Robert Koch: centenary of the discovery of the tubercle bacillus, 1882.

This is an account of the life and work of Robert Koch (1843-1910), Nobel Laureate in Medicine and a founder of the science of bacteriology. In particular, Koch's researches into tuberculosis are described--the discovery of the tubercle bacillus, the controversy regarding the human and bovine types, the Koch phenomenon, and the introduction of tuberculin, which proved to be ineffective as a cure but became important as a diagnostic tool in the management of tuberculosis. By his achievements in this field, Koch may be considered to be the father of the scientific study of tuberculosis. On the occasion of the centenary of Koch's discovery of the tubercle bacillus in 1882, we pay tribute to this great German master of medicine.     

Chirurgische Qualität der Organentnahme in Bayern

Surgical problems during organ procurement may propagate complications in the transplant recipient. Ultimately, these problems may result in the complete loss of already scarce donor organs. Donor reports (Eurotransplant donor report) of 1,492 donor organs from January 2010 to August 2012 in the German Foundation of Organ Transplantation (DSO) region of Bavaria and corresponding organ quality forms were analyzed. Surgical problems were classified into 3 categories: (I) surgical problems recognized and reported by the donor surgeon, (II) surgical problems observed by the recipient surgeon but not reported by the donor surgeon and (III) surgical problems leading to organ loss. Surgical problems during this 20-month time period were reported for 17.6??% of organs; category I in 5.5??%, category II in 11.1??% and category III in 1??%. Damage of graft vasculature in 9.1??% was the most frequently reported problem. The mean error index for individual surgeons was 16??% and one out of the five Bavarian organ procurement centers had significantly more problems in all categories (30??%). Interestingly, surgeons who performed rapid retrieval procedures had more problems with quality than surgeons who took more time. Organ retrieval is prone to surgical problems. Especially in a system of organ transport, consistent reporting of surgical problems and quality assurance is needed to maintain and to improve surgical quality.     

Facial restoration by transplantation

Hundred years ago, Sir Harold Gillies laid a foundation to the modern plastic surgery trying to reconstruct facial defects of severely disfigured soldiers of World War I. Some years later, Joseph Murray experimented with rejection of skin grafts aimed for treatment of burned patients who sustained their injuries on battlefields of World War II. In 1954, the acquired expertise and intensive research allowed him to perform the first successful kidney transplantation in the world at Peter Bent Brigham Hospital in Boston. For his achievements in organ transplantation he was awarded Nobel Prize in 1990. The face transplantation appears to be a natural evolution of the work of these two extraordinary plastic surgeons. The first case of partial face transplant from 2005 in France revealed the world that facial restoration by transplantation is superior to conventional reconstruction methods. Since 2009, our team has performed 7 cases of face transplantation at Brigham and Women's Hospital, which is to our best knowledge the largest living single center face transplant cohort in the world. In this article, we want to reflect on the experience with face transplantation at our institution from the past years. We aim to briefly review the key points of the know-how which was given to us from the care of these unique patients.     

Loss of liver transplant surgeons into alternate career paths

In Germany, long‐term commitment of surgeons to transplantation is rare. Most surgeons leave transplant surgery after a short stint and follow careers in other surgical fields. This rapid turnover of liver transplant surgeons may result in poor resource utilization and potentially compromise patient safety. In this report, we have analyzed the caseload and the careers of 25 surgeons in liver transplantation over a period of 22 years. The median time in liver transplantation was short. Of all surgeons who engaged in liver transplantation, the median time was 3.5 years. Surgeons who completed their training remained in the field for 7 years. Surgeons who prematurely stopped their training remained for 2 years. Individual total caseloads of transplant surgeons were relatively low. The median number of procedures was 40 for all surgeons, 153 for currently active surgeons, 51 for surgeons who completed training, 27 for surgeons currently in training, and a median of four liver transplantations for surgeons who prematurely stopped liver transplantation. The vast majority (75%) of surgeons prematurely quit liver transplantation to follow alternate surgical careers. Structural changes in academic transplant surgery have to be made to facilitate long‐term commitments of interested surgeons and to avoid “futile” transplant careers.     

Operative mortality after renal transplantation--does surgeon type matter?

PURPOSE: Currently there are 64 accredited renal transplantation fellowships in Canada and the United States. Only 27% are limited in scope to kidney transplants. In the remaining fellowships the trainee learns to transplant multiple abdominal organs. Given this evolution to the multiorgan transplant surgeon, we evaluated the effect of the current training paradigm on practice patterns and outcomes for kidney transplants. MATERIALS AND METHODS: Using data from the Nationwide Inpatient Sample, discharge records for kidney transplants (6,674) were abstracted (1993 to 2003). Through the Nationwide Inpatient Sample unique surgeon identifier we determined the proportion of kidney transplants performed by multiorgan and kidney only transplant surgeons. We fit multilevel regression models to examine the relationship between surgeon type and transplant outcome. RESULTS: We identified 99 multiorgan and 196 kidney only transplant surgeons who performed 3,255 and 3,419 kidney transplants, respectively. Kidney only transplant surgeons were more likely than multiorgan surgeons to practice in nonteaching, private, for-profit hospitals (p <0.05). Unadjusted operative mortality was higher in patients treated by kidney only vs multiorgan transplant surgeons (1.7% vs 0.9%, p = 0.002). After adjusting for patient and hospital factors, those who underwent renal transplantation performed by multiorgan transplant surgeons had 55% lower odds of inpatient death (OR 0.45, 95% CI 0.26-0.76) vs kidney only transplant surgeons. CONCLUSIONS: Despite the current training paradigm, kidney only transplant surgeons have a prominent role in renal transplantation. However, given the current donor organ shortage and the implications for quality, the observed mortality difference suggests that additional investigation is needed to determine whether this role should be decreased.     

The "right stuff": five Nobel Prize-winning surgeons

Alfred Nobel's will specified that his estate be placed in a fund, the interest of which was to be distributed on an annual basis "to those who during the preceding year had conferred the greatest benefit on mankind." The first Nobel Prize in Physiology or Medicine was awarded in 1901, and its receipt is widely regarded as one of the highest accolades in science. This article reflects upon five surgeons who have been recognized as worthy of this honor. They are Emil Theodore Kocher, Alexis Carrel, Frederick Grant Banting, Werner Theodor Otto Forssman, and Charles Brenton Huggins. By winning this coveted prize these men have elevated the discipline of surgery to the summit of the scientific world. We review their legacy as an inspirational reminder of what we, the future of surgery, are capable.     

Alexis Carrel: Genius,Innovator and Ideologist

Alexis Carrel was a Frenchman from Lyon, who gained fame at the Rockefeller Institute in New York at the beginning of the 20th century. He was the first to demonstrate that arteriovenous anastomoses were possible. Alexis Carrel was awarded the Nobel Prize for his contributions to vascular surgery and transplantation in 1912. He was a versatile scientist, who made numerous discoveries from the design of an antiseptic solution to treat injuries during the First World War to tissue culture and engineering, and organ preservation, making him the father of solid organ transplantation. Together, with the famous aviator and engineer Charles Lindbergh, they were the first scientists capable of keeping an entire organ alive outside of the body, using a perfusion machine. Due to his many dubious ideas and his association with fascism in the 1930s and during the Second World War, many of his scientific achievements have been forgotten today and taken for granted.     

The importance of vascular surgery training in a general surgery practice

The aim of this report was to document the practice of vascular surgery for graduates of 4 general surgery training programs.Graduating residents from 1991 to 1995 were surveyed by phone to document the number of reconstructive vascular and dialysis access procedures that they performed during the most recent 12 months. Those who pursued additional training beyond general surgery or who did not successfully complete the certifying examination of the American Board of Surgery (ABS) were excluded. In addition, the Resident Review Committee for Surgery (RRC-S) defined category report for these same general surgeons during their residency was examined.Fifty-five percent (26 of 47) of the board-certified general surgeons do either reconstructive or dialysis access vascular surgery. The average number of procedures in the RRC-S defined category for this cohort was 76. During the focused 12 months, 1986 vascular procedures were done by these 26 surgeons (76 cases per surgeon).In certain regions of this country, a significant volume of vascular surgery is done by general surgeons who have an ABS primary certificate alone. The technique of control and repair of major arteries and veins, the consequences of distal organ ischemia, reperfusion injury, thrombosis, and embolization are important anatomic and physiologic principles that must be taught in the curriculum to general surgeons, regardless of their future surgical careers. (Curr Surg 57:381-383. Copyright 2000 by the Association of Program Directors in Surgery.)     

The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer.

BACKGROUND: This study explores the volume-mortality relationship for 3 groups of cancer procedures to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated with lower in-hospital mortality. METHODS: New York's Statewide Planning and Research Cooperative System was used to identify more than 32,000 hospital inpatients with a cancer diagnosis who underwent colectomy, lobectomy of the lung, or gastrectomy between January 1, 1994, and December 31, 1997. The association of in-hospital mortality rates with provider (hospital and surgeon) volume was examined after adjusting for differences in age, demographics, organ metastasis, socioeconomic status, and comorbidities. RESULTS: For hospital volume for gastrectomy, the highest-volume quartile had an absolute risk-adjusted mortality rate that was 7.1% lower (P <.0001) than the lowest-volume quartile, although the overall mortality rate for the procedure was only 6.2%. For surgeon volume for colectomy, the highest- and lowest- volume quartiles differed by 1.9% (P <.0001), although the procedure mortality rate was only 3.5%. For hospital volume for lung lobectomy, the absolute difference in mortality was 1.7%. Patients undergoing operations performed by high-volume surgeons in high-volume hospitals usually had significantly lower risk-adjusted mortality rates than did patients who had low-volume surgeons or who were in low-volume hospitals, or both. CONCLUSIONS: For all 3 procedure groups, the risk-adjusted in-hospital mortality is significantly lower when the procedures are performed by high-volume providers.     

Hand-assisted laparoscopic surgery: an emerging technique

BACKGROUND: Some surgeons are finding that the placement of one hand in the abdomen during laparoscopic procedures returns tactile feedback lost during purely laparoscopic surgery and facilitates dissection, retraction, and control of bleeding. Studies comparing patient postoperative discomfort after laparoscopic and hand-assisted laparoscopic procedures have not found a significant difference. METHODS: This article is a review of the current literature on hand-assisted laparoscopic surgery and of the different hand-assisted devices on the market. Included in the review are opinions of expert laparoscopic surgeons who have used hand-assisted devices. RESULTS: More than 100 hand-assisted laparoscopic procedures have been described in the literature. At least four different companies are involved in hand-assisted laparoscopic devices. Three of these companies currently are Food and Drug Administration (FDA) approved in the United States. CONCLUSIONS: Hand-assisted laparoscopic surgery is not necessary for all laparoscopic procedures. Hand-assisted laparoscopic technique is advantageous for certain procedures and clinical situations such as en bloc resections and removal of solid organ tumors, large colon tumors, and the kidney after donor nephrectomy. This technique offers benefits when a large incision is necessary to complete surgery such an open colon anastomosis.     

Successful Kidney Transplantation from a Donation After Cardiac Death Donor With an Ileal Conduit

Kidney transplantation is the treatment of choice for those affected by end-stage renal disease. Consent for organ donation continues to be one of the greatest challenges to transplanting more patients waiting for a life-saving transplant. In an attempt to increase the donor pool for patients on kidney transplant waiting lists, transplant surgeons and physicians have expanded their acceptance criteria to include expanded criteria donors, donation after cardiac death donors, as well as those donors who present unique technical challenges to organ recovery. Here we report a successful kidney transplant from a kidney donor who died from cardiac causes and who previously underwent an ileal conduit for a neurogenic urinary bladder secondary to a spinal cord injury.     

Thoracoabdominal aortic aneurysms. A review and current status.

Surgical management of the thoracoabdominal aortic aneurysm is a formidable undertaking. Presently two fairly distinct operative methods are available. The conventional technique, pioneered by Etheredge, involves replacement of the aneurysm with a synthetic graft and then, step by step, revascularization of the abdominal organs with prosthetic side limbs taken from the primary graft. Individual organ ischemic time is limited to that time required for the performance of each distal side limb anastomosis. The second operative method, first described by Crawford, consists of proximal and distal control of the aneurysm, followed by its incision to simultaneously expose the origin of all four major intra-abdominal arteries. Replacement is then rapidly performed with a tubular Dacron graft including anastomosis of these major intra-abdominal arteries to four elliptical graft incisions, from within the aneurysm. Total operating time is reduced at the expense of prolonged organ ischemia. The conventional method allows for step-by-step intraoperative planning and action, and this technique is accordingly recommended to most surgeons, who have had little experience with this unusual lesion. Our recent successful experience with two cases of extensive thoracoabdominal aortic aneurysms is described as well as a discussion of additional measures which may become useful in certain cases to favor a successful outcome. Finally the problem of potential resultant paraplegia is discussed.     

Die Bedeutung von Alexis Carrel für die moderne Gefäßchirurgie

Fifty-two years after Alexis Carrel's death, the results of his research continue to be valid in vascular surgery. The basic principles of Carrel's suture technique are still applied several thousand times a day all over the world. In addition to end-to-end anastomosis, patch grafts, side-to-side anastomosis, homologous and heterologous grafts and microvascular surgery offer evidence of Carrel's outstanding foresight and ingenuity. For his almost legendary work Alexis Carrel received the Nobel Prize for Medicine in 1912. His book “Man the Unknown” made him a public figure. Today vascular surgeons look upon Alexis Carrel with admiration and gratitude.     

Surgery of metastases in renal cell carcinoma

Renal cell carcinomas (RCC) are endowed with impressive metastatic potential. Patients with RCC who present with apparently solitary metastatic lesions represent a small cohort. Due to the different long-term results achieved with surgical resection of metastatic RCC lesions, a generally accepted judgement about this treatment modality is not possible. Several studies suggest that aggressive surgical management can provide an effective treatment, especially in patients with solitary pulmonary metastases. Most noteworthy is the fact that because of the organ distribution of RCC metastases, surgical therapy is dominated by general and thoracic surgeons, neurosurgeons, and orthopaedic surgeons. Therefore, an interdisciplinary approach is one of the most important key points for a successful outcome in these patients.     

Metastasenchirurgie beim Nierenzellkarzinom

Renal cell carcinomas (RCC) are endowed with impressive metastatic potential. Patients with RCC who present with apparently solitary metastatic lesions represent a small cohort. Due to the different long-term results achieved with surgical resection of metastatic RCC lesions, a generally accepted judgement about this treatment modality is not possible. Several studies suggest that aggressive surgical management can provide an effective treatment, especially in patients with solitary pulmonary metastases. Most noteworthy is the fact that because of the organ distribution of RCC metastases, surgical therapy is dominated by general and thoracic surgeons, neurosurgeons, and orthopaedic surgeons. Therefore, an interdisciplinary approach is one of the most important key points for a successful outcome in these patients.     

Pelvic organ prolapse transvaginal repair by the Prolift system: Evaluation of efficacy and complications after a 4.5 years follow up

Objectives: The Prolift system is a polypropylene device designed for pelvic organ prolapse repair by a transvaginal approach. Numerous studies have reported on short‐term outcomes of this procedure, but long‐term studies are lacking. Methods: A retrospective study of patients who underwent pelvic organ prolapse repair by Prolift between September 2005 and September 2008 was carried out in two tertiary reference centers by two experienced surgeons. Preoperative and postoperative follow up was based on medical records of baseline and follow‐up visits with complete clinical examination, including Pelvic Organ Prolapse Quantification stage. At last follow up, the Pelvic Floor Distress Inventory‐20 questionnaire was assessed by telephone interview. Cure was defined as an anatomical success at last follow up, being a Pelvic Organ Prolapse Quantification stage ≤1 without further surgical intervention in any compartment. Results: A total of 75 patients were included in this analysis with a mean follow up of 53.7 ± 8.8 months (range 36–72 months). Patients were treated with two‐arm Prolift posterior, four‐arm Prolift anterior and six‐arm Prolift total in three (4%), 51 (69%) and 21 (27%) cases, respectively. At last follow up, 64 (85.3%) patients were cured, with no prolapse recurrence. Mesh exposure occurred in four (5.3%) patients. The Pelvic Floor Distress Inventory‐20 symptom score was low at last follow up (median 8, range 3–18), in accordance with objective cure data. Conclusions: The Prolift system is safe and efficacious for pelvic organ prolapse repair by transvaginal approach after a 4.5‐year follow up.