carcinoma of the stomach, and also carcinoma of the rectum and colon, can scarcely be justified on a costbenefit basis. This same spirit of conservatism can be said to apply to carcinoma of the thyroid, in which total thyroidectomy is confined to certain histological types such as medullary carcinoma and possibly follicular carcinoma (Wright, 1976). It is also beginning to be applied to carcinoma of the colon, where high ligation of the inferior mesenteric artery flush with the aorta is no longer insisted upon, and to carunoma of the rectum, where local excision of small malignancies has been advocated by York Mason (1976), and low posterior resection is being championed by Goligher (1976, personal communication) and Localio (1971). The very wide excision of malignant melanoma, with routine associated dissection of the regional lymph nodes, has given place to a more limited resection of the primary lesion AUST. N.Z. J. SURG., VOL.47-N0.
4, AUGUST,1977
NANSON
and subsequent node dissection if indicated, unless nodes are obviously involved clinically at the time of presentation (Davis et a& 1976)* In the management of varicose veins and varicose ulcers a more conservative approach is being adopted: stripping and extensive subfascia1 dissections have given place to saphenofemoral ligation and sclerosant therapy, with compression. This may have been triggered by the need to conserve the long saphenous veins for possible subsequent use on coronary vessels (Cole, 1973), and also because of the high demand on hospital beds, but chiefly because the end results of the two forms of treatment appear to be the same, with less morbidity following the latter procedure (Fegan, 1963 ; Doran and White, 1975). I n the management of liver trauma and liver malignancies the initial enthusiasm for massive liver resection such as hemihepatectomy has waned, and in liver trauma a return to adequate local debridement of devitalized tissue has occurred. The surgery of peptic ulceration has become progressively more conservative. The 3/4 gastrectomy has given way successively to truncal vagotomy plus a drainage procedure or antrectomy, to selective vagotomy plus a drainage procedure, and now to highly selective vagotomy with no drainage procedure (Johnston, 1975). The reason for this is the recognition of the importance of the functioning pylorus in regulating gastric emptying and in preventing bile reflux into the stomach. It is believed that a well-done highly selective vagotomy is probably a more thorough parietal cell vagotomy, and it is recognized that surgery is only an incident in this cyclical and self-limiting disease, so that the least done surgically the better, in order to control the problem adequately. For portal hypertension, associated with cirrhosis of the liver, there appears to be waning enthusiasm for shunt procedures, insofar as various reports, such as that from the Boston Interhospital Liver Group (Resnick et a&, 1974), indicate that the life span of patients who bleed from this cause is not prolonged in the overall series. The ultimate result is that the mortality is due to hepatic failure rather than hamorrhage. Where shunts are used, the H-graft mesocaval shunt
439
NANSON
ADVANCES I N GENERAL SURGERY
appears to be a real advance (Smith e t alii, 1974). There is renewed interest in sclerosing esophageal varices, and with the help of radiologists, the selective embolization of bleeding varices is proving promising. In the field of upper gastrointestinal bleeding, the early use 01 fibre endoscopy has made accurate diagnosis ot the cause of such bleeding much more certain, hence affording the opportunity to avoid blind surgery or indeed any surgery at all. Furthermore, for acute gastric erosions, the use of Hz antagonists, such as cimetidine, holds out great promise ot avoidance of surgery in those patients who are otten poor operative risks because ot severe sepsis, trauma, or renal failure. Th e enthusiasm tor operating on hiatal hernia per se is being tempered with caution. However, the importance of esophageal reliux due to low tone of the lower esophageal sphincter is now recognized. The necessity for the use of esophageal pressure studies to sort out motility disorders of the esophagus is now realized, and anti reffux procedures such as fundoplication have gained in popularity as against anatomical reconstruction of the esophageal hiatus alone. The management of peptic esophageal stricture is still a difficult problem, and the Leigh Collis fundoplasty plus a fundoplication seems to be gaining favour.
THEQUALITY CONTROL OF Suim.m There has been a growing awareness of the need for a more critical approach to some operative procedures, and hence in the last ten years there has been a burgeoning of controlled clinical trials in surgery, which are ethically sound in those areas where the effectiveness of treatment is in real doubt. This is particularly pertinent in the management of breast cancer already alluded to, and in surgery for peptic ulceration. Goligher et dii, of Leeds (19613), have developed the art of controlled clinical trials in surgery to a high degree. The prevention of deep venous thrombosis of the legs by low-dose heparin administration has been the subject of several controlled clinical trials (Nicolaides et atii, 1 9 7 2 ) ~and these would appear to indicate the effectiveness of this regimen. Thus surceons are beginning to look much more critically at the effectiveness of what they are doing, rather than follow blind custom or habit. 440
SOMESPECIFIC DEVELOPMENTS IN SURGICAL MANAGEMENT The following developments have become important or productive in the last decade. ( a ) There has been a marked increase of interest in the nutrition of the surgical patient and in the use of parenteral nutrition or hyperalimentation, stemming from the work of Dudrick and Wilmore (1967). This has produced dramatic improvement in the treatment of intestinal fistuk and severe abdominal sepsis. Furthermore, it is now thought that, in the management of abdominal malignancies, the conversion of the patient into an anabolic state prior to surgery by hyperalimentation may materially improve recovery and facilitate the functioning-of the patient’s immune mechanism against his disease. The use of total parenteral nutrition is to be regarded as a significant advance. ( b ) T o a lesser extent, the increasing use of suction drainage may be considered an advance. Its use is well recognized in head and neck surgery and surgery of the breast, because in these areas it is easier to keep flaps sucked down than pressed down. Its use in abdominal surgery is also extending, with success. The probable explanation for this is that suction drainage with adequate-sized cannulze removes postlaparotomy air, plus blood and serum, from the abdominal cavity. This will encourage the sealing anastomosis with omentum and adjacent tissues, will eliminate dead space which is a potent cause of sepsis, and hence will allow the natural antibacterial action of the peritoneal membrane to take place, assisted by its subperitoneal lymphatic drainage system. ( c ) There has been increasing appreciation of the importance of Gram-negative sepsis. The disastrous effects of anaerobic Grarnnegative infection, especially by Bacteroides organisms, have been recognized, along with the necessity for proper culture techniques to isolate these organisms. As a result, the appropriate use of antibiotics, both therapeutically and preventatively, has become common. There is recognition of the virtue of broad spectrum combination antibiotic therapy effective acainst Gram-positive and Gramnegative zrobes and anaerobes administered with the premedication drugs, and continued for 24 hours after operation, in situations AUST. N.Z. J. SURG.,VOL.47-No.
4, AUGUST, 1977
NANSON
ADVANCES I N GENERAL SURGERY
where wound contamination is likely, such as with emergency bowel resections, general peritonitis, diverticular abscess, and appendiceal abscess. The use of metronidazole for Gram-negative anzerobe contamination appears encouraging. This management system is known as preventative, as distinct from prophylactic, antibiotic usage, and is aimed solely at the control of contamination or a temporary bacterzmia. ( d ) There has been increasing but cautious acceptance of the usefulness of bypass smallbowel surgery for pathological obesity (Payne ct alii, 1973). More recently the virtue of gastric bypass has been shown as a means of limiting caloric intake without producing the metabolic upset that is prone to occur with the use of small-bowel bypass (Printen and Mason, 1973). ( c ) I t would appear that there has been a “plateauing off” of interest in transplant surgery. ‘This may be partly related to the problem of cost effectiveness, but the limiting factor is the rejection problem. Transplant surgery has given a tremendous stimulus to the study of immune mechanisms. Renal transplant surgery is now firmly established, with an overall effectiveness of about 45% threeyear graft survival when cadaver kidneys are used. The American figures (Libby et alii, 197s) are 42%, and the Australasian figures ( 1976) are 48%. The development of cardiac, liver. and pancreas transplants, except in highly specialized centres, has slowed down.
CONCLUSION I t would thus appear that there have been some real advances in general surgery, but also that surgeons have become more discrim-
A u s ~ .N.Z. T. Sunc., VOL. 47-No.
4, AUGUST,1977
inating, more critical, and more conservative in extirpative surgery, over the last ten years. For instance, it is doubtful whether hemicorporectomy would nowadays be considered an advance.
REFERENCES Australissinn 2 ruusplant Registry (1976). BONADONNA, G., BRUSAMOLINO, E., VALAGUSSA, P., Koss~,A,, BRUGNATELLI, L., BRAMBILLA, C., DE LLNA, M., TANCINI, b., IIAGETTA,E., MusuMFCI, K and VERON~SI, U. (1976), New hngl. J Med., 294: 40j. COLE, D. S. (1973), N.Z. m e d . J., 77: 127. L)kVIS, N., MCLEOD,K., BEARDMORE, ti., LITTLE, J., QUINN, K. and Horr, J. (1976), AUST. N.Z. J . SURG.,46: 188. DORAN, p. s. h. and WHITE, &I. (I975), Brit. J . Surg., b2 : 72. DUDRICK, S. J. and WILMORL, I t . 1). (1967), S u r g e r y , 64: I?A. FEGA;, W.’ G. (1963), Lancet, 2 : 109. GOLIGHER, J. C., L)E DOMBELL,F. T., PULVERTAFF, C. M., CONYERS,J . H., DUTHIE, H. L., FEATHER,D. B., LATCHMORE, A. J. SHOESMITH, 5. H., SMIDDY, F. G. and WILSONPEPPER, .I. (1@8), Brit. nted. J . , 2 : 781, 787. JOHNSION,I). (197j), Brit. nzcd. J., 4: 545. L I ~ H YG. , N., WEINSWIG,M. H. and KIRK, I(. W. ( r g s ) , J . Awter. w e d . Ass., 233: 787. LOCALIO,S. A. (1971), Surg. Gynec. Obstet., 132: 123. MASON,A. Y. (1976), AUST. N.Z. J. SURG.,46: 332. NICOLAIDES,A. N., DESAIS,S., DOUGLAS,J . N., DUPONT. P. A,. FOUVIDES. G.. LESIS. D.. IhDSWORTH, H . , ’ T U C K , I
RECENT ADVANCES IN GENERAL SURGERY’ ERICM. NANSON Department of Surgery, School of Medicine, Auckland, New Zealand In order to give an overview of recent advances i n geqeral surgery, It is necessary to define: ( i ) what is general surgery; (11) what is recent; and (lil) what constitutes an advance. General surgery appears t o have entered an era of conservatism. This Is particularly evident i n the surgery o f breast cancer, peptic ulceration, varicose velns, liver trauma, portal hypertension, upper gastrointestinal bleeding, and hiatal hernia. Controlled clinical trials In surgery have become popular. T h e following are considered to be advances: parenteral nutrition, suction drafnage, control o f Gram-negative sepsis, bypass surgery f o r pathological obesity, and a dlscriminatory approach to transplant surgery.
IT is a difficult assignment to discuss recent advances in general surgery because of three questions : (1) What is general surgery?-This is hard to define in the modern era, and like shifting sands, is subject to change, but broadly speaking, general surgery covers the surgery of the head and neck, breasts, abdomen, some endocrine glands, and most soft tissue lesions. (2) What is recent? - As 1977 is the jubilee year of the Royal Australasian College of Surgeons, it might be pardonable to consider a span of 50 years, but that is too long. One year, 1976, is too short. I t would therefore seem reasonable to take a span of five to ten years. (3) What is an advance?-This is probably the hardest question, to answer, especially after reading Medical Nemesis, by Ivan Ilich. All things new are not necessarily advances, and in surgery, as in many human endeavours, fashions and fads come and go. It could be agreed, however, that certain discoveries and developments have been advances, such as
armsthesia, asepsis, antibiotics, and open heart surgery. These have changed the face of surgery. But often it is necessary to wait several years to decide whether something new is a real advance. As with history, the perspective of time may be needed. Thus gastric freezing for duodenal ulcer and hyperbaric oxygen are examples of temporary surgical bandwagons. Rather than discuss a list of major or minor developments in the research, or the clinical or technical aspects of surgery, it is proposed to look at the changing thought and attitudes in general surgery, and to illustrate these with specific examples.
Presented at the 50th Jubilee General Scientific Meeting of the Royal Australasian College of Surgeons, Melbourne, May 1977. Reprints: Professor Eric M. Nanson, address as above.
THERETURNTO THE ERAOF CONSERVATISM It would appear that surgery is returning to an era of conservatism. This is particularly evident in the surgery of breast cancer. It is now recognized that many cancers, and breast cancer in particular, are systemic diseases, and the outcome depends on the battle between the invasive disease and the host’s resistance. Therefore major extirpative operations such as the radical mastectomy of Halstead, and the supraradical operation of Urban, are now pmsk. Simple mastectomy, extended simple or modified radical mastectomy, or even “lumpec-
438
Ausz N.Z.J. SURG.,VOL.47 - No. 4, AUGUST, 1977
ADVANCES I N GENERAL SURGERY
tomy”, are now generally used for breast cancer. The acknowledged aim of surgery is to control the local d i s e a s e t h e control of the systemic disease now depends more on adjuvant chemotherapy with or without boosting of the patient’s immune mechanisms. Thus the results of Bonadonna e t alii (1976) with cyclophosphamide, Methotrexate and fluorouracil, and the National Surgical Adjuvant Breast Project Study with L-PAM (1975)) must receive very serious consideration. The measurement of estrogen receptors on the breast tumour tissue removed, together with the urinary discriminant or Miller ratio, may prove useful as predictive factors for manipulation of the hormonal environment. Hypophysectomy and adrenalectomy are now rarely used for metastatic disease. Thus the principle is for surgery to eradicate the bulk of the tumour mass, and for systemic chemotherapy to take care of distant micrometastasis. This is because most cancers are already well advanced biologically by the time they manifest themselves to the patient and the doctor. I n this context, the Japanese (Yamada, 1975) are to be commended for their ability to diagnose early intramucosal carcinoma of the stomach by radiological and endoscopic methods and, by surgery, to achieve a 97% five-year survival rate in these early lesions. However, the worldwide use of screening programmes to detect carcinoma of the stomach, and also carcinoma of the rectum and colon, can scarcely be justified on a costbenefit basis. This same spirit of conservatism can be said to apply to carcinoma of the thyroid, in which total thyroidectomy is confined to certain histological types such as medullary carcinoma and possibly follicular carcinoma (Wright, 1976). It is also beginning to be applied to carcinoma of the colon, where high ligation of the inferior mesenteric artery flush with the aorta is no longer insisted upon, and to carunoma of the rectum, where local excision of small malignancies has been advocated by York Mason (1976), and low posterior resection is being championed by Goligher (1976, personal communication) and Localio (1971). The very wide excision of malignant melanoma, with routine associated dissection of the regional lymph nodes, has given place to a more limited resection of the primary lesion AUST. N.Z. J. SURG., VOL.47-N0.
4, AUGUST,1977
NANSON
and subsequent node dissection if indicated, unless nodes are obviously involved clinically at the time of presentation (Davis et a& 1976)* In the management of varicose veins and varicose ulcers a more conservative approach is being adopted: stripping and extensive subfascia1 dissections have given place to saphenofemoral ligation and sclerosant therapy, with compression. This may have been triggered by the need to conserve the long saphenous veins for possible subsequent use on coronary vessels (Cole, 1973), and also because of the high demand on hospital beds, but chiefly because the end results of the two forms of treatment appear to be the same, with less morbidity following the latter procedure (Fegan, 1963 ; Doran and White, 1975). I n the management of liver trauma and liver malignancies the initial enthusiasm for massive liver resection such as hemihepatectomy has waned, and in liver trauma a return to adequate local debridement of devitalized tissue has occurred. The surgery of peptic ulceration has become progressively more conservative. The 3/4 gastrectomy has given way successively to truncal vagotomy plus a drainage procedure or antrectomy, to selective vagotomy plus a drainage procedure, and now to highly selective vagotomy with no drainage procedure (Johnston, 1975). The reason for this is the recognition of the importance of the functioning pylorus in regulating gastric emptying and in preventing bile reflux into the stomach. It is believed that a well-done highly selective vagotomy is probably a more thorough parietal cell vagotomy, and it is recognized that surgery is only an incident in this cyclical and self-limiting disease, so that the least done surgically the better, in order to control the problem adequately. For portal hypertension, associated with cirrhosis of the liver, there appears to be waning enthusiasm for shunt procedures, insofar as various reports, such as that from the Boston Interhospital Liver Group (Resnick et a&, 1974), indicate that the life span of patients who bleed from this cause is not prolonged in the overall series. The ultimate result is that the mortality is due to hepatic failure rather than hamorrhage. Where shunts are used, the H-graft mesocaval shunt
439
NANSON
ADVANCES I N GENERAL SURGERY
appears to be a real advance (Smith e t alii, 1974). There is renewed interest in sclerosing esophageal varices, and with the help of radiologists, the selective embolization of bleeding varices is proving promising. In the field of upper gastrointestinal bleeding, the early use 01 fibre endoscopy has made accurate diagnosis ot the cause of such bleeding much more certain, hence affording the opportunity to avoid blind surgery or indeed any surgery at all. Furthermore, for acute gastric erosions, the use of Hz antagonists, such as cimetidine, holds out great promise ot avoidance of surgery in those patients who are otten poor operative risks because ot severe sepsis, trauma, or renal failure. Th e enthusiasm tor operating on hiatal hernia per se is being tempered with caution. However, the importance of esophageal reliux due to low tone of the lower esophageal sphincter is now recognized. The necessity for the use of esophageal pressure studies to sort out motility disorders of the esophagus is now realized, and anti reffux procedures such as fundoplication have gained in popularity as against anatomical reconstruction of the esophageal hiatus alone. The management of peptic esophageal stricture is still a difficult problem, and the Leigh Collis fundoplasty plus a fundoplication seems to be gaining favour.
THEQUALITY CONTROL OF Suim.m There has been a growing awareness of the need for a more critical approach to some operative procedures, and hence in the last ten years there has been a burgeoning of controlled clinical trials in surgery, which are ethically sound in those areas where the effectiveness of treatment is in real doubt. This is particularly pertinent in the management of breast cancer already alluded to, and in surgery for peptic ulceration. Goligher et dii, of Leeds (19613), have developed the art of controlled clinical trials in surgery to a high degree. The prevention of deep venous thrombosis of the legs by low-dose heparin administration has been the subject of several controlled clinical trials (Nicolaides et atii, 1 9 7 2 ) ~and these would appear to indicate the effectiveness of this regimen. Thus surceons are beginning to look much more critically at the effectiveness of what they are doing, rather than follow blind custom or habit. 440
SOMESPECIFIC DEVELOPMENTS IN SURGICAL MANAGEMENT The following developments have become important or productive in the last decade. ( a ) There has been a marked increase of interest in the nutrition of the surgical patient and in the use of parenteral nutrition or hyperalimentation, stemming from the work of Dudrick and Wilmore (1967). This has produced dramatic improvement in the treatment of intestinal fistuk and severe abdominal sepsis. Furthermore, it is now thought that, in the management of abdominal malignancies, the conversion of the patient into an anabolic state prior to surgery by hyperalimentation may materially improve recovery and facilitate the functioning-of the patient’s immune mechanism against his disease. The use of total parenteral nutrition is to be regarded as a significant advance. ( b ) T o a lesser extent, the increasing use of suction drainage may be considered an advance. Its use is well recognized in head and neck surgery and surgery of the breast, because in these areas it is easier to keep flaps sucked down than pressed down. Its use in abdominal surgery is also extending, with success. The probable explanation for this is that suction drainage with adequate-sized cannulze removes postlaparotomy air, plus blood and serum, from the abdominal cavity. This will encourage the sealing anastomosis with omentum and adjacent tissues, will eliminate dead space which is a potent cause of sepsis, and hence will allow the natural antibacterial action of the peritoneal membrane to take place, assisted by its subperitoneal lymphatic drainage system. ( c ) There has been increasing appreciation of the importance of Gram-negative sepsis. The disastrous effects of anaerobic Grarnnegative infection, especially by Bacteroides organisms, have been recognized, along with the necessity for proper culture techniques to isolate these organisms. As a result, the appropriate use of antibiotics, both therapeutically and preventatively, has become common. There is recognition of the virtue of broad spectrum combination antibiotic therapy effective acainst Gram-positive and Gramnegative zrobes and anaerobes administered with the premedication drugs, and continued for 24 hours after operation, in situations AUST. N.Z. J. SURG.,VOL.47-No.
4, AUGUST, 1977
NANSON
ADVANCES I N GENERAL SURGERY
where wound contamination is likely, such as with emergency bowel resections, general peritonitis, diverticular abscess, and appendiceal abscess. The use of metronidazole for Gram-negative anzerobe contamination appears encouraging. This management system is known as preventative, as distinct from prophylactic, antibiotic usage, and is aimed solely at the control of contamination or a temporary bacterzmia. ( d ) There has been increasing but cautious acceptance of the usefulness of bypass smallbowel surgery for pathological obesity (Payne ct alii, 1973). More recently the virtue of gastric bypass has been shown as a means of limiting caloric intake without producing the metabolic upset that is prone to occur with the use of small-bowel bypass (Printen and Mason, 1973). ( c ) I t would appear that there has been a “plateauing off” of interest in transplant surgery. ‘This may be partly related to the problem of cost effectiveness, but the limiting factor is the rejection problem. Transplant surgery has given a tremendous stimulus to the study of immune mechanisms. Renal transplant surgery is now firmly established, with an overall effectiveness of about 45% threeyear graft survival when cadaver kidneys are used. The American figures (Libby et alii, 197s) are 42%, and the Australasian figures ( 1976) are 48%. The development of cardiac, liver. and pancreas transplants, except in highly specialized centres, has slowed down.
CONCLUSION I t would thus appear that there have been some real advances in general surgery, but also that surgeons have become more discrim-
A u s ~ .N.Z. T. Sunc., VOL. 47-No.
4, AUGUST,1977
inating, more critical, and more conservative in extirpative surgery, over the last ten years. For instance, it is doubtful whether hemicorporectomy would nowadays be considered an advance.
REFERENCES Australissinn 2 ruusplant Registry (1976). BONADONNA, G., BRUSAMOLINO, E., VALAGUSSA, P., Koss~,A,, BRUGNATELLI, L., BRAMBILLA, C., DE LLNA, M., TANCINI, b., IIAGETTA,E., MusuMFCI, K and VERON~SI, U. (1976), New hngl. J Med., 294: 40j. COLE, D. S. (1973), N.Z. m e d . J., 77: 127. L)kVIS, N., MCLEOD,K., BEARDMORE, ti., LITTLE, J., QUINN, K. and Horr, J. (1976), AUST. N.Z. J . SURG.,46: 188. DORAN, p. s. h. and WHITE, &I. (I975), Brit. J . Surg., b2 : 72. DUDRICK, S. J. and WILMORL, I t . 1). (1967), S u r g e r y , 64: I?A. FEGA;, W.’ G. (1963), Lancet, 2 : 109. GOLIGHER, J. C., L)E DOMBELL,F. T., PULVERTAFF, C. M., CONYERS,J . H., DUTHIE, H. L., FEATHER,D. B., LATCHMORE, A. J. SHOESMITH, 5. H., SMIDDY, F. G. and WILSONPEPPER, .I. (1@8), Brit. nted. J . , 2 : 781, 787. JOHNSION,I). (197j), Brit. nzcd. J., 4: 545. L I ~ H YG. , N., WEINSWIG,M. H. and KIRK, I(. W. ( r g s ) , J . Awter. w e d . Ass., 233: 787. LOCALIO,S. A. (1971), Surg. Gynec. Obstet., 132: 123. MASON,A. Y. (1976), AUST. N.Z. J. SURG.,46: 332. NICOLAIDES,A. N., DESAIS,S., DOUGLAS,J . N., DUPONT. P. A,. FOUVIDES. G.. LESIS. D.. IhDSWORTH, H . , ’ T U C K , I
