The future: surgery of the spinal cord?

Surgery of the spinal cord is still experimental, and outcomes must be confirmed by more cases. In this field, knowledge and research are still figuratively in the Stone Age. Nevertheless, the author is confident that in the future, with the improvement of surgical and resuscitation techniques and with the introduction of new biotechnologic drugs and molecules that favor axon regeneration and inhibitor blocking, CNS-peripheral nerve connections can be performed with some functional improvement, even in tetraplegia.     

Aortic valve surgery: what is the future?

Modern surgical treatment for aortic valve disease has undergone significant improvements in all areas of this procedure. Successful treatment strategies for cardiovascular diseases have often been initiated and driven by surgeons. Radical excision of diseased tissue, repair and replacement strategies lead to long-term successful treatment of the underlying diseases and clearly improved patient outcome. In highly developed nations, valve surgery will be increasing applied in older people, with more co-morbidities and a higher incidence of concomitant coronary artery disease. Cardiovascular surgeons will be facing increased competition from the catheter-based procedures; these are already applied clinically, and their numbers will rise in near future. Right now interventional cardiologists supported by some cardiac surgeons are on their way to transform some conventional open surgical procedures into catheter-based less invasive interventions, such as valve repair and replacement. Cardiovascular surgery is undergoing a rapid transformation; socio-economic factors and recent advances in medical technology contribute to these changes. Further developments will come, and surgeons with all their expertise in the treatment of valvular heart disease need to be part of it. Cardiovascular surgeons have to adapt the exciting new approaches of transapical and transfemoral transcatheter valve implantation techniques.     

A reappraisal of thyroid surgery under local anaesthesia: Back to the future?

Background : Thyroid surgery is usually performed under general anaesthesia. However, for a selected group of patients, local anaesthesia may be preferable. The aim of this study was to review the authors’ experiences with local anaesthesia with regard to the safety and outcome of this approach. Methods : A total of 65 consecutive patients who underwent primary thyroid surgery were accrued prospectively into this study from May to December 1999. A field block with 0.5% bupivacaine and adrenaline in 1:200 000 dilutions was given in all cases. In addition, light sedative and narcotics were given as necessary to achieve patient comfort and cooperation. The pain experienced during surgery was recorded using a visual analogue scoring system on a scale of 1–10. Results : Unilateral thyroid resection was performed in 58 patients, isthmectomy in four patients and bilateral thyroid resection in three patients, two of which were in their second trimester of pregnancy diagnosed with papillary thyroid cancer. There were 55 women and 10 men with an average age of 38.2 years (range: 18–67 years). No conversion to general anaesthetic was needed, and the mean operating time was 80 min. The postoperative recovery was quick with this technique and, of interest, 22 (33.9%) patients were discharged within 6 h following the surgery. Overall 62 (95.4%) patients were discharged in the first 24 h and three (4.6%) patients after 24 h. There were no significant postoperative complications encountered except for wound infection in two (3.1%) patients. Conclusions : Thyroid surgery under local anaesthesia can be performed safely in a selected group of patients. It offers an effective alternative approach to general anaesthesia and is associated with low morbidity and high levels of patient satisfaction.     

A future role for the pulmonary artery catheter?

Either a moratorium prohibiting, or a prospective, randomized clinical trial on pulmonary artery catheter use has been proposed. Expert opinion regarding both this suggestion and on the therapeutic efficacy of interventions guided by pulmonary artery catheters in a variety of clinical settings has included (in my view incorrectly) physician prerogative and perceived threats to therapeutic freedom. The legitimate concerns of worsened patient outcome secondary to pulmonary artery catheter use and demonstrably inadequate intellectual preparation of practitioners and allied healthcare professionals, which may exacerbate these deficiencies, have also been discussed. The future of the pulmonary artery catheter is questioned; physicians must evaluate the available information and, more importantly, critique their current practice, before employing this technology.     

Day surgery—the future

Day surgery in Australia continues to expand but has not reached its potential of 60% of procedures. The concept of extended recovery for appropriate day surgery patients, involving overnight stay, was recently unanimously supported by the Australian Day Surgery Council. This should provide a significant stimulus for the further expansion of day surgery. There has been no formal undergraduate or postgraduate teaching of day surgery and this needs to be addressed.