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The Johns Hopkins Department of Surgery congratulates the American College of Surgeons on 100 years of excellence.
The Johns Hopkins Hospital is pleased to announce the opening of two new patient care buildings: Q
33 State-of-the-Art Operating Rooms
Q
Integrated Audio and Visual Systems
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Spacious Centralized Preparation and Recovery Areas
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Remembering Milestones and Achievements in Surgery: Inspiring Quality for a Hundred Years
1913-2012
Throughout the last century, our two organizations have worked hard to advance the medical profession and have successfully overcome so many challenges faced by surgeons and all physicians. We’ve come a long way together—however, our journey isn’t over. We look forward to working with you to shape the future of medicine on behalf of America’s physicians and patients for hundreds of years to come.
Introduction
by DAVID B. HOYT, MD, FACS
The leadership and staff of the American College of
during the first 75 years, including Dr. William Stewart
Surgeons (ACS) are privileged to be part of the College’s
Halsted’s creation of true resident training system,
Centennial celebration.
advances in surgical patient safety, organ transplanta-
To help commemorate the College’s Centennial, we have
tion, and advances in breast and bowel procedures.
produced Remembering Milestones and Achievements in
UÊ Dr. Richardson’s predecessor as Chair of the Board of
Surgery: Inspiring Quality for a Hundred Years, 1913-2012,
Regents, Carlos Pellegrini, MD, FACS, picks up where Dr.
a collection of thoughts on the evolution of surgical prac-
Richardson leaves off, noting the stark contrast between
tice over the past century. In this publication, the authors
general surgery of the first 75 years, when operations
write from their hearts and minds on a range of surgical
were highly invasive, and surgery of the last 25 years,
achievements as well as about selected College contribu-
which now revolves around the development of increas-
tions to the profession. Their personal recollections and
ingly less invasive procedures.
reflections provide a unique perspective on how surgical
UÊ Former ACS Governor Grace Rozycki, MD, FACS, and
care has changed across all specialties since the College
David V. Feliciano, MD, FACS, provide an overview of the
was established in 1913.
history of public hospitals.
Accompanying many articles are photographs of some
UÊ Past-President LaMar McGinnis, Jr., MD, FACS, shares
of the key figures who dedicated their time and leader-
his perspectives on the history of the Joint Commission,
ship to establish, expand, and sustain the College as
the successor to the College’s Hospital Standardization
the preeminent surgical association in North America.
program, and how its guidelines and policies have contrib-
Also depicted are the changing tools of our trade. This
uted in improved quality of care.
combination of remembrances, observations, and visual
UÊ Cliff Ko, MD, FACS, Director of the ACS Division of
flourishes make this document a scrapbook, if you will,
Research and Optimal Patient Care, offers an overview
of our shared history.
of ACS quality programs and how they have developed
Some of the ACS luminaries who volunteered to help us
and changed over time.
compile this collection and their contributions to it are as follows:
UÊ Fabrizio Michelassi, MD, FACS, writes about the College’s
UÊ Patricia Numann, MD, FACS, and A. Brent Eastman, MD,
relationship with the international surgical community
FACS, share their thoughts as the outgoing and newly
and commitment to global health care issues.
elected Presidents, respectively, of the ACS.
In addition, leaders from each of the surgical specialties
UÊ Past-Chair of the Board of Governors and a former Interim
(all Fellows of the College) look back at the major historical
Director of the College, David L. Nahrwold, MD, FACS, has
achievements in their disciplines. Examples include the
written the authoritative account of the College’s history,
following: John E. Connolly on cardiothoracic surgery;
titled A Century of Surgeons and Surgery. He draws on
Herand Abcarian on colon and rectal surgery; Karl C.
that experience here to reflect on the College’s early days
Podratz on gynecologic and obstetric surgery; Edward R.
and its everlasting commitment to surgical education.
Laws on neurological surgery; Barrett G. Haik on ophthalmic
UÊ Past-President George F. Sheldon, MD, FACS, writes
surgery; David G. Murray on orthopaedic surgery; Gerald
about the ACS as a “university” and his experiences as a
B. Healy on otolaryngology; Thomas V. Whalen on pedi-
surgical educator who has held many leadership positions
atric surgery; Mary H. McGrath on plastic and maxillofacial
in this organization over the course of the past 50 years.
surgery; Jack W. McAninch on urology; and Mahmoud Malas
UÊ ACS Past-President L.D. Britt, MD, FACS, provides
and Julie Freischlag on vascular surgery.
a detailed summary of the many contributions that
The College is indebted to each and every one of these
surgeons of African-American heritage have made to
authors for taking the time to share their insights with all
this organization and to surgical patient care.
of us as we begin the observance of the American College
UÊ The current Chair of the Board of Regents, J. David
of Surgeons’ first 100 years. I anticipate that you will find
Richardson, MD, FACS, discusses the major historical
their views are enlightening and compelling and provide an
achievements that have occurred in general surgery
excellent launching pad for our Centennial celebration. Q
7
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SURGICAL INNOVATION. The faculty and staff at Loyola congratulate the American College of Surgeons on its 100th Anniversary. We are proud to share the same long legacy of leadership and success with the college. Our mission is to train outstanding surgeons, at all stages of their careers, and to provide the highest quality care to our patients. The physicians and staff at our academic medical facility are known for their multidisciplinary care, attention to the human spirit and their technical skills. Whatever your surgical specialty, we have the latest technology and innovation to make sure you achieve your goals.
Find out more. Call us at (70 8) 32 7-D O C S (708-327-3627). LoyolaMedicine.org
Š2012 Loyola University Health System
Contents 7
Introduction By David B. Hoyt, MD, FACS
14
The Presidential View To celebrate its 100th anniversary, Dr. Patricia J. Numann and Dr. A. Brent Eastman lay out clear goals for the American College of Surgeons’ bright future based on its successful past. By Julie Sturgeon
20
The Role of the College in Surgical Education By David L. Nahrwold, MD, FACS
26
The American College of Surgeons as a University By George F. Sheldon, MD, FACS, FRCSEd (Hon), FRCSEng (Hon)
34
Michael O. Meyers, MD Associate Professor Division of Surgical Oncology & Endocrinology
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Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African-American Heritage By L.D. Britt, MD, MPH, FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon)
42
Major Historical Achievements in General Surgery: The First 75 Years By J. David Richardson, MD, FACS
50
Minimally Invasive Surgery: General Surgery’s Revolution The Past 25 Years in General Surgery By Carlos A. Pellegrini, MD, FACS, FRCSI (Hon)
56
A History of Public Hospitals By Grace S. Rozycki, MD, MBA, FACS, and David V. Feliciano, MD, FACS
66
Something in the Air “American Surgery’s Noblest Experiment”—C. P. Schlike, JAMA, 1973 By LaMar S. McGinnis, Jr., MD, FACS
76
ACS Quality Programs By Clifford Y. Ko, MD, FACS
84
The American College of Surgeons’ Contributions to International Surgery By Fabrizio Michelassi, MD, FACS
94
Progress in Cancer Surgery By Murray F. Brennan, MD, FACS
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Contents 100
Historical Achievements in Cardiothoracic Surgery By John E. Connolly, MD, FACS
106
Advances in the Twentieth Century: Colon and Rectal Surgery By Herand Abcarian, MD, FACS
113
Degrees of Freedom Advances in Gynecological and Obstetrical Surgery By Karl C. Podratz, MD, PhD, FACS
121
Neurosurgery and the American College of Surgeons By Edward R. Laws, Jr., MD, FACS, DMedCh Naples (Hon), FRCSEd (Hon), FRCPSG (Hon)
126
Through the Lens: A Century of Innovation in Ophthalmic Surgery By Barrett G. Haik, MD, FACS
132
Orthopaedic Surgery 1913 to 2012 100 Years of Evolution, Invention, and Innovation By David G. Murray, MD, FACS
140
Milestones in Otolaryngology–Head and Neck Surgery From leaders to lasers, the field of otolaryngology–head and neck surgery has impacted surgery in more ways than most patients—and fellow surgeons—would guess. By Gerald B. Healy, MD, FACS, FRCSEng (Hon), FRCSI (Hon)
147
The Large and the Small of It Advances in Pediatric Surgery By Thomas V. Whalen, MD, MMM, FACS
154
Plastic Surgery A Story of Innovation By Mary H. McGrath, MD, MPH, FACS
166
History of the Committee on Trauma “He who wishes to be a surgeon should go to war.”—Hippocrates By Donald D. Trunkey, MD, FACS
176
A Look Inside Advancements in Urologic Surgery By Jack W. McAninch, MD, FACS, FRCSEng (Hon)
184 No Roadblocks Advancements in Vascular Surgery By Mahmoud Malas, MD, MHS, FACS, and Julie Freischlag, MD, FACS
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Financial Controller: Robert John Thorne
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FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon)
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Publisher, North America: Ross Jobson
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Publisher, Europe: Peter Antell
LaMar S. McGinnis, Jr., MD, FACS Mary H. McGrath, MD, MPH, FACS Fabrizio Michelassi, MD, FACS David G. Murray, MD, FACS David L. Nahrwold, MD, FACS Carlos A. Pellegrini, MD, FACS, FRCSI (Hon) Karl C. Podratz, MD, PhD, FACS J. David Richardson, MD, FACS Grace S. Rozycki, MD, MBA, FACS George F. Sheldon, MD, FACS, FRCSEd (Hon), FRCSEng (Hon) Julie Sturgeon Donald D. Trunkey, MD, FACS Thomas V. Whalen, MD, MMM, FACS
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The Presidential View To celebrate its 100th anniversary, DR. PATRICIA J. NUMANN and DR. A. BRENT EASTMAN lay out clear goals for the American College of Surgeons’ bright future based on its successful past. by JULIE STURGEON
Presidents, no matter their organization or current status, bring one needed focus to the membership: vision. But as American College of Surgeons (ACS) President Patricia J. Numann and President-Elect A. Brent Eastman know, seeing into the future isn’t a matter of crystal balls or personal egos. Effective leadership guides the team in bridging the past with the future in a seamless way. Here’s a peek at how the outgoing and incoming leaders see the ACS’ strengths.
14
PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS
Patricia J. Numann, MD, FACS President
A. Brent Eastman, MD, FACS President-Elect
Lloyd S. Rogers Professor of Surgery
N. Paul Whittier Chair of Trauma, Scripps
Emeritus at Upstate Medical University in
Memorial Hospital La Jolla, CA; Chief
Syracuse, NY. Clinical interests: general,
Medical Officer and Corporate Senior
endocrine, and breast surgery; women’s
Vice President, Scripps Health; Clinical
professional issues; and surgical
Professor of Trauma Surgery, University
education. Launched the Comprehensive
of California, San Diego. Clinical interests:
Breast Care Center at University Hospital
general, vascular, and trauma surgeon
(now renamed the Patricia J. Numann
and leader in trauma and emergency
Breast and Endocrine Surgery Center)
surgical care. Member of the ACS Board
in Syracuse more than 20 years ago.
of Regents 2001–10, and Chair 2009–10.
15
On health care reform
N
been introduced. So the College is doing very specific things
ow more than ever, the College has
that can be seen and measured to assure the public that
been actively involved as advisor to
they receive safe, effective care. Letting public officials who
political leaders. As a surgeon working
are going to have to act on these bills know the quality and
in the system, you have a perspective on
value of care will allow them to make informed choices on
issues they may not have. You understand that some proposed
legislation regarding health care expenditures.
changes are problematic. So we try to help government offi-
The College isn’t just reacting. The College looks at
cials look at a system of paying for medicine that is equitable
what’s happening in all aspects of surgical care and tries
across the lines of specialties—within surgery and outside of
to improve it. The College gives you the roadmap for quality
surgery—look at the value delivered for that cost, and look
programs, but it’s the Fellows in their hospitals, in their
at developing systems of care that are more efficient. The
communities, who make sure to follow these guidelines,
College makes sure the public and our elected officials know
make sure their hospitals participate in these programs,
that quality of care is our foremost concern. The College has
and make sure the public can know that by seeking certi-
certification and verification programs for areas like the
fication and verification of their programs.
bariatric care programs, trauma care, and cancer centers, which assure the public of the quality of these centers. Over the last couple of years, we’ve introduced and expanded
When I came to my first College meeting in 1969, the
the ACS National Surgical Quality Improvement Program®
only women that I saw were spouses and nurses. There
(ACS NSQIP®) for hospitals. This program dramatically
were very few woman surgeons in the country. None of the
reduces the morbidity and mortality in hospitals that use
presentations were by women and none of the officials were
it. The Surgeon Specific Registry (SSR), which can allow
women, which bothered me. I didn’t know many woman
individual surgeons to track their performance, has just
surgeons nor did I know if there were many women involved
On health care access
T
data-driven society and we have to turn that data into
he crux of managing surgical care
clinical information that supports best practice. What is
nearly everywhere in the world
the best way to treat a trauma patient? What is the best
is the problem of barriers to access—
way to treat a patient with cancer? These clinical guide-
whether for lack of insurance, as for millions of Americans,
lines, all of which fall under our very robust education
or for long wait times, or distances, or because of weather
division, are responsible for the continued updating of
and terrain and maldistribution of surgeons nearly every-
our surgeons in best surgical practice.
where in the world. The ACS is committed to a policy of
Regarding systems of care, I think the ACS and the public
high-quality, safe, appropriate, and affordable surgical
should recognize the value of the ACS trauma program led
care. This is expressed very clearly in the ACS Inspiring
by the Committee on Trauma since 1922. Injury, or trauma,
Quality initiative: Highest Standards, Better Outcomes.
is the leading cause of death up to age 45 in the United
Our Health Policy and Advocacy Committee gathers input
States and in most of the world. The optimal response to
on this issue, allowing the ACS to help determine what
the injured patient has been my life interest and the trauma
constitutes efficient best surgical practices and appropriate
systems developed by the ACS have unequivocally reduced
surgical procedures. Who better than surgeons to make
death and disability. ATLS has absolutely set the worldwide
these critical decisions? That’s what we do every day and
standard for the initial care of the injured patient. The
every night. ACS NSQIP unequivocally addresses the value
inclusive trauma system model that has been so successful
equation. Dr. Numann has alluded to some of the specifics of
in optimizing the care of the injured patient may well be a
how we’re doing this at home; and we are also involved in
model for dealing with other emergent and time-sensitive
helping establish the best ways to practice surgery around
medical and surgical diseases.
the world. We are an international organization.
16
On women’s evolving role
I’m proud of the approach to surgical care the College
We help set standards of surgical care. We have regis-
has taken and indeed believe it is the only approach
tries in trauma. We have registries in cancer. We are a
that can be sustained. When I was Chair of the Board
with the College. So I posted a notice inviting women
surgeons in America are women. Of the incoming residents,
surgeons to come to breakfast to explore these issues. Out
more than 40 percent of them are women; in vascular, 60
of that, we ultimately formed the Association of Women
percent of the matched residents were women. So the repre-
Surgeons, which just celebrated its 32nd anniversary. My
sentation of women is changing dramatically. Fifty percent
original intent was that we would keep ourselves married
of medical students are women, and with that statistic, if
to the College. I do not believe in separatist organizations in
women don’t become surgeons, our profession will suffer.
that sense. Women did have interests and concerns that we
Certainly in my time in the College, we’ve moved not only
needed to address to make surgery an attractive career for
to incorporate women into the activities of the College, but
them. I felt having meetings separate from the College would
also to incorporate the residents and younger surgeons
be far less productive than to have them at the College and
more fully in the planning and the organization so that their
encourage women’s integration into the College.
views could come forward. Each generation is different in a
The College has been supportive—more than 10 years ago,
million other ways. You need to take that into consideration
it started a Women in Surgery Committee to look at areas
in your planning, in the programs that you offer, and in
such as maternity leave policies, aspects of leadership, and
their delivery. I can’t tell you how proud I am of how well
other issues important to women. The College has adopted a
the College really keeps up in these areas, even down to
lot of the suggestions, including ones on civility and behavior
using social media for communications. (You still get the
that we felt could be addressed better than they had been.
print copy if you want it.) We’re trying to be all things to all
Women have steadily been more visible within the College.
people, as best an organization can be.
Today I’m President, the second woman to hold that office. There are a number of women Regents. Until 2000, there had
On serving multiple audiences
never been a woman officer. The inclusion of women in the
One hundred years ago, the American College of
governance is important as in 2012 almost 28 percent of the
Surgeons was founded to look at the quality of care
of Regents, my colleague, Dr. Michael Zinner, Chair of
residents were claimed by World War II. Some of the
the Board of Governors, and I chose the keynote speaker
proudest moments of my career were my first two years
for a joint meeting of the Board of Regents and Board of
in practice beside this deft and compassionate surgeon
Governors. Dr. Brent James, surgeon and chief quality
with excellent results and a legion of admirers.
officer of the highly regarded Intermountain Healthcare,
Today, with over 50 percent of our medical school classes
told the surgeon leaders in no uncertain terms, “If you start
and 40 percent of our residency positions being held by
with the money, you will fail. If you start with quality, the
women, it is clear that the future of surgery will and should
money will follow.” He also said that only one generation
be heavily influenced by them. I believe the field of surgery
every 100 years has the opportunity to make a major differ-
and our surgical patients will be the benefactors of this
ence in health care and we are that generation.
critically important diversity.
On women’s evolving role
On reaching multiple audiences
I have to say that I have always known what women
Dr. Numann said that our College is ultimately about
surgeons could do—or at the very least since 1972, when
the Fellows, and I couldn’t agree more. Our diversity is
my first surgical partner was my mother-in-law, Dr. Anita
embodied in our very structure. We are the American
Figueredo. Anita was a pioneering surgeon in San Diego,
College of Surgeons of the United States and Canada, but
whose own mother brought her to New York from Costa
the Founders of 1913 truly considered ACS the College of
Rica as a 5-year-old child, specifically because she wanted
all the Americas, and we have chapters in Mexico and
to be a doctor and Costa Rica had no medical school. Anita
throughout Latin America, as well as around the world.
graduated from the Long Island College of Medicine in
At home, we continue to be cognizant of the different
1940 and was given the opportunity to become a resi-
demands on surgeons in rural versus urban versus
dent in surgery at the Memorial Cancer Hospital in New
suburban settings. And we must never forget that the ACS
York City (now Memorial Sloan-Kettering), after male
encompasses all surgical specialties. So we are focused at
17
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in hospitals and to accredit hospitals
delegate would not support adding surgical care for fear
because they wanted to be sure that
that it would take away from vaccination or some other part
surgeons worked in locations that could
of the program. But when you look at years of life and the
provide them the necessary resources.
quality of life lived, delivering surgical care may be even
Only 9 percent of the hospitals in America
more important than some vaccinations and immunizations.
met the standards at the beginning. Now, you have to meet the standards or you can’t be a hospital. Continuing to address the quality of surgical care in hospitals remains a prime focus of the College.
On standing out from other medical associations One value of the College is that if you, even as an individual, identify something you believe is important to the
Not only are the programs that have been developed
American people or surgery and you bring it to the organiza-
in America continuing to bring better quality care to our
tion, it will take it to heart, study it, and incorporate it if it
citizens, but they are also being adopted worldwide. Today
agrees on its merit. Just as I brought the women’s issue, the
we have 40 countries in addition to the United States with
rural surgeons recently brought their concerns to the Board
ACS chapters; they’re very robust and enthusiastic about
of Regents, which has agreed to work diligently to address
bringing, as they call them, American programs like our
them. Many years ago the issue of the poor coordination
cancer, education, and trauma programs to their countries.
and delivery of trauma care was brought to the College by
The NSQIP program in many ways closes the loop. It not only
a single Fellow. Within my career, Advanced Trauma Life
looks at the quality but provides feedback data that can be
Support® (ATLS®) and the nationwide system of trauma
used in an ever continuing loop for improvement. The public
centers were developed, which assures Americans the
can be assured that maximal safety and quality exist in that
finest trauma care. That’s why when I gave my presidential
hospital. So we’re starting the next century with yet another
address, I focused on stewardship and pointed out how
example of how the College develops programs that provide
individual Fellows have made incredible contributions.
the means to create and measure excellence in health care.
I wouldn’t want to lose that connection and ownership of
The College is very concerned about surgical care
the Fellows—it’s that which allows these quality program to
throughout the world. This last year at the Clinical Congress,
expand and new ones to be developed. Because you as an
the International Presidents went on record, as did the Board
individual Fellow work on these committees, help form the
of Regents, to make sure that the United Nations Healthcare
policy, and help implement the change, it belongs to you.
policies included surgical care. The U.N. wasn’t going to
The Fellows are the lifeblood of the organization. They make
include surgical care; we had heard that even the American
the College work and make it great. Q
the College on diversity in the broadest
possible outcome. Those are the broad shoulders on which
sense: in terms of gender, generations,
Dr. Numann and I and all surgeons stand today.
geographies, and specialties. Certainly,
What makes us different as a medical association is our
one of our greatest challenges today
potential to speak for surgery in its entirety—so crucial
is the engagement, recognition, and
in this era of health care reform with its emphasis on
support of those surgeons who serve in rural communi-
primary care. We must be able to speak with one voice
ties. Having grown up in Wyoming, the least populous
for all of surgery if we are to have sustainable health care
state in the U.S., I understand those challenges.
systems in our countries and an adequate workforce. We must influence public policy and collaborate with physi-
On standing out from other medical associations Looking back on our 100 years, one sees that a large
cians in all other disciplines for the benefit of those who rely on us to safeguard their health.
part of our rich history is based on altruistic principles.
In the final analysis, our actions in the office, in the clinic,
Our courageous founding surgeons were willing to say that
in the operating room, and in the world must always address
we are committed to ensuring that every patient entering
the fundamental question, “What is best for my patient?” If
a hospital for surgery is safe and may experience the best
we are guided by that, we will never be wrong. Q
19
The Role of the College in Surgical Education by DAVID L. NAHRWOLD, MD, FACS
W hen the founders established the American College of Surgeons (ACS) in 1913, they envisioned it as an educational institution. The annual Clinical Congress, its weeklong educational meeting, consisted of lectures, panel discussions, and exhibits. But the centerpiece of the meeting was the operative clinics, where expert surgeons performed operations in local hospitals and Congress attendees observed and learned how to emulate them.
the American Board of Surgery (ABS), which set high standards for training that had to be met for admission to its rigorous examinations. The board required that candidates have the MD degree, complete an internship and a three-year residency plus two years of surgical study or surgical
Soon, three or four three-day education sessions were held in medium-
of surgical care and the education and
practice. A written exam covered the
training of surgeons.
basic sciences and the principles and
sized cities each year. But College leaders recognized that education alone would not elevate the level of
practice of surgery, and, if the candi-
The College Responds to Its Critics
surgical care in the country, because
date passed Part I, he was admitted to Part II, which consisted of two days of examinations in clinical and opera-
so many hospitals had inadequate
When the College was founded, the
tive surgery. Candidates who met the
administration, facilities, and staff,
requirements for fellowship included
board’s standards for training and
including their doctors. To rectify
graduation from an approved medical
passed the examinations received a
this, they implemented the College’s
school, a one-year internship at a “cred-
certificate and were designated as
hospital standardization program, in
itable” hospital, two years of service
“board certified.” Although many
which standards for hospitals were
as a surgical assistant or evidence of
modifications have been made in the
established and College surveyors
an equivalent apprenticeship, and five
structure and educational content
inspected them for their compliance
to eight years of practice. In the mid-
of the surgical residency, the basic
with the standards. Much later, in
1930s, the academic elite—professors
requirement of five years of training
the 1930s, its familiarity with hospi-
at major medical schools—led by Dr.
plus written and oral examinations,
tals through this program allowed
Evarts Graham, chair of surgery at
required today, was established by the
the College to also set standards
Washington University in St. Louis,
board’s founders in 1937.
for surgical residency programs in
MO, were increasingly critical of
The Regents of the College believed
approved hospitals and inspect them
the College and its leadership. They
that its “examination” of candidates,
for compliance. In both programs,
believed that the College leadership
consisting of reviewing 50 of the
the College emphasized improve-
was out of touch and inbred. But their
100 cases submitted by applicants,
ment, publishing materials and
main complaint was that the College
interviews of candidates by respected
holding conferences to assist hospitals
admitted individuals to fellowship
surgeons, and opinions on their qual-
and their medical staffs to improve
who were not adequately trained and
ifications by fellows of the College in
the quality of care and of training.
whose surgical skills and knowledge
their local area, was more thorough
Through these programs, the College
were wanting. The dissidents’ solution
than the evaluation of the ABS. The
had a major influence on the quality
to the quality problem was to develop
College obtained information on the
20
A l ready vexed by t he you ng academics and the board certification movement, the ACS Board of Regents was embarrassed that the College was not represented in the AMA initiative. The Regents decided that the College must be involved in the training of surgeons. To do so they appointed a Committee on Graduate Training in Surgery, chaired by Dr. Samuel C. Harvey, chairman of surgery at Yale and a protégé of the famous Dr. Harvey Cushing. The committee was charged to determine the best possible methods to train surgeons. The committee reviewed all the existing methods of training and rejected all of them except the residency system, then in use only in a few hospitals associated with medical schools. Residencies essentially prolonged the internship for several years and allowed the student to obtain a concentrated surgical experience,
Dr. Evarts Graham, founder of the American Board of Surgery and later President of the American College of Surgeons.
but the number of residency positions was insufficient to populate the country with well-trained surgeons.
PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
The committee asserted that hospitals ethics and moral fitness of appli-
and dermatology and syphilology,
with the proper personnel, facilities,
cants, whereas the ABS was more
and representatives of several other
and organization should offer surgical
concerned about training qualifica-
organ izations. Many specialties
residencies and that minimum stan-
tions and the results of examinations.
were about to establish certifying
dards should be established for resi-
Most of the surgical specialties, such
boards, and the AMA wanted to
dency training. The committee also
as orthopaedic surgery and urology,
exert its control over the certification
recommended that residents be taught
were also in the process of estab-
process by setting common standards
special knowledge pertinent to surgery,
lishing certifying boards, further
for the boards. The convened group
including the fundamental sciences of
challenging the College as the sole
established the Advisory Board for
anatomy, physiology, and pathology.2
arbiter of surgical credentials.
Medical Specialties (later to be called
The Committee on Graduate
In 1934, while the College lead-
the A merican Board of Medical
Training in Surgery made the auda-
ership was being criticized by its
Specialties [ABMS]). The Advisory
cious proposal that the College support
fel low su rgeons, t he A mer ica n
Board was given authority to oversee
the creation of the American Board of
Medical Association (AMA) Council
the examination and certification
Surgery and use board certification as
on Medical Education and Hospitals
of physicians and surgeons by the
a criterion for admission to the College.
convened the leadersh ip of the
certifying boards, and by virtue of
The College, trying to mollify its critics,
existing certifying boards, which
the boards’ requirements to sit for
quickly adopted the ABS requirements
were opht ha l molog y, otola r y n-
examinations, the education and
for training, but allowed exceptions on
gology, obstetrics and gynecology,
1
training of specialists.
an individual basis. A few years earlier
21
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100
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it would have been unthinkable for the Regents to allow a group of dissidents to influence how candidates for fellowship should be vetted.
Developing the Surgical Residency System Regent Allen Kanavel, a Past President of the College and editor of its journal, envisioned that the College’s hospital standardization program could be used to standardize the training of surgeons by requiring hospitals that had residencies to meet the College’s standards for training.3 Through this, the College could gain control of graduate surgical education and thereby minimize the influence of the new Board.
Dr. Malcolm MacEachern, Associate Director, American College of Surgeons, architect of the hospital standardization program and author of surgical residency requirements.
At Kanavel’s urging, Dr. Malcolm
PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
MacEachern, leader of the hospital standardization program, developed
of residency program approval by
comprehensive standards for surgical
the College in conjunction with its
residencies and promulgated them in
hospital standardization program
symposia and in the Bulletin of the
was implemented, but was short
After a period of contentious nego-
American College of Surgeons, widely
lived. The AMA had inspected the
tiations, the AMA, the ABS, and
read by hospital administrators,
internships of hospitals since 1919
the College formed the Conference
beginning in 1938.4 MacEachern also
and residency programs since 1927,
Committee on Graduate Training
called for hospitals approved by the
and the ABS used the AMA’s list of
in Surgery in 1950, established to
College to develop residency programs
approved programs for its require-
inspect and approve surgical resi-
to ease the shortage of competent
ments. The AMA rejected College
dency programs. The Conference
surgeons and supplied them with
proposals to create a joint residency
Committee took over the functions
information on how to establish resi-
approval program.
of the AMA and the College, both of
Regulation of Graduate Medical Education
dencies. For the first time, a list of
The College no longer had the ability
which had been accrediting programs
approved programs was published in
to inspect residency programs after
independently. Many programs were
the Bulletin, greatly facilitating the
1950, when its hospital standardiza-
inadequate and it took several years
ability of medical school graduates
tion program was eliminated for finan-
to eliminate them. To more accu-
then in internships to apply to quality
cial reasons and the Joint Commission
rately depict its function, the name
prog ra ms. Hospita ls responded
on Accreditation of Hospitals was
was changed to the Residency Review
immediately, and by late 1939 were
established by the College, the AMA,
Committee for Surgery (RRC) in 1953.
projected to produce almost 600
the American Hospital Association
RRCs for all the surgical specialties
trained surgeons annually, which the
(AHA), and the American College of
were established during the 1950s,
College thought would be sufficient to
Physicians. The Joint Commission
with the respective specialty certi-
meet the needs of the public.5, 6
continues to set standards, inspect
fying board, the College, and the AMA
Although MacEachern’s efforts to
hospitals, and accredit them, but is
as sponsors, often called “parents.”
set standards for surgical residency
not involved in regulating graduate
Eventually, RRCs were established for
programs were successful, his vision
medical education.
all specialties of medicine.7
23
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In 1967, the Citizens Commission
term in 1975. His brilliance, careful
actively engage residents in the activi-
on Graduate Medical Education noted
preparation for meetings, and ability
ties of the College and to provide a
that there was wide variation in the
to develop reasonable solutions to diffi-
path leading to College fellowship.
residency program standards of
cult problems were recognized by the
Its activities in graduate medical
the specialties. It became clear that
CMSS and the other LCGME parents.
education enable the College to engage
certain standards were germane to
He restored the College’s influence
residents in its mission to improve the
all of them. For example, an adequate
in graduate education. In 1981, the
care of the surgical patient and to safe-
library, appropriate supervision, and
name of the LCGME was changed to
guard standards of care in an optimal
adequate compensation were essential
the Accreditation Council for Graduate
and ethical practice environment. Q
for the training and the well-being of
Medical Education (ACGME) and
residents. This led to the formation of
burdensome reporting functions were
the Liaison Committee on Graduate
eliminated. In 2000, the organization
Dr. Nahrwold is Emeritus Professor at
Medical Education (LCGME) in 1972,
was separately incorporated, lessening
Northwestern University, where he was
in an effort to improve graduate educa-
the influence of its parents and stream-
the Loyal and Edith Davis Professor and
tion by creating general requirements
lining its operations. Since then the
Chairman of the Department of Surgery
for all residency programs and stan-
ACGME has changed the paradigm of
and Surgeon-in-Chief at Northwestern
dardize the operations of the RRCs.
graduate medical education substan-
Memorial Hospital. He served as a
The sponsors of the LCGME were the
tially by imposing resident duty hours
Regent, Chairman of the Board of
AMA, Association of American Medical
and requiring programs to implement
Governors, First Vice-President, and
Colleges (AAMC), AHA, ABMS, and the
competency-based education.
Interim Director of the American
Council of Medical Specialty Societies (CMSS), of which the College was, and still is, a member. The RRCs received
College of Surgeons, and received
The College Continues Its Involvement
administrative support from the AMA,
its Distinguished Service Award. He represented the College at The Joint Commission, where he was Chairman
which also was the primary support
The College continues to support
for the LCGME, leading it to dominate
g raduate educat ion i n su rger y
the organization. The sponsors, each of
through a large number of publica-
which had veto power over decisions
tions, courses, and other educational
made by the organization, fought over
offerings designed to assist residents
the relationship of the RRCs to the
in learning and demonstrating the
LCGME, its method of financing, and
six general competencies required by
a proposal by the AAMC that graduate
the ACGME. Especially popular are
medical education should be controlled
an ethics curriculum; the Surgical
by medical schools rather than hospi-
Educat ion a nd Sel f-A ssessment
tals. There were many more debates
Program (SESAP), which helps resi-
over lesser issues.
dents prepare for board examinations;
Before the LCGME was formed, the
Selected Readings in General Surgery,
College had lost its voice in graduate
a service providing information and
medical education. Dr. C. Rollins
commentary on surgical research;
“Rollo” Hanlon, then Director of the
and courses in surgical and tech-
College, was determined to get it back.
nical skills. The College also provides
He represented the College at CMSS
research scholarships for residents,
meetings, which were dominated by
a job bank, and many other offerings
discussions and arguments over the
directed toward graduate medical
role and actions of the LCGME. Hanlon
education. The Resident and Associate
became a leader in CMSS activities and
Society, which meets annually at the
was elected its president for a two-year
Clinical Congress, was created to
of the Board of Commissioners. References 1. American Medical Association, Minutes of the House of Delegates 84th Annual Session, Milwaukee, June 12-15, 1933. 1933; Available from: http://192.159.83.55:8080/AMA_NDLS/ jsp/vieweer2.jsp?doc. 2. Minutes of the Adjourned Meeting of the Board of Regents of October 19, 1934. 1934, Archives of the American College of Surgeons: Chicago. 3. Abstracted minutes of the Administrative Board, Archives of the American College of Surgeons: Chicago. 4. MacEachern M. Criteria for graduate training for surgery and a manual of graduate training in surgery. Bulletin of the American College of Surgeons, 1938. 5. Minutes of the meeting of the Board of Regents of October 29, 1939. 1939, Archives of the American College of Surgeons: Chicago. 6. Minutes of the meeting of the Board of Regents of October 20, 1939. 1939, Archives of the American College of Surgeons: Chicago. 7. Griffen WO Jr. The American Board of Surgery in the 20th Century—Then and Now. Philadelphia: American Board of Surgery; 2004.
25
The American College of Surgeons as a University by GEORGE F. SHELDON, MD, FACS, FRCSED (HON), FRCSENG (HON)
Franklin H. Martin, the founder of the American College of Surgeons (ACS), is properly recognized during the 100th anniversary of the College’s founding in 1913. In his book, Fifty Years of Medicine and Surgery, he notes that his 50 years “dwell briefly upon cooperation with progressive men during the years of transition in medical care 1880 to 1920,” during which the “art was superseded by the science and art” of medicine.1
Franklin Martin traveled to London to observe the Fellowship ceremony of the RCS. Before the journey, Martin had proposed formal regalia for the ACS ceremony, an idea roundly criticized by Crile, C. J. Mayo, and the new Board of Regents as “undemocratic.” Martin records that as the RCS ceremony
For this article, I was asked to
the horrors of a lack of cleanliness
evolved, Crile, in the processional, was
describe some of my experiences
and hygienic practices in the Chicago
bedecked with full regalia. He raised his
during my nearly 50 years of working
stockyards, which led to the founding
hand in defeat when asked by Martin
in a variety of roles with the ACS. One
of the Food and Drug Administration.
how he could don such an “undemo-
of the themes that characterize this
The reforms of the Progressive Era
cratic” costume. The day was won and
largest organization of surgeons in
included medical education—notably
the formal regalia has been part of the
the world is that it offers its members
by the publication of the “Flexner
College ever since. Sir Rickman Godlee,
who choose to be active participants
Report” in 1910, which resulted in the
nephew of Lord Lister, was the College’s
a rich experience, which is a graduate
closing of marginal medical schools
first honorary Fellow and presented the
education. Participation in the overall
and the lowering of the total number
ACS with a gavel of wood from Lister’s
work of the College is available to all
from 133 in 1890 to 85 in 1920.
2
chair for the opening ceremony, which
Fellows through its committees and
The practice of surgery by unqualified
through elected positions that are
and unethical doctors, characterized by
local, regional, and national in scope.
their widespread practice of fee splitting,
The surprising stature of the new
has been used in every convocation since that time.4
The ACS was founded during the
was one of the stimuli for the founding
organization was recognized within five
Progressive Era (1890–1920), which
of the ACS. The ethical practices and
years of its founding, when President
was a reaction to the Gilded Age (1865–
educational requirements for surgeons
Woodrow Wilson requested of Martin
1900) of Rockefeller, Gould, Carnegie,
who were admitted to Fellowship at the
that he organize hospitals for the
and Ford, an age that saw the birth of
founding of the College remain stan-
American Expeditionary Force (AEF)
unions and an unregulated economy.
dards to the present day.
in World War I. The bond between the
Government regulation of business
The founding of the ACS was heavily
British and American surgeons was
began to occur as evidenced by the
influenced by W. C. and C. J. Mayo
solidified through joint service during
1887 Interstate Commerce Act, the
and their expansive vision of health
World War I. In 1920, Lord Moynihan
Sherman Antitrust Act, the Commerce
care as embodied in the Mayo Clinic.
presented the ACS with the Great Mace
Commission, the Federal Trade
George Crile, Alfred Kanaval, and
to signify that connection; it has been
Commission, and others. Presidential
J.B. Murphy—the “stormy petrel of
used during the convocation ceremony
leadership
included
Theodore
Roosevelt and Woodrow Wilson.
3
surgery”—were also highly influential.
since that time.
The American College of Surgeons
Shortly after the founding of the
Health was highlighted by journalist
was heavily modeled after the Royal
ACS in 1913, the College estab-
“muckrakers” led by Upton Sinclair,
College of Surgeons (RCS) of England.
lished the Minimum Standards for
whose 1906 book The Jungle showed
Prior to the first convocation of the ACS,
Hospitals, the precursor to The Joint
26
Commission, which itself was estab-
his entire tenure with the ACS, he timed
to assume the role of Director in
lished in 1951. True to the progressive
every formal presentation, including
November 1986. Linn’s role eventually
environment of its founding, the ACS
all of the Presidential Addresses! His
expanded into Director of the Division
has expanded the number of accredi-
administrative and meeting manage-
of Integrated Communications. There
tation programs during the course of
ment skills were without parallel.
was little in the ACS that Linn didn’t
its history to include the Advanced ®
From 1977 to 1981, I represented
influence positively. Always a construc-
Course, the
the Society of University Surgeons on
tive team player, she led a devoted staff
Trauma Center Verification Program,
the ACS Board of Governors and also
of communications professionals who
the Commission on Cancer, and the
served as its Secretary. I learned a
did an excellent job in handling the
bariatric surgery and breast center
great deal during that experience from
Division’s expanded responsibilities.
verification programs, among others.
the College’s outstanding Comptroller
An early innovation of Linn’s was to
In the quality area, the American
who functioned as the Chief Financial
have socioeconomic updates in each
College of Surgeons National Surgical
Officer, Robert G. Happ. That was
issue of the Bulletin of the ACS, which
Quality Improvement Program® (ACS
during the President Jimmy Carter
previously had been a limited circula-
NSQIP ) has injected modern stan-
inflation years, which had a major
tion, “yellow pages” type of publication.
dards with metrics for determining
impact on everyone. The first of two
I was asked to be the first Editorial
and developing quality surgical care.
main duties of the Secretary of the
Advisor for the Bulletin. In many
My mentors, Dr. J. Englebert
Board of Governors was to Chair the
ongoing readership surveys, socioeco-
Dunphy, President of the ACS; Francis
Governors’ Fiscal Affairs Committee,
nomic topics have retained a role as the
D. Moore, Vice President; and F. W.
which meant offering the dues recom-
most read part of the Bulletin.
Blaisdell, Chair of the Committee
mendation for the succeeding year to
In 1982, Dr. Loyal Davis, ACS
on Trauma, had all been active in
the nearly 300 Governors of the ACS.
President and long-term Editor of
the College. At that time, residents
Happ convinced the members of the
Surgery, Gynecology, and Obstetrics,
were encouraged to present papers
Fiscal Affairs Committee that a large
the precursor to the Journal of the
during the Surgical Forum sessions
dues increase ($50) was warranted
American College of Surgeons, died.
at the annual Clinical Congress. That
to secure the successful future of
A memorial service and reception
was my early involvement, followed
the College. The Governors had a
were held at the Murphy Memorial
by participation in local chapter
lively, open discussion, but ultimately
Auditorium and the Nickerson Mansion,
programs. In 1972, at the Clinical
approved the increase, which then
historic buildings owned by the College
Congress in San Francisco, I partici-
had to be validated by the Board of
and located across the street from its 55
pated in the last “wet clinics” that
Regents. I noted to Dr. Hanlon that it
E. Erie St. headquarters. The service
were part of the Clinical Congress
was appropriate that the second iden-
was attended by ACS leaders and guests
educational program.
Trauma Life Support
®
tifiable responsibility of the Secretary of
and by Dr. Davis’ daughter, Nancy
In 1978, I had the task of presenting
the Board of Governors—saying grace
Reagan, and her husband, President
the opening ceremony lecture at
during the annual banquet—was a
Ronald Reagan. Dr. Armand Hammer,
the Clinical Congress on Philip Syng
good marriage of the two duties! The
a friend of Dr. Davis, could only make
Physick, “the Father of American
dues increases during that period posi-
a brief appearance at the service as
Surgery.”5 C. Rollins Hanlon, MD, FACS,
tioned the ACS stock portfolio for the
he was on his way to attend Leonid
became one of my “professors” and
growth years of the 1980s and 1990s.
Brezhnev’s funeral in Russia! Hammer
advisors over many years. The letter
After I became a Regent in 1984, I
noted that he wanted to endow an
from Dr. Hanlon inviting me to speak
became Chair of the Communications
international scholarship in Dr. Davis’
at the opening ceremony noted that the
Committee. That Committee assumed
memory. The Scholarship Committee,
length of my talk would be precisely
enhanced importance as the Director of
chaired by Dr. Frank Spencer, had been
17½ minutes! A little known fact of Dr.
that department, Heinz Kuehn, retired.
developing more and better scholar-
Hanlon’s unmatched administrative
The Search Committee selected Linn
ships for residents and had a draft of a
skills as Executive Director, Regent, and
Meyer, Manager of Public Information
model close to Dr. Hammer’s vision. So
President of the College was that during
in the Communications Department,
a check was written, larger than most
27
of us have ever seen, and Dr. Hammer went on to Russia. Following my term on the Board of Governors, I became a member of the Board of Regents for the usual nine years. During that period, the “Dean” of the ACS, Dr. Hanlon, retired as Executive Director but fortunately remained as President for one year and then served as Executive Consultant. Our debt to him for education, example, and leadership is unparalleled. In 1985, I received an urgent call from Dr. Olga Jonasson (who would go on to Ohio State University to become the first woman to head a department of surgery). Her call was derivative of a brief meeting at Chicago’s O’Hare Airport with Senator Dave Durenberger (R-MN), who was chair of the Senate Subcommittee on Finance. She had met him at a meeting of the Council of Medical Specialty Society (CMSS). At that time, the Consolidated Omnibus Reconciliation Act (COBRA) was being considered during the legislative process. At risk in the draft bill was funding for Graduate Medical Education (GME); the proposal was for only three years of funding, or no
Dr. George F. Sheldon presents testimony before the United States Senate Subcommittee on Finance on S.1158—the Dole, Durenberger, Bentsen Bill re: Medicare Payment for Cost of Graduate Medical Education. The presentation was televised on C-SPAN, June 1985.
funding at all. Senator Durenberger surgeons didn’t get behind five-year
extra year for three-year residencies
cuts in the plan outlined in the
funding and get involved in the legis-
that may extend an additional year.”
Bowles-Simpson Commission report,
lative process, a three-year maximum
I was asked by Senator Durenberger
the battle continues.
would be unavoidable.
to testify before the Senate Finance
As most of the ACS leadership was
Committee. At the same table, testi-
at a meeting in Australia, she called
fying for less generous support, was
me for advice. We managed to arrange
Dr. Henry Desmarais, at that time
a meeting with Senator Durenberger,
director of the Office of Management 6
Blueprint for the Twenty-First Century The most important reorientation of
which was attended by Dr. Oliver
and Budget (OMB).
Of interest,
the ACS during my time of involvement
Beahrs of the Mayo Clinic, Dr. David
Dr. Desmarais eventually became
was the retreat held from June 16–18,
Sabiston of Duke University, and me.
director of the ACS Washington, DC,
1985, at the Harrison Conference Center
In Senator Durenberger’s office, we
office under Dr. Samuel Wells, and
in Lake Bluff, IL.7 It was a retreat of the
wrote language that exists in the
today he remains an ACS consultant.
Regents, staff, and Officers of the Board
Medicare law to this day. It reads “first
As funding of GME is again today
of Governors, led by the Chair of the
certification or five years, with an
under question and targeted for
Board of Regents, Oliver Beahrs, MD,
28
USED WITH PERMISSION FROM MARY JANE KAGARISE AND COLIN THOMAS, JR., MD, FACS
let Dr. Jonasson know that if the
FACS. The conference was designed to
Committee was available to be shown
Dr. David Sabiston. Dr. Paul Ebert,
bring to definitive action three main
there because it had been on C-Span.
professor and chair of the Department
items that had been discussed for some
The third major item during the
of Surgery at the University of
time without closure. The first was the
retreat was to develop a robust endow-
California-San Francisco, was hired
need to be active in Washington, DC,
ment program. Dr. Beahrs, familiar
as Executive Director. Dr. Ebert was
and to create a Washington office as the
with the value of an endowment as a
well known to all as the preeminent
College’s advocacy arm. The College,
funding source from his time at the Mayo
pediatric heart surgeon in the world,
scrupulously compliant with its 501(c)
Clinic, made this his pet retreat project.
and he had been chair of the depart-
(3) tax status as a not-for-profit organi-
Accordingly, funding for the position of
ment while I was at UCSF. Paul had
zation, had neither undertaken a move
an endowment officer was approved,
a different style from Dr. Hanlon but
of its headquarters to Washington—
the scholarship funds were targeted for
was equally effective. He had a great
as had the Association of American
great expansion, and all of the Regents
knack of not getting too involved in
Medical Colleges (AAMC)—nor estab-
and Officers were asked to pledge a
minutiae. As Dr. Hanlon described
lished a second organizational office as
substantial contribution. The fund is
him, if you were behind one point in
had the American Medical Association
still known today as the Regents’ Fund.
a basketball game with 10 seconds
(AMA). The ACS, as an organiza-
It is difficult to imagine the current
left, and you had a player at the free
tion respected in Washington, did
ACS without these important commit-
throw line with two shots, you would
participate in hearings at the request
ments from the 1985 retreat.
want it to be Paul Ebert. With Dr.
of Congress or the executive branch,
In 1986, Dr. Hanlon retired as
Gerald Austen as Chair of the Board
much like the model Franklin Martin
Executive Director. The Search
of Regents, Dr. Ebert established
established after World War I. However,
Committee Chair for his successor was
incredibly effective relationships
it was becoming apparent to many ACS
with industry, other organizations,
officials that the “listening post,” which
and with Congress. In addition, Paul
was the limit of our political involve-
almost single handedly negotiated the
ment, was insufficient. As a result, the
bold move from 55 E. Erie St. to the
idea of buying a building in Georgetown was endorsed and money accumulated in the building fund was used for that purpose. A budget was developed and additional staff was hired, under the direction of Dr. Hanlon and James Haug, the Director of the Socioeconomic Affairs Department. Several years later, when Dr. Samuel Wells was Executive Director, Dr. Desmarais was hired as the Director following Mr. Haug’s retirement from the College. With the opening of the College’s new building in Washington, DC, in June 2010, the structure and complexion of the staff continues to evolve. The second major focus of the 1985 Regents’ retreat was on GME, with its funding threatened then as now under Medicare. The retreat followed our work with Senator Durenberger, and my testimony before the Senate Finance
In Senator Durenberger’s office, we wrote language that exists in the Medicare law to this day. It reads “first certification or five years, with an extra year for three-year residencies that may extend an additional year.”
College’s current headquarters location of 633 N. Saint Clair St. In 1992, I was invited to present the Scudder Oration on Trauma. This was especially memorable as trauma was my clinical focus and I had served on the Committee on Trauma (COT). At the time of my award, current ACS President Brent Eastman was COT Chair. This was my second opportunity to present a major named ACS lecture. My title was “Trauma Manpower in the Decade of Aftershock.”8 Dr. Ebert served 12 years and was succeeded by Dr. Samuel Wells. Dr. Wells had a great vision for the ACS. The cancer research program, the first NIH-funded clinical trials awarded to a professional organization, still thrives today. Dr. Wells also recruited Dr. Desmarais for leadership of the Washington office.
29
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www.FloridaHospital.com
The Resident and Associate Society (RAS) was founded in 1999 during my year as ACS President, to involve surgeons in the ACS at the beginning of their careers. I worked with Dr. Olga Jonassen, who was the ACS staff member for this organization. Dr. Michael DeBakey was the inaugural speaker at the first meeting of the RAS. Following Dr. Wells, Dr. Tom Russell, a Regent of the College, was selected as Executive Director by a search committee during my year as President (1998–1999). Dr. Russell’s strong administrative skills, hands-off management style, and energetic contact with chapters, Fellows, and other organizations created a wonderful environment for Fellows and staff. His new management model allowed contracted program
Andy C. Kiser, MD, from UNC Cardiothoracic, the first President of the Resident and Associates Society (RAS), is pictured at the inaugural meeting of the RAS with guest speaker Michael E. DeBakey, MD, FACS.
development to be led by surgeons
COPYRIGHT 2000 BY CHUCK GIORNO PHOTOGRAPHY, USED WITH PERMISSION
outside the Chicago office; previously all program development was done by
In 2009, I was invited by the Advisory
from 10 Downing St. specifically high-
surgeons located in the Chicago office
Committee on General Surgery to give
lighted his service to the American
under full-time contracts. Dr. Russell
the Edward D. Churchill Lecture of
College of Surgeons’ Health Policy
also negotiated a unique arrangement
the Excelsior Surgical Society. My
Research Institute as one of the reasons
by which the Nickerson Mansion and
topic dealt with surgical workforce
for his elevation. The funding for the
the Murphy Auditorium, properties
in the era of health reform.
HPRI provided access to more than 160
of important sentimental and historic
A second new initiative was a product
investigators who provide expertise
value, could be retained without
of the Health Policy Committee led by
part-time to the ACS. The institute has
continuing to be a major burden on
Dr. Charles Mabry. It was a search,
produced more than 70 publications,
the College’s budget. In addition, Dr.
chaired by Dr. LaMar McGinnis, for
congressional testimonies, and other
R. Scott Jones, who had been ACS
a Director to found a Health Policy
consultations to Congress. After six
President, was recruited to found
Research Institute (HPRI). I was asked
years of being located at UNC, it has
the Division of Research and Optimal
to become the inaugural Director, a
since been relocated to the Washington,
Patient Care, now brilliantly led by Dr.
task I shared with Tom Ricketts, Ph.D.,
DC, office under Christian Shalgian, the
Clifford Ko. After a search committee
of the Cecil G. Sheps Center for Health
Director of the Division of Advocacy
for an Editor of e-FACs.org, the online
Services Research at the University of
and Health Policy.
portal recommended by the Committee
North Carolina at Chapel Hill. A distin-
A tradition of the ACS is at termi-
on Informatics led by Dr. Peter Greene
guished advisory board was recruited,
nation of service to provide some
of Johns Hopkins, concluded its work, I
which included the president of the
concluding observations.
was asked to take on this responsibility.
Royal College of Surgeons of England,
I believe it has been a useful adjunct to
Sir Bernard Ribeiro, an Honorary
the ACS, as it includes more than 28
Fellow of the American College of
communities and nearly 300 editors
Surgeons. When Sir Ribeiro was later
and associate editors, with 3,702,666
elevated to the peerage (his title now
1. Globalization. For more than
page views since launching.
being Lord Ribeiro), the announcement
30 years, efforts have been made
For the Future: Some Areas of Opportunity
31
to bring the surgical colleges from
is important that peer-reviewed health
member of the Institute of Medicine of
across the world into a unified group
policy research with metrics continues
the National Academy of Science, and
to address global health and surgical
to be developed, under the direction
he is the first Surgeon—not dean—to
quality. In 1963, the Joint Conference
of Medical Director Dr. Don Detmer.
be Chair of the Association of American
of Surgical Colleges (JCSC) was formed,
Currently, the Washington office is
Medical Colleges since 1879. He holds
bringing together the presidents of
developing health services expertise.
Honorary Fellowship in the Royal
the American, English, Edinburgh,
It is essential to understand that good
College of Surgeons of both England
Glasgow, Irish, Canadian, South
health policy is good advocacy and
and Edinburgh.
African, and Australasian colleges, as
is the future. This may be the most
well as the presidents of the surgical
important developmental challenge
academies of Hong Kong, Singapore,
for the College for the next 25 years.
and Malaysia. In 2000, Royal College
I extend thanks for the friendship
of Surgeons of England President Sir
and help of the ACS staff over the many
Barry Jackson presided over the bicen-
years I served as an Officer, Governor,
tennial celebration of the RCS, which
Regent, and program leader. I especially
included a meeting of the JCSC. The
note Robert Happ, Dr. Ed Gerrish, Dr.
JCSC has not met since 2002. Perhaps
Frank Padberg, Jack Lynch, Barbara
we could follow the example set by the
Dean, and Maxine Rogers, long-serving
RCS at its bicentennial in 2000, and
and loyal staff who provided excellent
invite the JCSC to meet during the ACS’
assistance in all things. Linn Meyer,
Centennial celebration. The timing of
a colleague with whom I worked in
greater international collaboration is
a variety of capacities, was always
propitious with the communication
constructive, insightful, and institution-
advances of the Internet.
oriented. In more recent years, my
2. Challenges of an umbrella orga-
colleague, Jerry Schwartz, Managing
nization. Efforts continue to educate
Editor of e-FACs.org, has been an
surgeons, especially young surgeons,
outstanding resource for the ACS.
about the importance of participating
The portal would not have succeeded
in the ACS as well as their specialty
without him. Howard Tanzman, always
societies. Attraction to the College as
helpful in informatics, continues to be a
the leading organization of surgeons
resource as we evolve into more depen-
in the world requires coalition
dence on technology. Q
building. It also requires the production of health service products with metrics that shape policy.
Dr. George F. Sheldon’s career with
3. Washington influence. The
the ACS includes Secretary of the
Washington office staff has been
Board of Governors, Regent, President,
active in advocacy efforts. Its large
and Scudder and Excelsior Surgical
staff and magnificent new building
Society Orator. He was Founding Editor
provide an imposing statement of the
of the portal e-FACS.org and Founding
College’s determination to become
Director of the ACS Institute for Health
an important source of input for
Policy Research. He has also been Chair
Congress, the executive branch, and
of the American Board of Surgery and
the bureaucracy. With a decision
President of the American Surgical
to make the Washington office the
Association, the American Association
source site for health policy research,
for the Surgery of Trauma, and the
a different paradigm is in evolution. It
Society of Surgical Chairmen. He is a
Bibliography Sheldon GF. Trauma manpower in the decade of aftershock. Scudder Oration On Trauma. Bull Am Coll Surg. May 1992;77(5):6-12. Sheldon GF. The A merican Col lege of Surgeons In The Millennium: An Analysis. Handout to the Board of Regents. Oct 1999. Sheldon GF. The Su rgeon Shor t age: Constructive Participation during Health Reform. Excelsior Surgical Society Edward D. Churchill Lecture. J Am Coll Surg. June 2010; 210(6):887-894. References 1. Martin FH. Fifty Years of Medicine and Surgery: An Autobiographical Sketch. Chicago, IL: The Surgical Publishing Company of Chicago; 1934. 2. Bowles MD and Dawson VP. With One Voice: The Association of American Medical Colleges 1876-2002. Washington, DC: Association of American Medical Colleges; 2003. 3.D av i s L . Fel l o w s h i p o f Su r g e o n s: A Hi stor y of the Amer ican College of Surgeon s. Spr i ng f ield, IL: C h a rle s C. Thomas Books; 1960. 4. Jackson B. The American College of Surgeons and the Royal College of Surgeons of England: Eighty Years of Friendship. J Am Coll Surg. Oct 2000; 191(4):435-440. 5. Sheldon GF. Philip Syng Physick, M.D. (1768-1837): The Father of American Surgery. Bull Am Coll Surg. May 1979; 64:16-27. 6. Sheldon GF. Statement of the American College of Surgeons regarding S. 1158—To Amend Title XVIII of the Social Security Act with Respect to Medicare Payment for Direct Costs of Approved Educational Activities. Washington, DC: June 1985. 7. Report on a Planning Meeting held by the Board of Regents, June 16–18, 1985, at the Harrison Conference Center, Lake Bluff, IL. ACS internal document courtesy of Susan Rishworth, ACS Archivist. 8. Sheldon GF. Trauma manpower in the decade of af tershock. Scudder Oration On Trau ma. Bull Am Coll Surg. May 1992;77(5):6-12.
33
Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African-American Heritage by L.D. BRITT, MD, MPH, FACS, FCCM, FRCSENG (HON), FRCSED (HON), FWACS (HON), FRCSI (HON), FCS(SA) (HON)
As the American College of Surgeons (ACS) celebrates its Centennial and underscores its legacy of being a beacon for quality and patient safety, the Fellowship earnestly reflects on the innumerable contributions of individual surgeons of diverse backgrounds who have played pivotal roles in advancing American surgery before and after the College’s inception. Many surgeons of AfricanAmerican heritage have played key roles in these developments. Because several of their stories have been well chronicled recently, this article serves as brief tribute to these other individuals, rather than as a comprehensive historical account. Nonetheless, during this Centennial celebration, the stalwart efforts of past, current, and future leaders should be recognized. The list of surgeons of African-American heritage continues
Kenneth Forde, MD, FACS – one of the founding members
to grow and transcend generations. Table I highlights those
of the Society of American Gastrointestinal and Endoscopic
surgeons of African-American heritage who have ascended
Surgeons and its first and only African-American presi-
to the top leadership positions in major organizations.
dent; first African-American professor of surgery at
Table II presents an impressive list of surgeons of AfricanAmerican heritage who are members of the Institute of Medicine of the National Academies.
Columbia University Alexa I. Canady, MD, FACS – the first African-American woman to be accepted into a U.S. neurosurgery residency program
In addition, the number of surgeons of A frican-
Clive Callender, MD, FACS – one of the foremost special-
American heritage who have been selected to chair
ists in organ transplant medicine, he founded the Minority
departments of surgery has grown exponentially in
Organ Tissue Transplant Education Program (MOTTEP),
the past few decades. Current chairs of departments of
which aims to increase the number of donors among all
surgery are listed in Table III.
minority groups in the U.S.
Many of the leading surgeons of African-American heri-
Arthur Fleming, MD, FACS – thoracic surgeon; one of the
tage headed the Society of Black Academic Surgeons (Table
founding fathers of the Society of Black Academic Surgeons
IV)—building a strong foundation for this organization.
Lenworth Jacobs, MD, MPH, FACS – recognized leader
The following list (although incomplete) of notables and
in trauma and critical care, founder of the College’s
“firsts” truly reflects the depth and breadth of contributions
Advanced Trauma Operative Management program and
made by African-American surgeons:
current ACS Regent Velma Scantlebury, MD, FACS – the first African-
Notables
American woman to be a transplant surgeon
Levi Watkins, Jr., MD, FACS – cardiac surgeon, professor
Sharon M. Henry, MD, FACS – an endowed professor at
of surgery, and associate dean at the Johns Hopkins
the University of Maryland Shock Trauma Center; first
University School of Medicine; performed the world’s first
African-American woman to be a member of the American
implantation of the automatic defibrillator
Association for the Surgery of Trauma
34
TABLE I
The Top Leadership Positions in Major Organizations Held by Surgeons of African-American Heritage
LaSalle Leffall, Jr., MD, FACS
President, American College of Surgeons (1995-1996); President, Society of Black Academic Surgeons; President, Society of Oncologic Surgeons; President, American Cancer Society (1978-1979)
Claude Organ, Jr., MD, FACS*
President, American College of Surgeons (2003-2004); Chair, American Board of Surgery; President, Society of Black Academic Surgeons
Haile Debas, MD, FACS
President, American Surgical Association (2000-2001); President, Society of Black Academic Surgeons
Samuel Kountz, MD, FACS*
President, Society of University Surgeons (1974)
Adam Robinson, Jr., MD, FACS
Surgeon General, U.S. Navy (2007-2011)
Kenneth Forde, MD, FACS
President, Society of Gastrointestinal Endoscopic Surgeons
Eddie Hoover, MD, FACS
President, Society of Black Academic Surgeons; Editor-in-Chief, Journal of the National Medical Association (2004-present)
Steven Stain, MD, FACS
Chair, American Board of Surgery (2009-2010); President, Society of Black Academic Surgeons
Henri Ford, MD, FACS
President, Association of Academic Surgeons (2002-2003); President, Society of Black Academic Surgeons
Robert Higgins, MD, FACS
President, UNOS (2008-2009); President, Society of Black Academic Surgeons
Fiemu Nwariaku, MD, FACS
President, Association for Academic Surgery (2007-2008)
L.D. Britt, MD, MPH, FACS
President, American College of Surgeons (2010-2011) President, Southern Surgical Congress (2007-2008); President, Southeastern Surgical Congress (2008-2009); Chair, Residency Review Committee-Surgery (2005-2007); President, American Association for the Surgery of Trauma (2011); President, Halsted Society; President, Society of Surgical Chairs (2004-2005); President, Society of Black Academic Surgeons (19992001), Executive Director (present); President, American Surgical Association (present); Commissioner, The Joint Commission (present)
*deceased
Patricia L. Turner, MD, FACS – recently hired as the Director of the ACS Division of Member Services, the highest
professor of surgery at the University of Illinois, Chicago, and Rush University
salaried position held by an African-American at the College
Debra Ford, MD, FACS – the first fellowship-trained,
Cato Laurencin, MD, PhD, FACS – the consummate
board-certified, African-American woman colorectal
academic orthopedic surgeon is recognized as one of the
surgeon, she is a professor of surgery at Howard University.
premier thought leaders in American medicine. He is a
Robert Higgins, MD, FACS – recently elected to both the
prolific researcher and innovator, with an impressive track
American Board of Thoracic Surgery and the Residency
record of extramural funding and patent acquisitions.
Review Committee–Thoracic Surgery
Butch Rosser, MD, FACS – an accomplished innovator in
L.D. Britt, MD, MPH, FACS – the first surgeon of African-
advanced minimally invasive surgery and simulation and
American heritage to serve as Chair of the ACS Board of
a professor of surgery at Morehouse School of Medicine
Regents and the first African-American to have an endowed
Kimberly Joseph, MD, FACS – first woman to serve in the
chair in surgery—the Henry Ford Professor and Edward
National Medical Association–Surgical Section; associate
Brickhouse Chair of Surgery at Eastern Virginia Medical School
35
CONGRATULATIONS to the American College of Surgeons for 100 Years of Improving Surgical Patient Care
Covidien is proud to collaborate with the American College of Surgeons as we continue our mission to improve the standard of patient care. Visit us at this year’s ACS Annual Meeting — Booth #1819 www.covidien.com COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and/or internationally registered trademarks of Covidien AG. All other brands are trademarks of a Covidien company. © 2012 Covidien 8.12 M120784
TABLE II
Surgeons of African-American Heritage Who Are Members of the Institute of Medicine LaSalle Leffall, Jr., MD, FACS
Howard University School of Medicine
Asa G. Yancey, Sr., MD, FACS
Grady Memorial Hospital and Emory University
Cato Laurencin, MD, PhD, FACS
University of Connecticut
Danny O. Jacobs, MD, MPH, FACS
Duke University
Selwyn Vickers, MD, FACS
University of Minnesota
TABLE III
Current Departmental Chairs of Surgery Danny O. Jacobs, MD, MPH, FACS
Duke University
Steven Stain, MD, FACS
Albany Medical College
Selwyn Vickers, MD, FACS
University of Minnesota
Edward Cornwell, MD, FACS
Howard University
James H. Thomas, MD, FACS
University of Missouri-Kansas City
Lynt Johnson, MD, FACS
Georgetown University
Ed Childs, MD, FACS
Morehouse School of Medicine
Selwyn Rogers, MD, FACS
Temple University
L.D. Britt, MD, FACS
Eastern Virginia Medical School
“Rising Stars”
Presidential Early Career Award for Scientists and Engineers.
Fortunately, the pipeline is replete with a legion of estab-
Electron Kebebew, MD, FACS – head of the endocrine
lished surgeons and “rising stars” who have distinguished
section at the National Cancer Institute, National Institutes
themselves in the major surgical disciplines. Fortunately,
of Health
the list is too long to adequately underscore their many
Terrence Fullum, MD, FACS – a prominent advanced
accomplishments and contributions. However, the following
minimally invasive surgeon, he is associate professor of
are some of the future leaders in American surgery:
surgery at Howard University.
Lisa Newman, MD, FACS – professor of surgery at the
David Jacobs, MD, FACS – executive director of the
University of Michigan and a highly regarded surgical
National Medical Association – Surgical Section, he is a
oncologist
trauma surgeon at Carolinas Medical Center.
Patricia L. Turner, MD, FACS (see “Notables” section) Carla Pugh, MD, PhD, FACS – vice-chair of education and patient safety, department of surgery, University of Wisconsin,
André Campbell, MD, FACS – acute care surgeon and surgical educator, professor of surgery at the University of California, San Francisco (UCSF)
Madison; she is also director of the university simulation center.
Kenneth Davis, Jr., MD, FACS – recently elected presi-
President Barack Obama recently presented Dr. Pugh with the
dent of the Society of Black Academic Surgeons, he is a
37
But for Ohio State, the field of surgery wouldn’t have been shaped by so many legends. As the American College of
in cancer, critical care, heart,
Surgeons celebrates 100 years of
imaging, neurosciences and
accomplishments, we at The Ohio
transplant, the Department of
State University Wexner Medical
Surgery is improving people’s
Center were inspired to reflect on
lives through personalized
our own legacy.
surgical care. Olga Jonasson, MD, FACS
The Department of Surgery at Robert M. Zollinger, MD, FACS
Ohio State’s Wexner Medical
The completion of the
Center has a long and respected
$1.1 billion expansion project
tradition of excellence in clinical
at Ohio State’s Wexner
practice, research and education. Many surgical greats,
Medical Center will expand
including the legendary Robert M. Zollinger, MD, and
the Department of Surgery’s
Edwin Ellison, MD, have walked
clinical care, create more
the department’s halls.
research opportunities, and
H. William Clatworthy, Jr., MD, FACS
allow our experts to continue educating and Thanks to the accomplishments
training the next generation of surgical legends.
of our outstanding faculty, staff,
Visit medicalcenter.osu.edu to learn more.
residents and medical students, Ohio State’s Department of Surgery is nationally and
Arthur G. James, MD, FACS
internationally recognized for its exemplary clinical care, educational programs and innovative research. In partnership with the Medical Center’s signature programs
TABLE IV
professor of surgery and anesthesia and vice-chairman of the department of surgery at the University of Cincinnati College of Medicine. Ronda Hendry-Tillman, MD, FACS – an accomplished
Past-Presidents of the Society of Black Academic Surgeons 1989-1991
Arthur Fleming, MD, FACS
1991-1993
Onye E. Akwari, MD, FACS
Sherilyn Gordon-Burroughs, MD, FACS – an academic
1993-1995
Eddie L. Hoover, MD, FACS
transplant surgeon and program director in the depart-
1995-1997
Claude H. Organ, Jr., MD, FACS
ment of surgery at Methodist Hospital in Houston, TX
1997-1998
LaSalle D. Leffall, Jr., MD, FACS
1998-1999
Haile T. Debas, MD, FACS
1999-2001
L.D. Britt, MD, MPH, FACS
Michael Watkins, MD, FACS – academic vascular surgeon
2001-2003
Clive O. Callender, MD, FACS
at the Massachusetts General Hospital and assistant
2003-2004
Edward Cornwell III, MD, FACS
2004-2005
Robert L. McCauley, MD, FACS
2005-2006
Selwyn M. Vickers, MD, FACS
2006-2007
Michael T. Watkins, MD, FACS
2007-2008
Steven C. Stain, MD, FACS
2008-2009
Robert S. Higgins, MD, FACS
2009-2010
W. Lynn Weaver, MD, FACS
2010-2011
Henri Ford, MD, MHA, FACS
2011-2012
Danny O. Jacobs, MD, MPH, FACS
breast surgeon and professor of surgery at the University of Arkansas
Hobart Harris, MD, FACS – professor of surgery and chief of the division of general surgery in the department of surgery at UCSF
professor of surgery at Harvard Medical School Raphael Lee, MD, FACS – prolific investigator and professor of surgery at the University of Chicago Karyn Butler, MD, FACS – trauma surgeon and director of surgical critical care at Hartford Hospital Edward Barksdale, MD, FACS – chief of pediatric surgery at Rainbow Children’s Hospital and professor of surgery at Case Western Reserve University Orlando Kirton, MD, FACS – professor of surgery at the University of Connecticut Jeffrey Upperman, MD, FACS – pediatric surgeon and associate professor of surgery at the University of Southern
in Nashville, TN, which encompasses George W. Hubbard
California Fred Cason, MD, FACS – chief of surgery at the Cleveland VA and professor of surgery at Case Western Malcolm V. Brock, MD, FACS – associate professor of thoracic surgery at Johns Hopkins Raymond Bynoe, MD, FACS – professor of surgery at the University of South Carolina, Columbia
Hospital, founded in 1909, were, for many years, the only major training facilities that freely accepted AfricanAmerican applicants. These institutions, along with Homer G. Phillips Hospital in St. Louis, MO, trained and produced a competent cadre of African-American surgeons. In addition, several black surgeons who trained in other countries returned to the U.S. during this time period.
A Rich History
Luminaries who emerged during this renaissance period
The rich history of surgeons of African-American heritage
included Charles R. Drew, MD, FACS, professor of surgery
can never be downplayed. Each chapter was essential in
at Howard, chief of surgery at Freedman’s, and a pioneer
providing the formidable foundation necessary to enhance
researcher in the use of blood plasma for transfusion; and
our involvement in American surgery and establish the
Daniel Hale Williams, MD, FACS, founder of Provident
necessary avenues to leadership positions.
Hospital in Chicago, the first black-owned and -operated
In the 19th and early 20th centuries, several institutions provided a cultivating environment where young
U.S. hospital. Dr. Williams is credited with performing the first successful open-heart surgery in 1893.
physicians of African-American heritage could train to
Other important figures from this era include John Henry
become surgeons. Freeman’s Hospital in Washington, DC
Hale, MD, and Matthew Walker, MD, of Meharry Medical
(which in 1868 became the official teaching hospital of
School—both giants in surgery and great surgical educators.
Howard University College of Medicine, now known as
The list of 20th century pioneers who followed is equally
Howard University Hospital), and Meharry Medical College
impressive and includes the following:
39
Congratulations to the
American College of Surgeons 0n its centennial anniversary Since 1885, the Keck School of Medicine of USC has been dedicated to providing quality care and advanced educational programs, while conducting innovative research that will advance the future of surgical practice. Our outstanding faculty include many active fellows and associate fellows of the American College of Surgeons. The Keck Medical Center of USC includes Keck Hospital of USC, USC Norris Cancer Hospital and USC Norris Comprehensive Cancer Center, one of the original eight comprehensive cancer centers designated by the National Cancer Institute. For more information, please visit surgery.usc.edu.
Vaugh Starnes, MD Chair, Department of Surgery
Anthony Senagore, MD Vice Chair, Department of Surgery
TABLE V
Honorary Fellows of the Society of Black Academic Surgeons Õ iÊ Ài ÃV >}]Ê ]Ê * «Ê Ìi ]Ê ]Ê -
UÊ >-> iÊ ivv> ]Ê À°]Ê ]Ê -Ê7>Ã }Ì ]Ê
® UÊ ÕÀ iÊ-Þ« >Ý]Ê À°]Ê ]Ê -Ê7>Ã }Ì ]Ê
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Dr. Britt is the Brickhouse Professor and Chairman,
Ì ÞÊ °Ê iÞiÀ]Ê ]Ê* ]Ê -
Department of Surgery, Eastern Virginia Medical School,
iÀ >À`Ê >vvi]Ê ]Ê -
Norfolk, VA. He is a general and acute care surgeon and
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Past-President and Past-Chair of the Board of Regents of
À ÃÊ Ã ]Ê ]Ê -
the American College of Surgeons.
*deceased
41
Major Historical Achievements in General Surgery: The First 75 Years by J. DAVID RICHARDSON, MD, FACS
Any attempt to briefly describe the major highlights in general surgery is difficult on several fronts: The field is so broad that categorization of “major achievements” is difficult and most of the noteworthy advances in “general surgery” have often morphed into specialty areas that will be detailed by other authors in the chapters of this publication. However, it is important to note that general surgery was the progenitor of most advances that eventually led to subspecialty development.
Care of the injured was initially provided by general surgeons rather than
to define the technical expertise required by
trauma surgeons per se: the first abdominal aortic aneurysm operation
surgical oncologists or hepatobiliary surgeons,
was done by a generalist; the pancreatoduodenectomy, which is often used
was developed by general surgeons, etc. This contribution will attempt to briefly define some of the achievements in general surgery made in the first 75 years of the A mer ica n Col lege of Su rgeons’ (ACS) existence. In the following article, Carlos Pellegrini, MD, will review some of the contributions of the last 25 years, including the revolution in care of our patients engenby endoscopy and minimal access surgery.
The Model for Surgical Training One of the major achievements in general surgery must clearly be the development of the training model by which future surgeons, and indeed future physicians in all disciplines, would be trained. William Stewart Halsted of Johns Hopkins in Baltimore, MD, William Stewart Halsted and his residents.
42
is considered the father of the American
PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS
dered by the technologic changes afforded
residency system. Halsted came to Baltimore a f ter t ra i n i ng ex ten sively i n Eu rope visiting prominent continental surgeons. In Baltimore, he developed a system by which trainees did a surgical internship followed by five or six years of junior residency. This was followed by two years as a chief resident. The concept of “concentrated responsibility” was inculcated in the chief residency years—a concept that has remained intact for the past century. Residents who trained under the Halstedian system then populated major surgical chairs throughout the United States and instituted similar residency systems. The concept of a residency system then became the established norm for training surgeons and this educational concept spread from the surgical disciplines to eventually include non-surgical disciplines as well. By the late 1920s, the American Medical Association (AMA) had begun to set standards for residencies in several disciplines. For the first several decades of the existence of the ACS, surgical training could be broadly categorized into two types: extensive (for that time) and difficult to obtain at elite institutions; or relatively brief training, often contained in a one-year internship. As the population
Halsted, the “father of the American residency system,” performing surgery.
grew and hospitals improved through early attempts at standardization, patients were
increased considerably and the training further evolved. Although
more willing to undergo operative proce-
the ACS eventually relinquished its surgical residency accreditation
dures but there was clearly a shortage of
role to the Accreditation Council on Graduate Medical Education—a
well-trained surgeons.
partnership with the AMA and the American Board of Surgery—the
By the late 1930s, it was recognized that
development of high-quality resident training in general surgery must
more defined standards for the training
stand as one of the major historical achievements in the first 75 years
of surgeons needed to be developed. The
of the existence of the ACS. This model for training and its accredita-
ACS had already established a committee
tion was adopted by all of the surgical specialties in the United States
for the standardization of hospitals and in
and similar models have been adopted worldwide. Millions of patients
1937 the Clinical Congress held a session on
have clearly benefited from this focus on improved surgical training.
the accreditation of hospitals for graduate medical education. The ACS then began to
Toward Safer General Surgical Operations
accredit hospitals and define standards for residency training in general surgery. For a
Most of the common general surgical procedures—appendectomy,
number of years there were woefully small
hernia repair, mastectomy, cholecystectomy, colectomy, thyroidectomy,
numbers of hospitals approved for residency
etc.—were developed prior to the founding of the ACS. While the develop-
training, and after World War II, as the popu-
ment of general anesthesia and antiseptic principles had made surgery
lation grew, the number of programs was
safer and more humane, mortality from most surgical procedures was
43
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Following World War II, there were dramatic changes in safety for surgical patients. Hospitals improved through a variety of forces including the accreditation processes. Surgical training was dramatically ramped up as previously noted. Anesthesia safety was markedly enhanced. Improved knowledge of fluid and electrolyte balance, the introduction of antibiotics, and the concept of “intensive care” allowed for better outcomes irrespective of the technical performance of operations. still high. The founding principles of the ACS
The other common general surgical procedure, then as now, was
included the education of surgeons to enhance
cholecystectomy. Gallbladder removal, which today has a mortality of
the safety of surgical operations.
far less than 1 percent even in patients with multiple comorbidities,
A review of the literature on surgical
had a mortality of 2.6 percent in the 16,980 cases reported in 1923 from
mortality for common operations performed
the Mayo Clinic. Those who required common bile duct procedures had
the first few decades following the founding
7.8 percent mortality. In 1930, a report of 500 cholecystectomies from
of the ACS is illustrative of the high death rate
Memphis, TN, noted a 4 percent death rate.
of the day. Appendectomy, which today has a
Cancer of the stomach treated by operation also had a high likeli-
mortality rate of about 0.01 percent and often
hood of a fatal outcome, particularly when viewed from the perspec-
a one-day length of hospital stay, was still a
tive of our current relatively low mortality. A report from 1939 on the
very dangerous operation even two decades
experience of the previous decade with gastric resection disclosed
after the formation of the ACS. A 1929 report
11.5 percent mortality. By the end of World War II, the Mayo Clinic
from New York City disclosed that 755 cases of
performed partial removal of the stomach with a 3.2 percent death rate
appendicitis carried an operative mortality of
while one in six died when the entire stomach was removed. Five years
6.37 percent; Barnes Hospital in St. Louis, MO,
later, those numbers still had shown little improvement (6.2 percent
reviewed 1,824 cases performed during the
and 12.9 percent, respectively). Operations on the pancreas were very
years 1915 to 1932 with an overall mortality
uncommon, but a collected series of opening of the pancreas to remove
of 3.4 percent. Both of these reports noted
stones had a death rate greater than 17 percent.
much higher death rates in patients who were
By the mid-20th century, the death rate for elective operations on
“elderly.” Of interest today as our population
younger patients had declined dramatically but for operations done on
ages, the definitions of elderly were over age 51
older patients, particularly when performed on an emergency basis, it was
and greater than 60 years of age in these two
still very high. A 1950 review of patients requiring emergency operations
reports; the mortality rate was 25 percent and
disclosed a mortality of 17.3 percent. Interestingly, operations for injury
42 percent respectively in these older patients.
were not among the top five indications for emergency operation: The
Perforated appendicitis was the most
primary indications were cholecystitis, bowel obstruction, appendicitis,
common cause of peritonitis in the 1920s
complications of inguinal hernia, and amputation for extremity gangrene.
and an extensive literature review covering
In those patients who were over 60 years of age, nearly 40 percent died.
the years 1920 to 1924 disclosed a 30 percent
In 1955, Carl A. Moyer, MD, and J. Albert Key, MD, reported on the
mortality rate for those requiring operation.
changes in mortality over a time period that coincided closely with the
Operations for removal of the large intestine
founding of the ACS to the then present. They examined the Barnes
as reported by the Mayo Clinic in 1920 had a
Hospital mortality rate for a number of common general surgical proce-
mortality of 17 percent, while another report
dures from 1916 to 1938 and compared those outcomes to those results
from the same year noted a 12.5 percent
achieved from 1948 to 1953. The death rates from operations on the bile
death rate. Cancers that required removal of
ducts had declined from 16.5 percent to 2 percent; emergency opera-
the rectum had an even higher mortality: A
tions for perforated ulcers decreased from 41 percent to 7 percent; and
report from cases done from 1928 to 1932 had
appendectomy mortality had decreased to 0.7 percent. Operations outside
a death rate of 30 percent, which decreased
the chest and abdomen, namely thyroidectomy and mastectomy, had
to 17 percent in the ensuing five-year-period.
marked improvement in death rate. The death rate for removal of the
45
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thyroid decreased from 6 percent to 1 percent
been extraordinary. This is the greatest achievement in the field of
while mastectomy mortality declined fivefold
general surgery in my opinion.
from 1 percent to 0.2 percent over this period. Removal of the esophagus for cancer, still a
The Development of Organ Transplantation
formidable procedure today, improved from 55 deaths per 100 patients in the earlier era to 16.
The transplanting of diseased organs has long been a dream for
It should be noted that these mortality rates
surgeons. The first corneal transplant was done in 1905 but solid organs
were reported by some of the best institutions
were a different matter. In 1909, a French surgeon transplanted a
in America; undoubtedly the death rates in
rabbit kidney into a young girl who died two weeks later. In 1913, a
other hospitals throughout the country were
monkey kidney was unsuccessfully transplanted into a child as well.
much higher. Following World War II, there
Alexis Carrell, who later won the Nobel Prize, performed canine kidney
were dramatic changes in safety for surgical
transplants at about the time of the founding of the ACS and devel-
patients. Hospitals improved through a variety
oped vascular suture techniques still used today. In 1933, a Ukrainian
of forces including the accreditation processes.
surgeon named Yurii Voronoy performed the first human-to-human
Surgical training was dramatically ramped
kidney transplant, which failed after two days. During the 1940s, Sir
up as previously noted. Anesthesia safety was
Peter Brian Medawar in England performed seminal work on immu-
markedly enhanced. Improved knowledge of
nology that greatly enhanced the understanding of rejection and eventu-
fluid and electrolyte balance, the introduction
ally led to his recognition with awarding of a Nobel Prize.
of antibiotics, and the concept of “intensive
The first successful kidney transplantation was performed in the
care” allowed for better outcomes irrespec-
United States in 1954 by Joseph Murray, MD, at the Peter Bent Brigham
tive of the technical performance of operations.
Hospital in Boston. Identical twins who were 23 years old, one of
Surgical procedures such as appendecto-
whom had glomerulonephritis, comprised the donor and recipient,
mies, cholecystectomies, and emergency
thus avoiding the problem with rejection. Both of the twins went on
hernia operations now rarely result in death.
to long, successful lives. This team of surgeons performed multiple
Complicated cancer operations that would not
kidney transplants in twins in the 1950s, and a recent article in the
have been contemplated during the first 50
New England Journal of Medicine outlined the history of the Nightingale
years of existence of the ACS are now done
twins, one of whom received a transplant from her sister at age 12 in
routinely with a mortality of 2 percent or less.
1960. Both sisters had returned to the Brigham and Women’s Hospital in
Equally remarkable is the incredible distribu-
2011, and the recipient, who is now 63 years old, is the longest-surviving
tion of high-quality surgical care throughout
kidney transplant patient. In 1962, the Brigham team performed the
the country. While highly complex procedures,
first cadaveric kidney transplant using the immunosuppressive drug
such as removal of the pancreas or esophagus,
azathioprine. The patient lived for 21 months.
may be regionalized to specialty centers, the
During the 1960s, a host of “firsts” were accomplished in the field of
operations that were commonly performed at
solid organ transplantation. In 1963, James Hardy, MD, performed a lung
the time of the ACS founding (with often high
transplant at the University of Mississippi and three years later a team at
death rates at excellent hospitals) are now
the University of Minnesota conducted the first pancreas transplant. In
done routinely throughout this country with a
1967, Thomas Starzl, MD, performed the first successful liver transplant
mortality far less than 1 percent.
after an initial failure in 1963. The successful graft functioned for 13
While reports in the 1930s categorized
months. Heart transplantation had pioneering laboratory work done by
patients over age 50 as “elderly,” octogenar-
Norman Shumway, MD, of Stanford University, but the first human effort
ians now routinely undergo both elective
was achieved by Dr. Christiaan Barnard in South Africa in 1967. A number
and emergency operations with remarkably
of operations in America by Dr. Shumway followed, beginning in 1968.
low death rates that often approach that of
The enhanced understanding of immunology and mechanisms of
much younger patients. While it is vital to
rejection with the addition of new immunosuppressant agents such as
continue to make operative care safer—from
cyclosporine and tacrolimus led to organ transplantation becoming a
morbidity as well as a mortality standpoint—
relatively common procedure that has been lifesaving to thousands of
the advances made in these regards have
patients. The transplant community has performed remarkable services
47
a modified total mastectomy including lymph node removal to removal of the lump with or without breast radiation. This trial, initiated in 1976, disclosed the safety of so-called “lumpectomy” with radiation; a recently published 20-year follow up has continued to show the safety of lumpectomy plus radiation compared to removal of the entire breast. The project has also been involved with a variety of other studies such as chemoprevention for breast cancer and a number of Kidney transplant, 1996.
studies on colon cancer. The NSABP has, through its network of surgeons and other
to patients in its organized approach to ethically obtaining organs and
healthcare workers, had an enormous positive
ensuring fair distribution of organs to those who are most in need
impact on the lives of thousands of patients
of transplantation. While donor shortage remains a huge issue, live
and their families. These studies have also
donors as opposed to cadaveric retrieval has greatly expanded the pool
demonstrated the power of a network of physi-
of available organs for some forms of transplantation. In 2008, there
cians with strong leadership asking important
were more than 16,000 kidney transplants performed in the United
clinical questions to find answers to queries
States—10,551 from cadaver donors and 5,966 from living donors. In
that could never be determined through even
the same year, the United States had 6,069 liver transplants performed
the best single-institution trials.
and more than 1,200 lung and 1,800 heart transplants.
Summary The National Surgical Adjuvant Breast and Bowel Project (NSABP)
General surgery can certainly be viewed as
While surgical oncologists may attempt to lay claim to this topic, when
today. This brief review could have focused
the NSABP was founded in 1958, the specialty of cancer surgery had
on hundreds of topics of importance during
not been clearly defined, and even today many of the participants are
the first 75 years of the history of the ACS.
general surgeons working in community hospitals. It is no exaggeration
Many of these will undoubtedly be discussed
to state categorically that this endeavor dramatically changed surgical
in other sections of this report. The focus on
practice particularly in the field of breast cancer treatment.
surgical education, the safety of operative
Dr. Halsted, whose impact on residency education was previously noted,
procedures, the development of transplanta-
developed an operation to remove the breast, underlying muscle, and
tion, and the use of large-scale clinical trials
lymph nodes from the axilla. This “radical mastectomy” was designed
to answer important clinical questions are
to treat the far-advanced cancers often seen at that time, but it was a
topics of great importance to our patients.
disfiguring operation and its use was extended in subsequent years to
The last 25 years of the century of the ACS
women whose tumors were less advanced. Bernard Fisher, MD, led a
have seen the explosion of minimally invasive
clinical trial, beginning in 1971, to test whether a radical mastectomy
procedures, which have added a new dimen-
provided superior results to removal of the breast alone, a so-called “total
sion of safety and comfort for our patients and
mastectomy.” The preliminary results of the 1,600 women entered in
will be reviewed in the following article. Q
the trial were published in 1975. The findings disclosed no difference in outcome between the more radical procedure and the lesser one. Longterm follow up after 25 years published in 2003 showed the same results.
J. David Richardson, MD, FACS, is Professor
Having demonstrated the utility of total mastectomy, the project
and Vice-Chair of the Department of Surgery at
embarked on an extension of the hypothesis that more radical opera-
the University of Louisville and currently serves
tions might not offer advantages over lesser procedures by comparing
as the Chair of the Board of Regents of the ACS.
48
PHOTO BY DAVID JOEL; COURTESY OF RUSH-PRESBYTERIAN-ST. LUKE’S MEDICAL CENTER
the parent of many of the surgical specialties
For 100 years of the highest standards, our highest praise. Cleveland Clinic congratulates The American College of Surgeons. Thank you for 100 years of clinical excellence and an abiding commitment to advancing patient care.
clevelandclinic.org/refer123 Same-day appointments available.
Minimally Invasive Surgery: General Surgery’s Revolution by CARLOS A. PELLEGRINI, MD, FACS, FRCSI (HON)
A high-level overview of general surgery’s evolution during the last 100 years shows a stark contrast between the first 75 years and the last 25. While the first period was characterized by relative stability in techniques and instrumentation, the second is characterized by constant change in approaches, new techniques, and frequent introduction of new devices. The landmark event that divides these two eras was the introduction and rapid adoption of minimally invasive techniques. This article
with both hands, which made the performance of more complex procedures possible.
reviews the revolutionary impact that minimally invasive surgery (MIS)
The advent of widespread minimally invasive
had in general surgery—in its appeal, its philosophy, its patients, and
surgery has transformed everything about the
among those who practice or are training to do so—and highlights the
field of general surgery—its effect on patients,
role our College had in this revolution.
its appeal to students and trainees, the introduction of additional new technologies, and the
Background
ways in which surgery is taught today—and MIS still represents one of the most exciting
The concept of accessing the abdomen or chest through a small incision
frontiers in medical science.
and performing procedures directed by an endoscope was introduced at the beginning of the twentieth century, but the innovation was slow to
Patient Care
take hold. Surgeons found early laparoscopes too limiting; the direct view simply didn’t reveal tissues as well as needed for most procedures, and the
The first clear benefit of minimally invasive
scopes were difficult to manipulate—one hand was typically used to move
surgery was faster patient recovery. Rather
the scope around while the surgeon operated with the other. With marginal
than disrupt several layers of tissue, surgeons
exposure, cumbersome instrumentation, and access to the field limited to
could, using specially designed instruments,
the operating surgeon, the use of these techniques remained limited for
enter the cavity through a very small portal
the most part to examination of the peritoneal cavity or the performance
and navigate existing interior margins and
of a limited operation (liver biopsy, tubal ligation, etc.).
spaces. An abdominal operation causes
In the late 1980s, the widespread use of minimally invasive procedures was
two sorts of trauma: incisional trauma and
enabled by digital imaging technology. A camera with a microchip, attached
so-called “target trauma” that occurs in
to the telescope and capable of capturing an image that could be projected
the area of operation itself. For more than
onto a monitor, made viewing the operating field possible to the surgeon and
a century, the surgical wound had been the
all other members of the operating team. This innovation was the centerpiece
site of major concerns regarding postopera-
of the disruptive technology that set this revolution in motion. It was now
tive pain, discomfort, and complications such
possible for the assistant to operate the camera and for the surgeon to operate
as sepsis, hemorrhage, or herniation. After
50
most laparoscopic procedures, a patient could
the same extent as the surgeon. It allowed students and trainees to partici-
immediately re-enter society, return to work,
pate mentally and emotionally in the operation. It showed anatomy, and the
and otherwise resume normal living with
effect of surgery on it, in a way that had not previously been experienced,
minimal pain, rapid postoperative recovery,
and it reversed the downward trend that had been observed in the interest
and a dramatically reduced risk of direct or
in surgery among students.
indirect wound-related complications. These benefits, in turn, sparked an immediate change of attitude among all physicians.
Constant Innovation Changes the Practice of General Surgery
The absence of a wound, the lack of need for substantial pain medication, and the perceived
This new generation of surgeons immediately set to improve on the
reduced risk of complication promised better
early stages of laparoscopy. Working in close collaboration with device
outcomes—lower morbidity and mortality
manufacturers, surgeons and engineers from these companies explored
rates. General internists, gastroenterologists,
areas in instrumentation that had remained stable for the last 100 years.
and others became less resistant to indications
Almost anything that was being done was questioned and improved, and
for procedures known to be more effective than
new devices that facilitated the performance of laparoscopic operations led
medical therapy, but also known to carry the risk
to more surgeons adopting the new technology. The advent of the automati-
of an operation. The substantial reduction of
cally advancing clip applier, for example, motivated more general surgeons
“incisional trauma” became particularly notice-
to perform laparoscopic cholecystectomy—today still one of the most
able in operations that had a relatively small
used laparoscopic procedures. For the first time in a century, completely
target trauma and in which the greatest burden
new instruments were developed that bore only passing resemblance
posed by the intervention on the recovery of
to anything that had come before them. Devices that would allow rapid
the patient was incisional trauma (i.e., Heller
suturing, better dissection, and stapling of tissues allowed for more and
myotomy, Nissen fundoplication). In these opera-
more applications of these techniques to more complex procedures. Soon,
tions, postoperative recovery was dictated by the
the focus turned to developing ways to further minimize the invasiveness of
course of incisional healing more than by the
surgery—smaller incisions, better and smaller cameras, higher resolution
trauma inflicted at the operative site.
monitors, and smaller and fewer portals. In just a few years, a new concept evolved: the idea of accessing the
Appeal to Students and Trainees
abdominal cavity through natural orifices and thus eliminating altogether the need for an incision in the abdomen. Natural orifice translumenal endoscopic
The interest in minimally invasive proce-
surgery (NOTES) arose in the midst of this revolution as an experimental
dures, post-1989, was sudden and widespread
surgical method in which an operation was performed by instruments
in general surgery, a field that had, since the
inserted through a natural orifice—the mouth, anus, urethra, or vagina—and
early twentieth century, lacked a certain spice,
then into the abdominal cavity via perforation of, respectively, the stomach,
while other fields, such as cardiac and vascular
colon, bladder, or vaginal wall. The method has been used for both diagnostic
surgery, plastic surgery, and neurosurgery,
and therapeutic purposes; in 2007, the first transgastric cholecystectomy
had experienced quantum leaps. Students and
and transvaginal appendectomies were performed in the U.S.
trainees of general surgery had only experienced
NOTES procedures generally require the use of flexible endoscopes that
closeness to the operative field by holding retrac-
must be piloted through more complex structures, over longer distances. For
tors, a demanding and feared task, with minimal
surgeons experienced in the use of rigid laparoscopes, the two-dimensional
opportunity for learning. General surgery was,
images projected through these endoscopes can create problems in depth
compared to other fields of study, boring; proce-
perception and spatial orientation. Just as they have with laparoscopy,
dures were for the most part hurdles for students
however, surgeons and engineers are working together on new technologies
to overcome if they wanted to be surgeons.
—three-dimensional and off-axis imaging systems, for example—that may
The new digital imaging, however, allowed
help formulate an accurate representation of the surgical site in NOTES.
medical students and surgical residents—and
While NOTES is seen by some as the new frontier in minimally
anyone else who wanted to look—the ability to
invasive surgery, its advantages are still being debated. The potential
“insert themselves” into the operative field, to
for “scarless” abdominal surgery and for limiting the complications
51
associated with transabdominal wounds is still being weighed by the
extended the use of the computerized environ-
surgical community against the relative safety and simplicity—and in
ment. A robot essentially became an “informa-
many cases the closer proximity to the surgical site—offered by other
tion systems with arms”—just as the CT scanner
effective MIS options such as laparoscopy.
years earlier had become an information system
One of the ideas that spun off NOTES was the use of the umbilicus (by
“with eyes.” The main advantages to robotic
extension considered a “natural orifice”) as the single access site through
surgery are the finer calibration of movements;
which an operation could be done. Using a slightly larger (which is the
tremor and slippage are virtually eliminated
Achilles heel of this new concept) albeit “natural” portal, the surgeon
by the filtering software of robotic systems, the
was now able to introduce the endoscope and at least two sets of instru-
representation in a three-dimensional field,
ments. Additional instruments were placed directly through punctures
and the “wrist” provided to its instruments.
to aid in the performance of the operation. While this concept has the
The first robotically assisted surgery—a heart
advantage of using rigid endoscopes that provide better spatial orienta-
bypass—was performed in 1998, almost a
tion when compared to flexible endoscopes, and while manufacturers
decade after the first MIS procedure, and in the
have developed a slew of new instruments that can access the target from
years since, other surgical specialists—cardio-
the side, a lot of difficulties associated with the current techniques will
thoracic, gynecological, gastrointestinal, ortho-
have to be surmounted before these procedures will be broadly adopted.
paedic, vascular, and neurosurgeons—have all
They reflect, however, the rapid and almost constant innovation that has
pioneered their own robot-assisted procedures.
characterized surgery in the last quarter-century.
In early 2000, surgeons at Ohio State University
The electronics and computerization enabling MIS procedures have natu-
began exploring the use of robotic systems in
rally led to the development of surgical procedures performed with the aid
esophageal and pancreatic surgeries. In April
of robots. In robotic surgery, the surgeon does not directly manipulate the
2008, a group of surgeons at the University of
instruments, but does so through an interface with either a computer or tele-
Illinois at Chicago performed the first mini-
manipulator that commands a set of mechanical arms. While utilizing the
mally invasive, robot-assisted liver resection
concept of MIS in terms of access to the chest or abdomen, robotic surgery
on a living donor, removing 60 percent of the
52
PHOTOS COURTESY OF DR. CARLOS PELLEGRINI
Robot-assisted surgery at the University of Washington. Simulation-based training is increasingly being used to train surgeons to perform such minimally invasive surgical procedures.
patient’s liver and yet allowing him to leave the
immediate and widespread use of that technique to remove the gallbladder
hospital—with four stitched punctures, rather
in the late ’80s and the beginning of the 1990s also had a downside: a
than an abdominal incision—within two days
substantial increase in injuries of the bile duct. It soon became clear that this
of the procedure.
increase was due to the fact that the new method of operating also required
Robotic systems have enabled science
a new method of training. For decades, surgical students learned procedures
fiction to become reality. On September 7,
by imitating the procedures of others and by performing operations with
2001, a surgeon in New York performed the
the hands-on guidance of a mentor. With laparoscopy, this approach has
“Lindbergh Operation”—a minimally invasive
two distinct obstacles: First, the use of digital imaging projects images that
cholecystectomy on a 68-year-old woman more
tend to make procedures seem simpler than they are. These images create a
than 3,800 miles away in Strasbourg, France—
two-dimensional world, but the surgeon’s actions—pulling, pushing, lifting,
using sophisticated surgical robotics and a
shifting—are performed in three dimensions, and are often not processed
high-speed fiber-optic communications link.
accurately by those observing the procedures on a monitor. Second, the
As more expert surgeons use such special-
complete absence of peripheral vision impairs situational awareness, and
ized systems, procedural data may be stored
when this is combined with image distortion, it can lead to misinterpretation
in computerized systems. In 2006, a surgeon
or misidentification of structures.
in Boston, using a software program that
Laparoscopy also precludes the old-school collaboration between
combined data compiled by several surgeons
teacher and student. Before, the trained surgeon and untrained surgeon
over thousands of operations, monitored from
shared access, with their hands, through the abdomen of the patient
a computer as a robotic system performed the
while the trained surgeon coached and directed—exposing certain
world’s first unmanned robotic surgery—the
tissues, manipulating tissues closer to the trainee’s instruments, even
placement of a defibrillator—on a 34-year-old
manipulating and placing the hands of the trainee. In laparoscopy, these
patient in Milan, Italy.
methods are not possible; each individual performing a portion of the
The surgeon who performed the Lindbergh
operation has his or her own instruments and tasks, and those instru-
Operation, Dr. Jacques Marescaux, stated after
ments are manipulated independently of others’ actions. Further, the
his team’s procedure that the transatlantic
focus on safety that sprang from the Institute of Medicine report at the
operation was the third revolution the surgical
turn of the century simply dictated that an untrained surgeon should not
field had experienced in the past remarkable
be performing a procedure on a patient, even with guidance from a more
decade. “The first,” he said, “was the arrival
seasoned surgeon. MIS practitioners quickly realized that the best way
of minimally invasive surgery, enabling proce-
to adequately teach these operations was to combine task analysis with
dures to be performed with guidance by a
laboratory-based simulations. Task analysis broke complex procedures
camera, meaning that the abdomen and thorax
into discrete psychomotor skills—knot tying, tissue handling, or vascular
do not have to be opened.”
division, for example. Some operations were decomposed into 50 to 60
The second, said Marescaux, was the intro-
smaller pieces. Each of these smaller elements was learned in a labora-
duction of computer-assisted surgery, in which
tory under simulated conditions, and then integrated and combined into
artificial intelligence could be used to both
procedures that were performed on mannequins, or animals, or, more
enhance and control a surgeon’s movements
recently, in virtual reality created by computerized simulators.
during a procedure. Operation Lindbergh, he
It wasn’t until the year 2000, however, that the first study of simulation-
said, was “a richly symbolic milestone. It lays
based training in laparoscopy was published. That study, and more than
the foundations for the globalization of surgical
two dozen other studies since, have validated the effectiveness of the
procedures, making it possible to imagine that
simulation-based approach in enabling the transfer of learned skills to
a surgeon could perform an operation on a
the clinical environment. In 2002, for example, a validation trial revealed
patient anywhere in the world.”
that residents who demonstrated expertise in virtual reality laparoscopic skills training performed laparoscopic cholecystectomies 29 percent faster,
Teaching Surgeons
and with six times fewer errors, than did a control group who underwent traditional on-the-job training.
The unbridled enthusiasm that followed the
With the evidence mounting in validation of simulation-based training,
introduction of laparoscopic surgery and the
several national initiatives have been launched, such as the joint laparoscopic
53
SAGES Congratulates
the American College of Surgeons on 100 Years Join SAGES. SAGES is an unconventional surgical association in the best sense of the word. It is a collegial group in which newcomers are welcomed like long-term members of the “family.” SAGES Annual Meetings are filled with formal and informal networking opportunities. If you participate, you are valuable. If you work for the Society, you are invited into its leadership circle. SAGES is inclusive while preserving quality. It is statistically more difficult to have a paper accepted for podium presentation at a SAGES meeting than almost any other group, but new ideas are welcome. We have a service oriented staff. SAGES was founded FOR our members, and its primary responsibility is TO our members. Visit www.sages.org for more information or to join today.
R e s ou rc e s & P ro g r a m s : iMAGES
at
SAGES
iMAGES provides access to vast library of digital images, photos and graphics. SAGES TV is a central “searchable and fully navigational” depository for SAGES videos S-Wiki is a surgical “Wikipedia” that has signicant potential to become the most authoritative surgical reference on the web.
SAGES Webinars
SAGES Webinars have been developed specifically for residents and will feature expert panelists from SAGES. SAGESPAGES is a surgeon-to-surgeon social network that has replaced the previous SAGES member area. SAGES University facilitates online education content for MOC Part 2 Self assessment CME credit.
MYCME SAGES Guidelines
MYCME/MYMOC is a central repository to track all SAGES awarded MOC Part 2 CME credit. A complete list of all currently published SAGES Guidelines on the SAGES publication page. SAGES International Proctoring Courses are a vehicle for SAGES to “give back” to the world community by leveraging its leading educational and training activities to become a leader in bringing safe minimally invasive surgery to the developing world.
MIS Safety Checklist
The MIS Safety Checklist was developed by SAGES and AORN to aid operating room personnel in the preparation of equipment and other duties unique to laparoscopic surgery cases.
SAGES Pearls Series – Step by Step Short Video Clips · Expert Narratives Tips · Tricks · Important Steps SAGES Top 21 DVD contains the most common minimally invasive procedures performed by general surgeons, as determined by the SAGES Educational Resources Committee. SAGES Top 21 replaces the very popular SAGES Top 14 DVD, with all new videos and commentaries. SAGES Grand Rounds Master Series offers video, slide presentations, discussion and in depth education. The SAGES Educational Resources Committee developed these patient information brochures to assist surgeons in preparing their patients for surgery. Given the variations in technique, SAGES designed these handouts to describe the most commonly performed techniques. Fundamentals of Laparoscopic Surgery is an on-line based education module designed to teach physiology, fundamental knowledge & technical skills. The Fundamentals of Endoscopic Surgery (FES) Program is a test of knowledge and skills in flexible gastrointestinal (GI) endoscopy. FES is the flexible endoscopy equivalent of the Fundamentals of Laparoscopic Surgery™ (FLS) Program developed by SAGES. The Fundamental Use of Surgical Energy (FUSE) Program is an educational program/ curriculum that will cover the use of energy in interventional procedure in the operating room and endoscopic procedure areas.
Society of American Gastrointestinal and Endoscopic Surgeons 11300 West Olympic Blvd., Suite 600 · Los Angeles, CA 90064 Phone: 310-437-0555 · Fax: 310-437-0585 · www.sages.org
skills training curriculum launched in 2004 by
that would set standards for educational institutes. Shortly thereafter, this
the American College of Surgeons (ACS) and
committee became the official accreditation body for those centers that met
the Society of American Gastrointestinal and
its standards. As more centers became “ACS certified,” it became obvious
Endoscopic Surgeons (SAGES). In the mean-
that each had a different pool of individuals with expertise in different
time, validation of the method has led to its
areas of MIS education and training, and the idea was born to create an
adoption among other surgical fields; in 2008,
ACS Consortium of Accredited Institutes that would further standardize
the Residency Review Committee for Surgery
curricula, validate new methods of training, and determine the overall
mandated that all residency programs should
direction of simulation-based training and assessment for the future.
have access to simulation centers. The close collaboration with industry in the development
Conclusion
of new tools and techniques led to a substantial investment by commercial entities in the devel-
MIS has introduced an explosion in surgical innovation that may have
opment of training centers around the country.
some surgeons longing for the stability of the decades prior to 1989, when
Over time, the simulation-based education
the unrelenting uniformity and standardization of procedures facilitated
and training models necessitated by MIS have
teaching, allowed for predictable outcomes, and ensured surgical residents
grown—and will continue to grow—more
that the skills they were learning would be applied for at least the next five
comprehensive and sophisticated throughout
or six years. Today, with surgery continuing to revolutionize itself from the
the continuum of surgical careers. Simulation
inside of the patient outward, residents have little idea when their newly
is now speculated as a means by which surgery
acquired skills will be outdated.
residents might be selected and screened,
Despite these uncertainties, surgeons continue to innovate new MIS proce-
and various models for conducting long-term
dures. Cardiac and vascular surgeons have benefited greatly from the advent
follow-up with simulation-based learners are
of digital endoscopes and catheters, which have allowed them to swap out
being debated among the surgical community.
heart valves or deploy grafts or stents through single puncture sites. In summary, the introduction of MIS had a substantial impact on general
The Role of the ACS
surgery. It became, almost overnight, a philosophy that was embraced by most practicing general surgeons in this country and that increased the
The American College of Surgeons played a
utilization of surgery, as its benefits remained the same but its complications
substantial role in this revolution. Shortly after
and sequelae were lessened. It provided a new environment in the OR: one
the first successful laparoscopic cholecystec-
characterized by a team approach now that all members could follow every
tomy had been reported in France, at the Clinical
step of the operation. It provided the “spice” that had been slowly dwindling
Congress the first movie of this technique was
away from the specialty and captured the imagination of young students and
shown. The enthusiasm that it sparked was
surgeons-to-be. It brought together surgeons and device manufacturers,
evident by the overflow at the room where this
both groups feeling the need to continue to innovate and to move the field
movie was shown. Conscious of its mission to
forward at a fast pace. Finally, it opened the door to safer and more effective
provide the safest and most efficient surgical
methods of training surgeons in all specialties. And this is just the tip of the
care for patients, the ACS focused its efforts in
iceberg—a lot more is in store for the next 100 years. Q
the education and training of surgeons. Working in collaboration with SAGES—the professional organization that had made MIS the core of
Carlos A. Pellegrini, MD, FACS, FRCSI (Hon), is the current Henry
its existence—the development and validation
N. Hawkins Professor and Chair of the Department of Surgery at the
of the Fundamentals of Laparoscopic Surgery
University of Washington, a position that he has held since 1993. Prior
(now a requirement of the American Board of
to it, he was a Professor of Surgery at the University of California, San
Surgery for proffering certification) was made
Francisco. Dr. Pellegrini has played an important role in the American
available throughout the myriad of educational
College of Surgeons in several capacities including its Board of Regents,
institutes that had formed around the country.
which he chaired in 2010–2011. He was President of the American Surgical
In 2005, the Board of Regents directed the
Association in 2006. He is a Senior Director of the American Board of
Division of Education to create a committee
Surgery and a former Chair of the Residency Review Committee for Surgery.
55
A History of Public Hospitals by GRACE S. ROZYCKI, MD, MBA, FACS, AND DAVID V. FELICIANO, MD, FACS
Much has been written about public hospitals relative to their mission to care for the underserved, their role in medical education, and the continuous financial challenges that they encounter.1,2,3,4 But, despite doubts about their viability, public hospitals not only have withstood the test of time but have thrived and have evolved into a new entity, i.e., the safety net hospital. The Mission At the core of any public hospital is the mission of caring for the vulnerable (from the Latin word, “vulnus,” meaning “wound”) or underserved patient.5 The Agency for Healthcare Research and Quality defines underserved or vulnerable patients as “… those who face barriers to timely access to health services which provide the best possible health outcomes. Populations… include racial and ethnic minorities, low-income groups, women, children, elderly, residents of rural areas, and individuals with special health care needs.”6 In addition, there are geographical or population-based variables used to designate a medically underserved area, and these include the following: 1) percentage of the population below poverty level; 2) percentage of the population 65 years or older; 3) infant mortality rate; and 4) the ratio of primary care physicians per 1,000 population.7 Therefore, vulneradequate medical care, are socioeconomically, culturally, or geographically isolated from the Civil War surgeons of the Union Army’s 3rd Division pictured before a hospital tent in Petersburg, VA, 1864.
health care system (i.e., the disenfranchised population); and those who encounter severe barriers to accessing services. 7
56
LIBRARY OF CONGRESS
able patients are those who have not received
For more than 200 years, public hospitals have stayed true to their mission to care for the underserved. Although all hospitals care for the underserved, public hospitals are unique in that: 1) they are mission critical to the care of the underserved and to the education of health care providers; 2) they are mission centric to the community for the provision of resources during crises and disasters, making them a valuable community resource for both insured and uninsured patients; and 3) they are financially challenged despite external support. Core safety net providers have a legal mandate or explicit mission to offer patients access to services regardless of their ability to pay. Additionally, a substantial share of their patient mix must be uninsured, have Medicaid, and be other vulnerable patients.8
The Evolution of Public or Safety Net Hospitals Public hospitals have their roots in the
IMAGE COURTESY OF THE ARCHIVES OF THE FREDERICK L. EHRMAN MEDICAL LIBRARY
almshouses, a British practice of estab-
A view of Bellevue Hospital from the East River, 1879.
City Infirmary, established in 1736), and Charity Hospital (New Orleans Almshouse, established in 1736).9,10
lishing a specific institution for those who
At the time, most medical care occurred in patients’ homes (doctors
were viewed as “failures of society”.9,10
practiced medicine by making house calls), but doctors were encouraged
These so-called “poorhouses” were institu-
to give of their time and skill to treat patients in public hospitals. This
tions designed to assist and house the poor,
arrangement benefitted the patients, but was also valuable to the doctors,
disabled, and homeless, and to provide them
who gained experience in treating a wide range of maladies.11
with medical care in the event of serious
Whereas surgeons previously practiced in isolation, during the Civil
medical and surgical illnesses. In this regard,
War they functioned as a team, which contributed to the sharing of
they also served as a line of defense against
ideas and the setting of standards.12,13 They also recorded new surgical
infectious diseases that, if left uncontrolled,
techniques—such as the use of tourniquets to control acute hemorrhage
could become epidemics affecting greater
and arterial ligation for definitive vascular control—in manuals so they
numbers of people—including the wealthy—
could be shared with other surgeons and incorporated into medical
and disrupting commerce.11 Eventually,
school curricula.14,15
social reforms dictated that people housed
Hand-washing when caring for patients (Ignaz Philipp Semmelweis,
in almshouses for social reasons should
MD), the proposal that microorganisms cause disease (Louis Pasteur),
reside in other institutions, leaving only
and the advent of antiseptic surgery (Joseph Lister, MD) were significant
those with medical problems to inhabit the
medical contributions from Europe during this time period.16,17 These
almshouses. Dedicated to serving the medi-
findings revolutionized care of the sick and injured, and their imple-
cally underserved, the almshouses held fast
mentation meant surgical procedures were more often met with positive
to their mission and became predecessors
outcomes, which bolstered respect for medical practitioners and the
of some monumental public hospitals in the
hospitals in which they practiced.12
United States, including Philadelphia General
The second half of the nineteenth century saw a rising need for
Hospital (Friends Almshouse, established in
public hospitals and their services.12 Those who were wounded in war
1713), Bellevue Hospital Center (New York
required care, as did many of the immigrants coming to American
57
Gundersen Lutheran— more than a century of surgical excellence Since pioneering appendectomy surgery in Wisconsin more than 120 years ago, Gundersen Lutheran has had a long history of being a leader in cutting-edge surgery. In more recent years, this has included multiple vessel minimally invasive coronary bypass surgeries, coiling for brain aneurysms, robotic surgery, and one of the first to perform the LINX procedure to treat GERD. Our surgical outcomes and innovations have not gone unnoticed. Gundersen Lutheran has been named one of America’s 100 Best for Specialty Care in General Surgery* by HealthGrades in 2012.
gundluth.org/surgery *For 2012 by HealthGrades®
The American Hospital Association congratulates the
for its 100 years of inspiring quality As part of the American Hospital Association’s ongoing mission to improve the health of patients and communities, we introduced the Physician Leadership Forum to engage and partner with physicians to collaboratively advance excellence in patient care. The AHA’s Physician Leadership Forum also seeks to gather input from physicians to inform AHA policy and advocacy efforts while advancing physician leadership within the health care delivery system. Learn more about our resources for physicians at www.ahaphysicianforum.org.
shores, and urbanization contributed to the need as well. As a result, many public hospitals were established or expanded to meet the demand. Rotations at the Ellis Island Immigrant Hospital (opened in 1902) and Bellevue Hospital Center, to name two such institutions, were desirable due to the variety and complexity of patient cases, and medical schools increasingly established affiliations with public hospitals to enrich their students’ education.2,18,19 After World War II, new drugs such as penicillin and the Salk vaccine were available to treat and prevent disease, and effective outcomes from their use inspired respect and authority for the medical profession.12 By this time, the public’s perception of hospitals— particularly public hospitals—had changed; no longer just places where the ailing poor or “failures of society” were treated or housed, now hospitals could—and did—evaluate and treat with increasing success ill and injured patients of all income levels using medicine and surgical techniques made possible by medical advances made over the years.2,12,20
President Lyndon B. Johnson, with Harry S. Truman by his side, signs the Medicare bill into law, July 30, 1965.
Though they faced chronic financial hardship, public hospitals continued in their mission to provide care to the underserved.
located in urban areas—this meant a decrease in critical funding, even
Affiliations with medical and nursing schools
as outpatient visits rose (310 percent from 1944 to 1965).12
helped them weather monetary issues.12 The Hill-Burton Act of 1946 made funds
Medicaid to provide health insurance for the elderly and the poor. With
available to hospitals for the purpose of reno-
this publicly funded coverage, citizens who previously relied on public
vation or construction on the condition that
hospitals’ services could choose to spend their insurance benefits at
the hospitals provided a reasonable amount of
private or not-for-profit hospitals.11 Private and not-for-profit hospi-
uncompensated care to the indigent in return.
tals also had the ability to “cherry-pick” their patients—accepting
Many public hospitals had been in existence
those with coverage and turning away those who could not afford care,
for decades and were in need of repairs,
whereas public hospitals did not.2,11 Even though public expenditures on
upgrades, and expansions in order to continue
health care climbed, fewer dollars were finding their way into public
providing quality care to their large numbers
hospitals.11 The need for public hospitals persisted, however; some
of patients. As a survival measure, many such
citizens didn’t qualify for Medicare and/or Medicaid, and those who
public hospitals agreed to the stipulations and
did qualify found that the insurance didn’t necessarily cover all their
continued to serve the underserved.12,21
health care costs—costs that were rising (the consumer price index
Prosperity and the low unemployment rate ASSOCIATED PRESS
In the mid-1960s, the federal government enacted Medicare and
rose 300 percent between 1960 and 1980).12
following World War II saw many citizens
In addition to the uncompensated care, the number of admissions to
leaving the cities and moving to the suburbs,
public hospitals continued to rise and public hospitals struggled to fulfill
resulting in eroded tax bases in urban
their mission to serve the vulnerable. In 1976, the Commission on Public-
communities. For public hospitals—generally
General Hospitals was created to address this problem. Although its
59
The Duke Department of Surgery Congratulates the American College of Surgeons on Its Centennial Anniversary Celebrating 100 Years of the Highest Surgical Standards in Improving Patient Care
surgery.duke.edu
report recognized that urban public-general hospitals were unique in their needs and that special assistance was required, no concrete solutions were developed.12 Another major financial blow to public hospitals was the enactment of the 1981 Omnibus Reconciliation Act, which discontinued Medicaid reimbursement based on “reasonable costs.”22 But, the Act also included a provision for states to consider a reimbursement plan for hospitals that served a disproportionate number of low-income patients with special needs. These provisions became known as the DSH, or the Disproportionate Share Hospital, program.22,23 As state and federal funding were still far from adequate, public hospitals needed an advocate. In 1980, the National Association of Public Hospitals (NAPH) was established as an advocacy group to lobby for safety net health systems to have adequate resources to respond to the needs of their patients and
Dr. Karl Radke examines a patient at the Community Health Center of Central Wyoming in March 2011. Community health centers play an important role in meeting the health care needs of poor, uninsured, and rural populations.
communities.24 NAPH members were able to tap into a network of hospitals and experts who were familiar with their struggles and
Safety Net Hospitals Today
could provide support. Further, their voices
ASSOCIATED PRESS PHOTO BY TIM KUPSICK
were heard in Washington, DC.
Today’s safety net hospitals provide resources that benefit all members
During this period, some hospitals closed
of a community—such as trauma centers, burn care centers, HIV/AIDS
due to lack of funding, but others found ways
care, substance abuse counseling, and disaster response—and they are
to survive. Cutbacks in staffing and number
instrumental in training doctors since they are often sites for graduate
of beds were common. In some cases, changes
medical education.2,12,20,26 However, their mission to administer care to
in ownership or management aided struggling
the vulnerable remains at the forefront.
facilities, with some hospitals coming under
Vulnerable patients face many problems when it comes to accessing health
the control of medical schools or other orga-
care and in trying to aid this population, those problems become challenges
nizations.2,12 Importantly, this period also saw
for safety net hospitals, too. Some barriers to access include: geography
the development of trauma centers (the first
(for instance, lack of facilities in rural areas, or closure of a community’s
were established in 1966 at San Francisco
hospital due to lack of funds); language barriers; or immigration status.11,26
General Hospital and at Chicago’s Cook
When vulnerable individuals are able to access health care, they often
County Hospital—now the John H. Stroger,
present with advanced disease, increasing the acuity and complexity of their
Jr. Hospital of Cook County), many of which
medical or surgical conditions. Further, health issues can be compounded
were located within or affiliated with public
by socioeconomic factors like homelessness or poor nutrition.26
1,25
Offering such specialized care
Community health centers (CHCs) have a history of filling in health
helped public institutions compete in the
care gaps for poor or uninsured or those who otherwise lack ready
health care provider marketplace, but of even
access to other facilities, offering a place where people can receive
more significance: In providing care neces-
mainly family and primary care (though some, like women’s clinics,
sary to the insured and uninsured alike, the
have a more specialized focus). While CHCs do help in addressing issues
public hospital became a safety net for the
of access, they face challenges as well, particularly securing funding
hospitals.
whole community.
2,12,26
to continue providing services.11
61
th AN AN NNI NIVE N NI IIVE VER VE RS SAR S ARY AR
1913-201 13 3
Over the decades, safety net hospitals have examined alternative methods of operation with cost savings and efficiencies as end points. These potential solutions include a reduction of services and/or personnel, enhancement of efficiency through mergers and streamlining of internal operations, and the development of collaborative initiatives with other health care facilities.27,28,29,30,31,32,33,34 One of the more successful strategies was that initiated by Cleveland MetroHealth, which developed a comprehensive public hospital system to include the MetroHealth Medical Center, Center
A medical student checks a patient in the emergency room at Harborview Medical Center. Safety net hospitals are important sites for graduate medical education.
for Rehabilitation, Center for Skilled Nursing Care, Clement Center for Family Care, and the MetroHealth Life Flight.35 But with all of the
San Francisco General Hospital; and the first civilian burn center—from which
problems that public hospitals face, including
the first civilian intensive care unit and the first post-burn fluid resuscitation
budget reductions, rapid growth of Medicaid
protocol formed—was founded in 1947 at the Medical College of Virginia
managed care, an ideology that promotes
(now Virginia Commonwealth University Medical Center).12,37,38,39,40,33,41 And
privatization of the safety net hospital, and the
while doctors training at safety net hospitals gain valuable experience in both
socioeconomic factors of language barriers,
the physiological and social issues that affect health—thanks to the often
homelessness, and illegal immigrants, it is
complex cases they take on—such settings also engender in them a sense of
doubtful that there is one best solution. Effective
commitment to and compassion for their patients.20,26
advocacy and the continuous collection of data
Public hospitals have a remarkable history, as described. And, although
specific to the safety net hospital that validates
each hospital may be unique, they are united in heritage and destiny. If
their unique problems may be the most effective
safety net hospitals engage the community successfully, continue to build
24,
trust, establish new capability and capacity, and continue in their educa-
The NAPH conducts an annual survey of its
tional mission, they will survive, evolve, and continue their tradition of
member hospitals with the purpose of identi-
service. This will further enrich their heritage and future generations
fying trends in challenges and care. Selected
will be proud to be part of the mission to care for the underserved. Q
avenues to potential solutions in the long run. 34
results from its 2010 survey show that safety net hospitals continue to provide billions of dollars in uncompensated care while continuing in their mission to care for the underserved.36 Aside from their commendable mission to
This article is based in part on Dr. Rozycki’s Southeastern Surgical Congress Presidential Address, which was originally published in The American Surgeon.
ASSOCIATED PRESS PHOTO BY ELAINE THOMPSON
serve those in need, public hospitals have been sites of medical innovation and education that
Grace S. Rozycki, MD, MBA, FACS, is Professor of Surgery at Emory
benefit all of society: The nation’s first ambulance
University School of Medicine. For the past 17 years, Dr. Rozycki has
service was instituted at Bellevue Hospital Center
served as the Director of Trauma and Surgical Critical Care at Grady
in 1869; the first blood bank (initially called the
Memorial Hospital in Atlanta, GA.
Blood Preservation Laboratory) was established at Cook County Hospital in Chicago in 1937;
David V. Feliciano, MD, FACS, is Past Chair of the ACS Advisory Council
groundbreaking research on blood flow within
for General Surgery from 2007–2011 and is General Surgery Community
the heart (use of cardiac catheterization) was
Editor, ACS Web portal. He is an attending surgeon at Atlanta Medical Center,
conducted at Bellevue Hospital Center starting
Professor of Surgery at Mercer University School of Medicine (Macon, GA),
in the mid-1940s; the first trauma centers were
and Adjunct Professor of Surgery at the Uniformed Services University of
developed in 1966 at Cook County Hospital and
the Health Sciences (Bethesda, MD).
63
References 1. Blaisdell FW. Changes in county hospitals during Sheldon’s tenure. Am J Surg. 2002;185:30-4. 2. Burns RP. The historic role and questionable future of public hospitals. J Am Coll Surg. 2008;206:767-81. 3. Friedman E. Problems plaguing public hospitals: Uninsured patient transfers, tight funds, mismanagement and misperception. JAMA. 1987:257:1850-7. 4. Gage LS, Andrulis DP. Our nation’s great public hospitals. JAMA. 1987;257:1942-3. 5. Random House Compact Unabridged Dictionary. Special Second Edition. New York: Random House; 1996. 6. U.S. Department of Health and Human Services. 2010 National Healthcare Disparities Report. AHRQ Publication No. 11-0005. 7. King TE Jr., Wheeler MB, Bindman AB, et al. Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations. New York; McGraw-Hill; 2007. 8. Lewin M, Altman S, eds. Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press; March 2000. 9. Fr iedman E. Pu bl ic hospitals: Doing what everyone wants done but few others wish to do. JAMA. 1987;257:1437-1444. 10. Law rence C. History of the Philadelphia Almshouses and Hospitals (1905). Whitefish, MT: Kessinger Publishing LLC; 2010. 11. Waitzkin H. The history and contradictions of the health care safety net. Health Serv Res. 2005; 40:941–952. 12. National Association of Public Hospitals and Health Systems. A place of trust: Two centuries of care in America’s public hospitals. The Safety Net. Spring 2006;20:1-37. 13. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 3, Civil War Surgery: Desperate Measures for Desperate Wounds, pp 75-92. 14. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 6, Learning to Treat Wounds: The Surgeons, the Operations, and the Results, pp 161-166. 15. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 1, In the Beginning: Ill-Prepared and Overwhelmed, pp 22-25. 16. Alexander JW. The contributions of infection control to a century of surgical progress. Ann Surg. 1985;201:423-8. 17. Bollett AJ. Civil War Medicine: Challenges and Triumphs. Tucson: Galen Press Ltd.; 2002. Chapter 7, Wound Infections: Laudable and Not-So-Laudable Pus, p 199. 18. Conway L. Forgotten Ellis Island: The Extraordinary Story of America’s Immigrant Hospital. New York: Harper Collins; 2007. Chapter 1, Constructing the Immigrant Hospital, pp 1-30.
19. Stetten D Jr. Bellevue Hospital: New York, July 1934–December 1936. PBM. 28:543–558, 1985. 20. Gourevitch M, Malaspina D, Weitzman M, Goldfrank L. The public hospital in American medical education. Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 85, No. 5: 779–786. 21. Opdycke S. No One Was Turned Away: The Role of Public Hospitals in New York Since 1900. New York: Oxford University Press; 1999. Chapter 3, Help in Time of Trouble, 1930-1950, pp 71-86. 22. Altman SH, Brecher C, Henderson MG, Thorpe KE, eds. Competition and Compassion: Conflicting Roles for Public Hospitals. Ann Arbor: Health Administration Press 1989; Chapter 1. Introduction. pp 6-8. 23. McKethan A, Nguyen N, Sasse BE, Kocot SL. Reforming the Medicaid disproportionate-share hospital program. Health Aff. 2009;W926 – W936. Available at content. healthaffairs.org/cgi/content/full/28/5/w926. Accessed February 2, 2012. 24. Available at: http://www.naph.org/. Accessed August 13, 2012 25. Trunkey DD. History and development of trauma care in the United States. Clin Orthop. 2000;374:36-46. 26. Meyer J. Safety Net Hospitals: A Vital Resource for the United States. November 2004. Available at http://www.esresearch.org/publications/NAPH_final.pdf. Accessed August 13, 2012. 27. Zuckerman S, Bazzoli G, Davidoff A, LoSasso A. How did safety-net hospitals cope in the 1990s? Health Aff. 2001;20:159-68. 28. Brown ER. Public hospitals on the brink: Their problems and their options. J. Health Politics, Pol Law. 1983:7;927-43. 29. Gabow P, Eisert S, Wright R. Denver Health: A model for the integration of a public hospital and community health centers. Ann Int Med. 2003;138:143-150. 30. Cousineau MR, Tranquada RE. Crisis & commitment: 150 years of service by Los Angeles County Public Hospitals. Am J Public Health. 2007;97:606-15. 31. Hall MA, Hwang W, Jones AS. Model safety-net programs could care for the uninsured at one-half the cost of Medicaid or private insurance. Health Aff. 2011;30:1697-1707. 32. Taylor R, Blair S. Public hospitals: Options for reform through publicprivate partnerships, 2002. Available at http://siteresou rces.worldbank.org/ EXTFINANCIALSECTOR/Resources/282884-1303327122200/241Taylo-010802.pdf. Accessed August 13, 2012. 33. Felland LE, Lesser CS, Staiti AB, et al. The resilience of the health care safety net, 1996-2001. Health Serv Res. 2003;38:489-502. 34. Felland LE, Ginsburg PB, Kishbauch GM. Improving health care access for lowincome people: Lessons from Ascension Health’s community collaboratives. Health Aff. 2011;30:1290-8. 35. Suchetka, D. MetroHealth, Cuyahoga County’s safety net health system, reports earnings for third year in a row. http://blog.cleveland.com/health_impact/print. html?entr y=/2011/01/metrohealth_system_repor ts_ear.html. Dow nloaded on February 8, 2012. 36. Zaman OS, et al. America’s Safety Net Hospitals and Health Systems, 2010: Results of the Annual NAPH Hospital Characteristics Survey. Washington, DC: May 2012, www.NAPH.org. 37. National Association of Public Hospitals and Health Systems. First Hospital Ambulance Service. Available at http://www.naph.org/Homepage-Sections/Explore/ History/First-Hospital-Ambulance-Service.aspx. Accessed August 13, 2012. 38. Telischi M. Evolution of Cook County Hospital Blood Bank. Transfusion. 1974;14:623-28. 39. Opdycke S. No One Was Turned Away: The Role of Public Hospitals in New York Since 1900. New York: Oxford University Press; 1999. Chapter 4, Many Voices, Many Claims 1950-1965, pp 99-100. 40. Feliciano, DV. Nobel Prize winners who were trained as surgeons. American Surgeon. 2009. Jan;75(1):15-9. 41. Dimick AR, Brigham PA, Sheehy EM. The development of burn centers in North America. J Burn Care Rehabil. 1993;14:284-99.
65
Something in the Air “American Surgery’s Noblest Experiment”—C. P. Schlicke, JAMA, 1973 BY L AMAR S. MCGINNIS, JR., MD, FACS
This American College of Surgeons (ACS) Centennial publication is replete with the proud accomplishments of our chosen profession over the past 100 years. These sentinel achievements in surgery represent the vision, creativity, determination, hard work, ethos, and brilliance of those who preceded us. Their achievements, scientific and technical, have revolutionized the standard of surgical patient care and the esteem in which surgeons are held. However, it’s worth remembering that progress isn’t guaranteed. The
The same year, Thomas Cullen, MD, FACS,
early 1900s setting in which the ACS’ founders worked might well have
another founder of the Clinical Congress of
deterred hope for improvement. The medical profession was fraught with
Surgeons of North America and the chair of
problems. Medical education consisted largely of diploma mills. Surgery
the Cancer Campaign Committee, joined with
was to be avoided as infections often resulted and outcomes were dismal.
Clement Cleveland, MD, FACS, the president
With exceptions, hospitals were likewise to be avoided.
of the American Gynecologic
Care decisions were not based on evidence as records and
Society, and others to form
outcomes were largely unavailable. Cancer was a death
the American Society for the
sentence, the word itself evoking justifiable terror.
Control of Cancer (ASCC, later, the American Cancer Society). The new organization revo-
professionals recognized that progress was possible. There
lutionized public awareness of
was something in the air. Still, change is never easy and
cancer, established systemic
resistance to change is ever-present. Observant, dynamic,
patient data collection, and
persistent visionaries are capable of and did succeed in
trumpeted the importance of
initiating beneficial change processes that persist today.
early recognition and treat-
Abraham Flexner’s review of the state of medical
Franklin Martin
ment. Subsequently, the College
education, reported in 1910, revolutionized this field and
formed its own Committee on
resulted in modern medical education. William Halsted,
the Treatment of Malignant
MD, established a new paradigm for surgical education and training and
Disease by X ray and Radium, chaired by
established a new American approach to surgical technique.
Robert Greenough, MD, FACS, which even-
Franklin Martin’s concern regarding the lack of available continuing
tually evolved into the ACS Committee on
surgical education propelled him to establish the journal Surgery,
Cancer and then into the present multidisci-
Gynecology and Obstetrics (SG&O, now the Journal of the American
plinary Commission on Cancer.
College of Surgeons—JACS). He established the Clinical Congress of
The American Joint Committee on Cancer
Surgeons of North America (now the ACS Clinical Congress, the largest
(AJCC) was yet another, later, ACS offshoot,
annual surgical meeting in the world) and, with others, the American
chaired initially by Murray Copeland, MD,
College of Surgeons in 1913.
FACS. R. Lee Clark, MD, FACS, was also very
66
PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
But opportunities abounded. The Industrial Revolution was changing the world and thoughtful, observant medical
Hospital (MGH). He had many fields of interest and expertise, from the diagnostic X ray to anesthesia (he formulated the anesthesia record with Harvard classmate Harvey Cushing), bone sarcoma, the shoulder, duodenal ulcer, tumor registries, and more. His impact on all of these areas was profound and long lasting, yet his most significant contribution was also his most controversial. He believed that surgeons and institutions should be accountable for their surgical results. Dr. Codman established the first mortality and morbidity conference at the MGH, where he famously declared, “Every hospital should follow every patient it treats long enough to determine whether or not the treatment has been successful, and then to inquire, ‘if not, why not?’” In other words, don’t just operate and discharge the patient; see what happens and learn from that. Dr. Codman strongly believed that health care professionals and their institutions should maintain accurate records, document and analyze their findings, and be very transparent with these findings. He also had the unusual belief (for that time) that
Ernest Amory Codman
hospitals should have quality standards. Though Dr. Codman reckoned that it might be 100 years before it would find acceptance, he established
NIH NATIONAL LIBRARY OF MEDICINE / THE BOSTON MEDICAL LIBRARY IN THE FRANCIS A. COUNTWAY LIBRARY OF MEDICINE
involved in the early days of the AJCC. The
the “end result” idea (outcomes studies, evidence-based medicine).
resulting emphasis on the proper staging
He was brilliant, different, challenging, and outspoken. He could also
of cancer became the basis for modern
be direct, abrasive—even offensive—but was always highly principled.
stage-based cancer therapy. Our College
Dr. Codman’s personally drawn cartoon lampooning the medical estab-
also formed, in 1922, the Committee on the
lishment for its disinterest in outcome data is a classic. His surgical
Treatment of Fractures, chaired by Charles
professional career unfortunately suffered as a result of his views. He
Scudder, MD, FACS. It ultimately became the
died in 1940, of melanoma, and his body is buried in an unmarked grave
ACS Committee on Trauma (in 1949) that
in his wife’s family plot in the Mount Auburn Cemetery in Cambridge, MA.
has contributed to a century of improvement in the offerings of this surgical discipline. So transcendent has been the evolution of these early 20th cent u r y development s t hat
Dr. Codman established the first mortality and morbidity conference at the MGH, where he famously declared, “Every hospital should follow every patient it treats long enough to determine whether or not the treatment has been successful, and then to inquire, ‘if not, why not?’”
today we take them for granted. Similarly, I suspect many Fellows and the public are unaware of the role our College has played in this evolution. That role is exemplified by the formation of The Joint Commission (originally the Joint Commission on Accreditation of Hospitals) and its chief architect, Ernest Amory Codman, MD, FACS. A Harvard-educated Boston Brahmin, Dr. Codman became a most successful staff surgeon
Ernest Amory Codman’s Back Bay golden goose cartoon.
at the Massachusetts General
67
Dr. Craig R. Smith and the Columbia University Department of Surgery
Congratulate the
American College of Surgeons 100th year in the pursuit of excellence in surgery
Clinical Congress of Surgeons
was formulated from
of North America President
ideals advanced by Dr.
Edward Martin, MD, FACS,
Codman and codified by
learned of Dr. Codman’s “end
John Bowman, PhD, the
result” idea and felt that a
ACS’ first Director. This
newly formed college would
Minimum Standard focused
be an excellent instrument to
on medical staff organiza-
introduce this concept into
tion, critical evaluation
hospitals and to standardize
of clinical practice, and
those hospitals. As our College
medical records standards.
was forming, its leaders had
Though it was decided
the great foresight to appoint
implementation of the
Dr. Codman as the first chair
Minimum Standard should
of the Standards Committee.
be voluntary, not manda-
Upon helping to found the College, Franklin Martin, MD, FACS, decided it should
In 1918, the College began
include among its original
surveying hospitals of 100
purposes the betterment of
beds or more, finding that
surgical education and of the
only 12.9 percent (89 out of
clinical practice of surgery.
the 692 hospitals surveyed)
He recognized that successful
met this Minimum Standard.
work is most easily and reliably accomplished in a proper environment.
IMAGE COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
tory, it achieved international fame and acclaim.
The survey findings were reported at a 1919 meeting at the Waldorf-Astoria hotel in New York
The absence of such an environment was
City, but information about individual hospitals’ identities and their
illustrated by the dilemma facing applicants
particular results were burned in the furnace the night before, an act
for fellowship in the ACS. Applicants were
infamously referred to as the “pyre in the Waldorf cellar.”
required to submit case records of their
The College continued surveying on an annual basis with a slow but
surgical work, but due to the absence of
steady improvement in compliance. By 1923, 86.2 percent of hospitals of
hospital documentation most could not. Many
100 beds or more met the Minimum Standard and 46.9 percent of hospitals
hospitals lacked central record-keeping facili-
under 100 beds met it. Dr. Franklin Martin reported the survey findings at
ties. Cases were either inadequately recorded
the 1923 Clinical Congress, with President Harvey Cushing presiding. Dr.
or not at all. Laboratory and radiologic
Franklin Martin later reflected, “The American College of Surgeons, with the
facilities were deficient, medical staffs were
exuberance of youth and unhampered by tradition, decided to make itself
unorganized, and educational requirements
responsible for the standardization of its own environment – the hospital.”
were undefined. Professional medical work
In the beginning, the College accumulated valuable data through
was generally unsupervised.
conferences, correspondence, and carefully conducted research into
Admirably, the College accepted the respon-
hospital management. This information suggested that not only was
sibility for correcting this deficiency. In 1917,
there a need for the application of the Minimum Standard, but also
the first Minimum Standard for Hospitals
the need for a personal visit to each institution by a representative of
In 1924, Dr. Franklin Martin observed, “The Minimum Standard has become to hospital betterment what the Sermon on the Mount is to great religion.” A movement had begun, with great benefit to all. 69
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at his hospital from the program. On the major problem of the time, fee splitting, he observed, “I do not know that it exists in New Brunswick, perhaps because a good many of the men down there are Scotch and hate to part with any money. You know they say that the difference between a Scotchman and a horse cart is that the cart tips.” The College initially wanted the American Medical Association (AMA) to run the standardization program but was turned down. Despite his organization’s refusal to participate, the chairman of the AMA Council of Evarts Graham
Medical Education stated at the time, “… this problem that confronts the American College of Surgeons, along with medical education, is the most
BECKER MEDICAL LIBRARY, WASHINGTON UNIVERSITY SCHOOL OF MEDICINE / PHOTO COURTESY OF THE JOINT COMMISSION
important thing in American medicine.” the standardizing agency and an accurate
That importance was demonstrated by the College’s commitment as
record of the findings of the representatives
sole executor of the hospital standardization program from 1918 to
that would be made available to the public.
1951. From 89 approved hospitals (12.9 percent of hospitals of 100 beds
The Carnegie Foundation, which had funded
or more surveyed) in 1918 to 2,067 approved hospitals (93.6 percent of
Flexner’s medical school survey and report,
hospitals of 100 beds or more) by 1945, rapid acceptance of the program
joined the ACS in funding this hospital survey
was apparent. The theme was “the proper care of the sick and injured.”
process over a five-year period, 1918–1923.
Nevertheless, opposition to standards and measurement remained,
This was complemented by cooperation from the
particularly with respect to transparency, a problem that continues to
American Hospital Association and the Catholic,
this day. Supporting the movement, Will Mayo, MD, FACS, said in 1929,
Protestant, and Methodist hospital associations.
“when hospitals and physicians accept standardization, the millennium
Assuming the hospital standardization move-
will have arrived.” Well, we are here. Over the years, cost became a
ment was destined to extend far into the future,
mounting concern. By 1950, total College investment in the program
the College shouldered the full financial and
came to $2 million, yet pride was taken in the fact that 3,290 hospitals
labor burden for this process beginning in 1923.
had been accredited by that year.
Bowman, the first ACS Director, set the
But that year, the ACS Board of Regents determined it was no longer
precedent of visiting hospitals. Subsequently,
possible to maintain the program solely from dues collected from Fellows. A
Malcolm MacEachern, MD, Associate ACS
power dance had begun. The American Hospital Association was determined
Director, took on this responsibility and main-
to take over the program. The AMA was as determined that they should
tained it for 28 years. The service was rendered
not. The College became the arbiter of the debate and after nine months of
free of charge to hospitals of more than 50
oft times acrimonious deliberation, Evarts Graham, MD, FACS, offered an
beds in the U.S. and Canada. Compliance
ultimately acceptable solution.
required competent laboratory and radiology
Dr. Graham proposed a new inde-
services, adequate medical documentation,
pendent, not-for-profit corporation
data analysis, and a culture of learning.
with governance to be split equally
In 1924, Dr. Franklin Martin observed, “The
between the AMA, the American
Minimum Standard has become to hospital
Hospital Association, and an equal
betterment what the Sermon on the Mount
number of representatives from the
is to great religion.” A movement had begun,
ACS and the American College of
with great benefit to all.
Physicians, along with one repre-
Joh n McKenzie, M D, FACS, of New
sentative from the Canadian Medical
Brunswick, Canada, proclaimed at that
Association (withdrew in 1959). The
time, “I have heard it said, and said it myself
A merican Hospital Association’s
through lack of knowledge, that the College
George Bugbee suggested the phrase,
program on hospital standardization is of
the “Joint Commission.”
very little value.” He then offered six sound points of beneficial impact that had occurred
Edwin L. Crosby
The idea was adopted and the Joint Commission on Accreditation
71
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Sophisticated treatments. Visionary research. Progressive care. Montefiore Einstein Center for Cancer Care is constantly evolving cancer treatmentâ&#x20AC;&#x201D;combining groundbreaking chemotherapy and radiotherapy with the latest surgical techniques, including robotics and regional therapies. In fact, we are the only center in the Northeast offering a full complement of regional therapies, including HIPEC, isolated limb perfusion and liver perfusion. As a result of our advanced approach, pairing pioneering medicine with an emphasis on quality of life, weâ&#x20AC;&#x2122;ve become the natural selection for nearly 6,000 cancer patients each year. We could not have come so far without the support of our colleagues at the American College of Surgeons (ACS) and the efforts of the Commission on Cancer. We congratulate ACS on its 100th anniversary as we continue to work in concert to drive surgery forward and transform cancer care.
Montefiore Einstein Center for Cancer Care www.montefiore.org/cancer
Today, The Joint Commission accredits more than 19,500 health care organizations and programs in the United States, including more than 10,500 hospitals and home care organizations (encompassing 86 percent of U.S. hospital beds) and more than 6,500 other health care organizations that provide long-term care, behavioral health care, and laboratory and ambulatory care services. It certifies more than 2,400 disease-specific care programs, primary stroke centers, and health care staffing services.
of Hospitals (JCAH) was formed in 1951 with
on Accreditation of Healthcare Organizations (JCAHO), as an expanded
funding from the member organizations.
coterie of health care organizations were made eligible for accreditation.
Surveys were to be carried out by a JCAH staff
In the 1990s, standards began to embrace performance improvement
of trained surveyors. The ACS transferred the
concepts, and five additional public members were added to the Board,
hospital standardization program in 1952, and
along with an at-large nursing representative. Unannounced random
in 1953, the JCAH began offering accreditation
surveys began, smoking in hospitals was prohibited, and laptop tech-
and published its first Standards for Hospital
nology was introduced to the survey process, bringing greater objectivity
Accreditation. As the JCAH scope of activity
and efficiency. Sentinel events reporting began, Sentinel Event Alerts
expanded, an increasing number of hospitals
were published, and the standards manual was revised to focus on
sought accreditation and costs increased. As a
processes and outcomes of care rather than standards of care.
result, in 1964, the JCAH began charging fees to organizations seeking accreditation.
In the first decade of the 21st century, international accreditation expanded rapidly, as did the number of health care sites eligible for
With the advent of Medicare in 1965, accred-
accreditation. Significant “white papers” were published and disease-
ited hospitals were “deemed” to be in compli-
specific care certification programs began. In 2007, the organizational
ance with requirements set for eligibility to
name was simplified to The Joint Commission. A number of new Board
participate in Medicare and Medicaid. To differ-
Members representing other areas of health care were added to the
entiate accreditation from just meeting govern-
Commission, and accreditation manuals were offered electronically. The
ment requirements, the JCAH determined to
Center for Transforming Healthcare was launched to develop solutions
focus its standards on the “optimum achievable”
through the application of Robust Process ImprovementTM methods and
rather than, as formerly, the “minimum essen-
subsequently these solutions have been offered to accredited institutions.
tials.” The standards were revised beginning
Today, The Joint Commission accredits more than 19,500 health care
in 1966 to reflect this new focus, and optimal
organizations and programs in the United States, including more than
achievable standards were published in 1970.
10,500 hospitals and home care organizations (encompassing 86 percent
Whether “optimal” or “minimum,” Edwin L.
of U.S. hospital beds) and more than 6,500 other health care organizations
Crosby, MD, the JCAH’s first President, asserted
that provide long-term care, behavioral health care, and laboratory and
in 1972 that “no other single idea has done as
ambulatory care services. It certifies more than 2,400 disease-specific
much to upgrade American hospitals and to
care programs, primary stroke centers, and health care staffing services.
assure that the facilities of the hospital maintained high standards of quality and safety.”
From its inception, The Joint Commission’s mission has been to help health care organizations improve the quality and safety of care through
By 1970, the hospital accreditation stan-
accreditation. But in recent years, accreditation itself has often been
dards manual had evolved from the one-page
perceived by health care professionals more as a “regulatory” activity
Minimum Standard of 1918 to 152 pages
than a quality improvement activity. Consequently, the Commission has
representing the state of the art of hospital
reframed its mission to improve health care by evaluating health care
care. The JCAH continued its evolution with
organizations and inspiring them to excel in providing safe and effective
the American Dental Association becoming a
care of the highest quality and value, with accreditation becoming but
corporate member in 1979 and the first public
one of the Commission’s tools for achieving this goal.
Board Member appointed in 1982. In 1987, the
The Commission reinvented its on-site survey process by tracing the
name was changed to the Joint Commission
care of patients throughout their hospital experience—from the emergency
73
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of the organization. Mark C ha ssi n, M D, a ssu med t he presidenc y of The Joint Commission in 2008, bringing surveys with a strong collaborative, educational tilt—and a sense of aspiration—that is today hera lded by accred ited organizations. The introduction of Robust Process Dennis O’Leary
Mark Chassin
Improvement pr i nciples along with problem-solving tools offers a bright outlook
department and the operating room, through
toward moving health care to a “high reliability industry.”
to the recovery or intensive care unit, all the
The Commission also shares its quality improvement and evaluation
way to the discharge planning process. The use
expertise internationally, currently accrediting 450 health care organiza-
of this “tracer” methodology enables surveyors
tions in more than 50 countries.
to provide expert guidance to staff that visibly
The Joint Commission’s vision is an environment in which “All people
impacts the quality and safety of patient care.
always experience the safest, highest quality, best-value health care
Even with this guidance, organizations
across all settings.” It has dedicated its resources, along with those
frequently are unable to implement and
of Joint Commission Resources, Inc., and the Center for Transforming
sustain effective solutions to some of the most
Healthcare, to help health care organizations achieve this goal.
intractable problems in health care, including
That “something in the air” in the early 20th century wrought multiple
some whose solutions appear straightforward,
institutions that persist today. Perhaps “American Surgery’s Most Noble
such as hand hygiene, prevention of surgical
Experiment” has been the most impactful. The standardization of hospitals
site infections, and prevention of wrong
(now virtually all health care organizations) was inspired by Dr. Codman
person/wrong site procedures.
and adopted by our College alone. ACS staffed, nurtured, financed, and
The underlying causes frequently differ
oversaw standardization during more than half of The Joint Commission’s
from organization to organization, such that
existence. This was done out of a sense of professionalism—yet never
a solution for one would not necessarily be
designed to be profession serving—and steadily advanced in the face of
effective for another. As such, Robust Process
both internal and external resistance. We should take pride in all that our
Improvement problem-solving methods (LEAN
College created and the capabilities and opportunities that continue for
Six Sigma, change management) are critical
further betterment of patient care in the 21st century.
to identifying organization-specific problems
Renowned anthropologist Margaret Mead once said, “We are continually
and designing cause-specific solutions. A
faced with great opportunities which are brilliantly disguised as unsolvable
Targeted Solutions ToolTM is made available
problems.” Our College and its Fellows are up to the challenge. Q
PHOTOS COURTESY OF THE JOINT COMMISSION
at no cost to accredited organizations to facilitate problem solving specific to that organiza-
LaMar S. McGinnis, Jr., MD, FACS, practiced general and oncologic
tion. However, a vigorous change management
surgery in Atlanta for 40 years. He is a former President of both the
process is crucial for the successful and
American College of Surgeons and the American Cancer Society and
sustained implementation of these solutions.
is presently a member of the Board of Commissioners of The Joint
The Joint Commission was led for 20
Commission and Vice-Chair of the Board of Joint Commission Resources.
years by President Dennis O’Leary, MD, who
Dr. McGinnis is Adjunct Professor of Surgery at the Emory University
bridged the centuries and began the changes
School of Medicine and former Medical Director of the Eberhart Cancer
necessary to bring the organization into
Center in Atlanta. He is presently serving as Senior Medical Advisor and
the “modern era” while becoming the face
Liaison for the National Home Office of the American Cancer Society.
75
ACS Quality Programs by CLIFFORD Y. KO, MD, FACS
Quality was the issue around which the American College of Surgeons (ACS) was formed, and it is embedded in the organization’s mission statement: to improve the quality of surgical patient care by setting high standards for surgical education and practice. Optimal patient care is the chief objective of the surgeon’s professional life—and of the College’s fellowship.
In the early 20th century, surgeons were initially
and Prevention (CDC) to reduce surgical complica-
drawn to join the ACS because of a goal advanced
tions. The ACS is also an active member of the Surgical
by its founders: to implement quality assurance and
Quality Alliance (SQA), a collaboration among more
standardization measures that were sadly lacking in
than 20 surgical specialty societies for the purpose
American health care. By 1917, the College had devel-
of improving the quality of surgical patient care, for
oped its first set of minimum standards for hospitals,
defining principles of surgical quality measurement
and began conducting inspections under its Hospital
and reporting, and for developing awareness about
Standardization Program in an effort to ensure safe
unique issues related to surgical care in all settings.
care environments and an effective system of care
While devising its own quality improvement initia-
for surgical patients. Of the 692 hospitals surveyed
tives, the College has remained a leader since its 1913
by the ACS, only 89 met its minimum standards.
inception. In 2000, as a result of the ACS’ long-range
The growing complexity of the accreditation
strategic planning process, the College was reorganized
program led to the establishment of what is known
into four divisions: the Division of Advocacy and Health
today as The Joint Commission, which began offering
Policy, the Division of Education, the Division of Member
accreditation in 1953. The ACS remains thoroughly
Services, and the Division of Research and Optimal
involved in the accreditation process, however;
Patient Care (DROPC). The DROPC encompasses all the
not only do three ACS commissioners serve on The
cancer and trauma programs, as well as the section of
Joint Commission, but the College conducts other
Continuous Quality Improvement (CQI), which houses the
accreditation services through its many programs.
American College of Surgeons National Surgical Quality
In addition to its internal programs, the College
Improvement Program® (ACS NSQIP®), the Metabolic and
participates in several other national-level quality
Bariatric Surgery Accreditation and Quality Improvement
improvement efforts. For example, it’s one of the 10
Program (MBSAQIP), the Surgeon Specific Registry (SSR),
organizations on the steering committee of the Surgical
and the ACS Clinical Scholars in Residence Program.
Care Improvement Project (SCIP), a partnership initi-
The following sections are brief descriptions
ated in 2003 by the Centers for Medicare and Medicaid
of these programs and highlight some of the
Services (CMS) and the Centers for Disease Control
quality and safety efforts ongoing in the ACS.
76
Committee on Trauma The
of trauma care. Using the infra-
care settings to measure cancer care
structure of the NTDB, TQIP, which
quality; uses data to monitor treat-
C om m it t e e
now has 1,245 participating trauma
ment patterns and outcomes and
on Trau ma (COT )
centers, collects data, provides feed-
enhance cancer control and clinical
develops the stan-
back to participants, and identifies
surveillance activities; and develops
dards used to verify
the institutional characteristics asso-
effective educational interventions
trau ma
centers.
ciated with improved outcomes in
to improve cancer prevention, early
The evaluation of trauma centers is
trauma care. The program includes
detection, cancer care delivery, and
accomplished through on-site reviews
a site visit analysis of the trauma
outcomes in health care settings.
by a peer-review team experienced
center’s data quality to prov ide
The Commission coordinates
in the field of trauma. There are
external data validation. Web confer-
national studies on care patterns and
currently more than 350 ACS-verified
ences, an online course, and monthly
patient outcomes through the annual
trauma centers. The Trauma Systems
quizzes offer ongoing education. An
collection, analysis, and dissemina-
Consultation Program provides an
annual meeting provides hospitals an
tion of data for all cancer care sites
on-site trauma system review of a
opportunity to share best practices
through the National Cancer Data
state or region by a multispecialty
for performance improvement. Case
Base (NCDB). Established in 1989, the
team. This review provides critical
studies are also presented.
NCDB is a nationwide, facility-based
analysis of the current system and recommendations for improvement.
oncology data set that captures about 75 percent of all newly diagnosed
Cancer Programs
Since 1989, the COT has compiled
cancer cases in the United States, and
information about traumatic inju-
now contains approximately 26 million
r ies from par ticipati ng trau ma
records from hospital cancer registries
centers, and the resulting database,
across the United States. Data on all
the National Trauma Data Bank ®
types of cancer—including data on
ALL LOGOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS
®
(NTDB ), is the largest aggregation
patient characteristics, tumor staging
of U.S. and Canadian trauma registry
and characteristics, first course
data ever assembled; it now contains
The multidisciplinary Commission
treatment, disease recurrence, and
more than 5 million records. In 2012
on Cancer (CoC ®) was established
survival—are tracked and analyzed by
alone, 733 facilities submitted records
by the ACS in 1922 to set standards
the NCDB, and then used to explore
to the NTDB, which is used by the
for high-quality cancer care. Today,
trends in cancer care. The data is
COT to synthesize reports analyzing
more than 100 people, representing
disseminated to CoC-accredited hospi-
both site-specific and national perfor-
49 national professional organiza-
tals in the form of regional and state
mance in trauma medicine.
tions, comprise the Commission—the
benchmark reports, survival reports,
Ultimately, the goal of the NTDB
only multidisciplinary accreditation
program practice profile reports, and
is to inform the medical community,
organization for cancer programs in
other formats, serving as a basis for
the public, and decision-makers
the United States—which has estab-
quality improvement.
about the variety of issues involved
lished patient-centered standards and
In 1998, the American College of
in the care of injured patients—
conducted the accreditation of more
Surgeons Oncology Group (ACOSOG)
i nclud i ng epidem iolog y, i nju r y
than 1,500 hospital cancer programs.
was established with the primary
control, research, education, acute
The CoC provides clinical oversight for
focus of improving the care of the
care, and resource allocation.
standard-setting and the development
surgical oncology patient. The
of patient care guidelines; conducts
Group is a cooperative effort to
The COT has built on the NTDB with the establishment of the Trauma
surveys in health care settings to
Quality Improvement Program (TQIP),
assess compliance with those
piloted in 2008 and developed as a
standards and g u idel i nes;
validated, risk-adjusted, outcome-
collects standardized data
based measurement of the quality
from CoC-accredited health
conduct randomized clinical trials, and it includes a broad cross-section of
ALLIANCE
FOR CLINICAL TRIALS IN ONCOLOGY
medical professionals: general and specialty
77
Weâ&#x20AC;&#x2122;re ready for the greatest challenges.
8&+ RU UCHOSPITALS.EDU
surgeons, professionals from related
education. As it matures, the program
Rigorous data collection methods, data
oncolog ic disciplines, and allied
will strengthen the scientific basis for
collector training and annual testing,
health professionals in academic
improving quality of care, develop
data audits, the use of clinical data,
medical centers and community prac-
consensus on criteria for quality
as well as some of the most advanced
tices throughout the United States and
performance and monitoring, and
risk-adjustment methods are just some
foreign countries. In 2000, ACOSOG
establish a National Breast Disease
of the reasons for ACS NSQIP being
become one of nine adult cooperative
Database to report patterns of care
recognized as “best in the nation.”
groups funded by the National Cancer
and enable quality improvement.
Institute to develop and coordinate multi-institutional clinical trials. In 2011, ACOSOG merged with two other
Today, the ACS NSQIP is available to all private-sector hospitals. Participating
Continuous Quality Improvement
hospitals and their surgical staffs can use ACS NSQIP data to make valid
adult cooperative groups to form the
comparisons among hospitals in the
Alliance as part of a national initia-
program and make informed decisions
tive to consolidate the NCI groups into
about their quality improvement efforts,
a clinical trials network. The Alliance
with the overarching principle being the
maintains its close relationship with
use of risk-adjusted outcomes data to
the ACS and the CoC to continue the focus on improving the care of the
drive improvement. ACS NSQIP: With the vision and
ACS NSQIP has numerous built-in
long-term goal of establishing and
mechanisms for providing feedback to
In 2004 and 2005, the CoC submitted
maintaining a repository of the best
participating hospitals and the program
quality of care measures for breast
evidence for the practice of surgery,
as a whole, including annual data
and colorectal cancer to the National
the College was a curious and careful
audits, site visits, and the sharing of best
Quality Forum in response to the
student of a program pioneered
practices. This structured response,
Forum’s solicitation. The revised care
in 1994 by the Veterans Health
orchestrated by program staff, ensures
measures helped to serve as a basis
Administration (VHA). The program,
consistent reporting of data across sites
for another ACS effort, first proposed
which became known as the National
and the rapid dissemination of informa-
in 2005, to develop a program for the
Su rg ica l
I mprovement
tion about the surgical practices and
recognition of breast centers in the
Program (NSQIP), was the first and
environments that produce the highest
United States.
on ly prospective, risk-adjusted,
quality of care.
surgical oncology patient.
Q ua l it y
The resulting initiative, the National
validated database for quantifying
The College has expanded ACS
Accreditation Program for Breast
30-day surgical outcomes. Led by
NSQIP to more than 500 private-sector
Centers (NAPBC), was established
the innovative thought leaders in the
hospitals, including pediatric surgery
as a consortium of national profes-
VHA, the use of NSQIP in VA hospitals
hospitals that have implemented the
sional organizations dedicated to
has decreased 30-day postoperative
pediatric module of ACS NSQIP, and
the improvement in quality of care,
mortality following major surgery by
the results have been dramatic. Studies
and in monitoring of outcomes of
27 percent, and 30-day morbidity by
have shown that in a given year, the
patients with diseases of the breast.
45 percent; postoperative lengths of
average adult hospital using ACS NSQIP
The consortium pursues this mission
stay have been reduced, on average,
prevents 250–500 complications, saves
through activities such as stan-
from nine to four days.
12–36 lives, reduces costs by millions
dards-setting, validation through
After several pilot tests of NSQIP
of dollars, and provides an ongoing
research, and patient and professional
methods at nonfederal university
learning cycle that enables continuous
hospitals, the College launched its own
improvement. More than 80 percent
version of the program in 2003; during
of hospitals improve their complica-
this time, the Institute of Medicine
tion rates statistically significantly,
declared ACS NSQIP the “best in the
and more than two-thirds statistically
nation” for measuring and reporting
significantly improve their mortality
surgical quality and outcomes.
rates. The top 12 American hospitals in
79
UnitedHealth Group congratulates the
AMERICAN COLLEGE OF SURGEONS on their 100-year anniversary.
Helping people live healthier lives and making the health system work better for everyone.
the U.S. News & World Report’s rank-
support the surgeon with evaluating
(ASMBS) approached College leader-
ings participate in ACS NSQIP.
and improving his/her quality of care.
ship regarding the possible unifi-
Mea nwh i le, recog n i z i ng t hat
To their credit, thousands of surgeons
cation of its program with the ACS
different hospitals may take different
have participated in the registry. More
program to achieve one standard
paths to quality improvement based
recently, an increasing number of
in accreditation for metabolic and
on their setting or specialty, the ACS
regulatory items have been created
bariatric surgery. This proposal
continues to refine ACS NSQIP. The
that require individual surgeon data.
was accepted, and in April 2012,
College has developed six program
The SSR has been advanced and modi-
the unified bariatric program was
options designed for all hospitals and
fied to address many of these regula-
unveiled. Under the newly unified
quality-improvement goals, regard-
tory items, including but not limited to
program, a Standards Committee
less of size, hospital type, patient
Maintenance of Certification by various
was formed and charged with devel-
population, and type and number of
boards of surgery, and the Physician
oping a unified set of standards and
procedures performed.
Quality Reporting System, put forth
writing a standards manual. Once
The success of ACS NSQIP has
by the CMS. There are currently more
the standards have been vetted and
caught the attention of the federal
than 4,000 surgeons participating in
approved, all new bariatric centers
government’s non-veteran health care
the SSR, and the registry contains in
seeking accreditation and those
agencies. In 2011, CMS announced a
excess of 1 million cases. Ongoing
coming up for re-accreditation will
measure to encourage participation
work is being performed to enhance
do so under the new standards. A
in a general surgery registry, such as
the registry’s use for other regula-
goal of January 2013 has been set for
ACS NSQIP, and expressed its inten-
tory items such as Ongoing Practice
implementation of the new standards.
tion to move toward the reporting of
Performance Evaluation from The
As of June 2012, there were more
clinical data and outcome measures.
Joint Commission, and Maintenance of
than 750 facilities in the program,
In the spring of 2012, the ACS and
Licensure from individual state boards.
now ca l led t he Meta bol ic a nd
the CDC joined in a three-year project
Bariatric Surgery Accreditation and
that will combine the strengths of both
Quality Improvement Program. This
organizations’ quality improvement
partnering of the ACS with the ASMBS
programs—ACS NSQIP and the CDC’s
again shows how surgical societies
National Healthcare Safety Network—
are able to work together to improve
to target surgical-site infections and related complications. Other important
surgical quality, outcomes, and safety. Metabolic
and
Bariatric
partnerships to further surgical quality
Surgery Accreditation and Quality
improvements have been developed
Improvement: In 2006, the ACS
with The Joint Commission Center
developed an accreditation program
for Transforming Healthcare and the
to evaluate and improve the quality of
Institute for Healthcare Improvement.
Surgical Safety: Nora Institute for Surgical Patient Safety
care in bariatric surgery. More specifi-
Safety in surgery is an impor-
R eg i s t r y:
cally, the program sought to establish
tant aspect of the field. To this end,
Increasingly, there are a number of
standards of care, provide reliable
the Nora Institute champions the
advantages for evaluating provider-
outcome data, delineate approvals/
reduction and elimination of safety
specific quality of care. To this end,
verification processes for hospitals
issues within surgery. Advances in
the SSR, which has grown out of the
and outpatient facilities, and establish
the use of checklists, the surgical
ACS Case Log system, has become
credentialing criteria for surgeons.
time out, and pre-surgical brief-
a means for surgeons to record and
Since the inception of this program,
ings have been important topics in
review their cases—with risk adjust-
the outcomes of bariatric surgery
ment and benchmarking an important
have markedly improved, including
hallmark of the system.
decreased mortality rates.
Su r ge o n
Sp e c i f i c
Since the inception of this registry,
In late 2011, the American Society
the aim has always been to assist and
for Metabolic and Bariatric Surgery
81
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this regard. Through the Institute,
NTDB, guideline development, and
Scholars program. These individuals
the ACS published a patient safety
accreditation programs.
have noted that they have had excel-
manual titled Surgical Patient Safety:
In addition, participants earn a
lent, productive experiences that have
Essential Information for Surgeons in
master’s degree in health services
been useful in launching their careers
Today's Environment. This manual
and outcomes research or health
in the field of academic surgery.
provides information and guidance
care quality and patient safety during
With many scholars having already
for surgeons and others involved in
their two years at ACS Headquarters
completed the program, the residents
patient safety. It analyzes the human
in Chicago, IL. The goal of this aspect
have demonstrated great dedication to
factors, systems, and processes that
of the program is to educate clini-
outcomes research and the improve-
affect surgical patient safety, and
cians to become effective health
ment of the quality of surgical care in
also outlines broad error-prevention
services and outcomes researchers.
line with the goals of the ACS.
methods such as the use of surgical
The health services and outcomes
The ACS Clinical Scholars have
simulation, educational interventions,
research curriculum focuses on these
presented their findings at numerous
and quality improvement initiatives.
issues within institutional and health
national meeting presentations and in
care delivery systems, as well as in
high-impact, peer-reviewed publica-
the external environment that shapes
tions, in addition to having contributed
ACS Clinical Scholars Program
health policy centered on quality and
a great deal to the ACS quality improve-
Since 2006, the ACS has had a
safety issues. The program takes
ment programs. Furthermore, scholars
Clinical Scholar in Residence. The
approximately two years to complete.
have gone on to gain prestigious fellow-
program is designed for surgical
In addition to the master’s degree, the
ships in several fields, including surgical
residents to pursue a two-year on-site
program also offers a variety of educa-
oncology and pediatric surgery.
fellowship in surgical outcomes,
tional programs from which Clinical
health services, and health care policy
Scholars may benefit, including an
research. The program is intended
Outcomes Research Course, the Young
to advance the College’s quality
Surgical Investigators Course, and the
improvement initiatives and to offer
Clinical Trials Course.
Summary The ACS mission of quality evaluation and improvement in surgical
opportunities for residents to work on
The Clinical Scholars program offers
care and outcomes continues to
ACS quality improvement programs.
a team of mentors who meet regularly
expand and mature. The College’s
More speci f ica l ly, t he C l i n ica l
with each Clinical Scholar. Scholars
continual advances and refinements to
Scholars perform research relevant
also have opportunities to interact
programs such as ACS NSQIP ensure
to ongoing projects in the ACS Division
with various surgeons who are affili-
that it remains a leader in evaluation
of Research and Optimal Patient
ated with the ACS and the Division of
and improvement of surgical care,
Care. The ACS Clinical Scholars in
Research and Optimal Patient Care.
outcomes, and reducing costs. Q
Residence Program is intended to
Whereas mentorship is one of the
prepare surgical residents to become
most important aspects of the fellow-
successful surgeon scientists. The
ship, having guidance from multiple
At the American College of Surgeons,
program is a unique practical experi-
individuals from diverse backgrounds
Clifford Y. Ko, MD, FACS, is the Director
ence in surgical research.
will provide the best opportunity for
of the Division of Research and Optimal
The primary objective of the fellow-
success. In addition, a core of ACS staff
Patient Care, which houses the ACS
ship is to address issues in health care
statisticians and project analysts serve
Quality Improvement P rograms
quality, health policy, and patient
as invaluable resources to the Clinical
including ACS NSQIP, Trauma, Cancer,
safety, with the goal of helping the
Scholars in Residence.
and Bariatrics. He remains clinically
Clinical Scholar in Residence prepare
Since its inception, surgical resi-
active at UCLA, where he is Professor
for a research career in academic
dents from throughout the U.S.,
of Surgery and Public Health/Health
surgery. The ACS Clinical Scholars
including California, Connecticut,
Services. He is internationally recog-
have worked on projects and research
Colorado, Illinois, Louisiana, and
nized for his work in surgical quality
within the ACS NSQIP, the NCDB, the
Ohio, have participated in the Clinical
and has published over 250 articles.
83
The American College of Surgeons’ Contributions to International Surgery by FABRIZIO MICHELASSI, MD, FACS
Over the past half-century, the American College of Surgeons (ACS) has developed educational, research, and clinical offerings for surgeons outside of North America. Many ACS divisions have contributed to this effort by producing programs and products for international Fellows and surgeons. This chapter summarizes, and puts into perspective, some of the College’s most noteworthy contributions to international surgery. Division of Membership Services
Hawley became the first director of
the Director of the ACS, which he led
medical services for the U.S. Veterans
from 1950 to 1961.
Administration (1946–1947) and chief
Dr. Hawley’s experience abroad led
International Relations Committee
executive officer of the Blue Cross
him to encourage international collab-
(IRC). The IRC was developed under
and Blue Shield insurance associa-
orations. He realized that funding the
the leadership of former ACS Director
tions (1947–1948) before becoming
travel of surgeons from abroad to the
Paul R. Hawley, MD, FACS (Hon). During World War II, Gen. Hawley was stationed in Europe as chief surgeon of the European theater of operations. Dr. Hawley was an acclaimed surgeon Distinguished Service Medal, the Legion of Merit, the Bronze Star, and the Lasker Award. He was also a global traveler whose achievements were recognized in France (the Croix de Guerre with Palm); Great Britain (Order of St. John of Jerusalem in the grade of Knight); Belgium (Order of the Crown in the grade of Commander); Norway (Order of St. Olav in the grade of Commander); and Nicaragua (Presidential Medal of Merit). After leaving the military, Dr.
84
Gen. Paul R. Hawley
PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
and administrator who received the
annual ACS Clinical Congress would
Subcommittee, which, from its incep-
In 2011, this fellowship became a
encourage the international exchange
tion, has been extraordinarily selec-
two-way exchange, with the ANZ trav-
of ideas and information about surgical
tive. The IGS provides each scholar
eling surgeon sponsored by the ANZ
practice and education and the estab-
with an opportunity to attend the
Chapter and the Royal Australasian
lishment of professional and academic
annual Clinical Congress, where he
College of Surgeons. North American
collaborations and friendships. In the
or she is publicly recognized and
ANZ Fellows are expected to spend
end, this activity would benefit not only
receives free admission to all lectures,
a minimum of two to three weeks in
the selected international surgeons,
demonstrations, and exhibits associ-
Australia and New Zealand, where
but also the ACS and the American
ated with the conference, as well as
they attend and participate in the
surgical programs these traveling
selected postgraduate courses. After
Annual Scientific Congress of the Royal
scholars would visit. The seed for
the Clinical Congress, scholars are
Australasian College of Surgeons; they
the IRC was planted during these
offered assistance in arranging visits
also visit at least two medical centers
exchanges. For the past 45 years, the
to various surgery clinics and depart-
in Australia and New Zealand. Spouses
ACS has built on this concept through
ments of their choice. IGS scholars are
are permitted to accompany successful
the international scholarship programs
expected to provide a detailed written
applicants in their travels. Likewise,
administered by the IRC.
report of their experiences upon
the ANZ ACS Chapter, in partnership
International Guest Scholarships
completion of the program in an effort
with the Royal Australasian College,
(IGS). The IRC’s flagship scholarship
to disseminate their acquired know-
supports a young surgeon from
program, the International Guest
ledge to the greater ACS community.
Australia or New Zealand to attend
Scholarship, was established in
In 2011, two additional scholar-
the Clinical Congress, and then to tour
1968, three years after Dr. Hawley’s
ships—one focusing on evaluation and
North American institutions in which
death. The first scholarship—funded
adoption of new technologies and the
they are interested.
directly through a bequest from Dr.
other on innovative surgical educa-
The ANZ Traveling Fellowship has
Hawley—supported the travel of
tion and training—were launched in
become the prototype for two other
Enrique Muyshondt-Contreras, MD,
collaboration with the ACS Division of
traveling fellowships co-sponsored by
of El Salvador to the Clinical Congress
Education. One scholar was accepted
the College, with the participation of
and, afterward, to several U.S. surgical
from the United Kingdom and the other
national ACS chapters and national soci-
centers. For its first 12 years, the
from India. These young international
eties in Japan and Germany. The Japan
program focused on promising surgical
faculty members attended the Clinical
program was established in 2003, and
scholars from Latin America and grad-
Congress, participated in the post-
the Germany program in 2005. Similar
ually increased the number of fellow-
graduate course Surgical Education:
to the ANZ Traveling Fellowship, fellows
ships. The program was expanded in
Principles and Practice, and attended a
are required to spend a minimum of
1980 to include travelers from Europe,
variety of sessions that addressed educa-
two weeks in the host country, part of
and then again in 1981 to welcome
tion and training. Following the Clinical
which is spent attending and partici-
surgeons from anywhere in the world.
Congress, each scholar visited a leading
pating in the annual meeting of the
Over the past decade, these scholar-
institution with recognized expertise in
Japan Surgical Society or the German
ships have been awarded to anywhere
surgical education and training.
Surgical Society, respectively. Travelers
from eight to 10 surgeons annually. In
ACS Traveling Fellowships. In 1982,
are also required to visit at least two
2011, the number of scholarships was
the ACS established its first Traveling
medical centers outside the host city
increased to 12 each year.
Fellowship, which would allow a North
and share clinical and scientific exper-
Today, IGSs in the amount of $10,000
American surgeon to travel to Australia
tise with local surgeons. The Japan and
are offered to young (35- to 45-year-
and New Zealand (ANZ) with the finan-
German surgical societies, likewise,
old) surgeons from outside the U.S.
cial and organizational assistance of
each select a scholar annually to visit
and Canada who have demonstrated
the ANZ ACS Chapter. After existing
the annual ACS Clinical Congress and
a strong interest in surgical educa-
on a sporadic basis for several years,
academic surgical centers.
tion and research. Candidates are
the ANZ Traveling Fellowship became
The Value of ACS International
selected by the IRC’s Scholar Selection
a permanent annual award in 1989.
Fellowships. Since 1968, more than
85
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We created the Tribute Plan to provide doctors with more than just a little gratitude for a career spent practicing good medicine. Now, the Tribute Plan has reached its five-year anniversary, and over 22,700 member physicians have qualified for a monetary award when they retire from the practice of medicine. More than 1,300 Tribute awards have already been distributed. So if you want an insurer that’s just as committed to honoring your career as it is to relentlessly defending your reputation, request more information today. The ACS has sponsored our medical professional liability program since 2002. To learn more about our program for ACS members, including the Tribute Plan, call (800) 352-0320 or visit us at www.thedoctors.com/tribute.
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250 surgeons, from six continents and 65 different nations, have partici-
ACS Honorary Fellows Who Were International Guest Scholars
pated in the international scholarship programs of the ACS. Most have been general surgeons, but as surgeons around the world have become more specialized, more subspecialties have been represented. Of all the international scholars over the past 45 years, half of them hold by now a professorial rank at their home institution, onethird are division heads and 21 are department chairs, two are presidents of foreign surgical societies, and four have been recognized as Honorary Fellows of the ACS. In an effort to estimate the effect Olajide Ajayi
Attila Csendes
Juan M. Acosta
Dario Birolini
in their own practice, research, and
selection committees or to host visiting
all with skill and fidelity,” through its
education activities. One of the greatest
scholars, as well as the generosity of
mission to facilitate surgical humani-
validations of the IGS program is that
donors who have steadily increased the
tarian outreach. OGB is an informa-
86 percent of respondents to the IRC’s
endowment over the years.
tion resource that connects surgeons
of these scholarships, in 2003 the IRC distributed a survey to the 161 International Guest Scholars who had participated in the program. Half of the participants responded, and virtually all felt the IGS had a positive effect on their careers. In addition, many respondents felt they had made excellent contacts with North American surgeons, and some felt they had made friends for life. Many reported that their visit resulted in an ongoing exchange program. IGS visits, the survey revealed, affected clinical care, with many scholars reporting that they had learned new techniques. In addition, scholars uniformly agreed that their contact with
PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS
leading surgeons led to improvements
survey said they had encouraged others to apply for the scholarship.
Operation Giving Back (OGB).
with opportunities to volunteer their
Recognizing the dedication of its
talents—in patient care, training, or
Originally endowed through Dr.
Fellows to meeting the needs of the
education—or to donate equipment and
Hawley’s legacy, the IRC’s scholarship
underserved in communities domesti-
supplies to underserved communities
program has grown steadily over the
cally and around the world, the ACS
around the world. OGB helps to focus
years. Its continued success relies on
established OGB in 2004. OGB serves
these talents on critical public health
the support of the College’s senior
to perpetuate the ACS motto, Omnibus
issues related to the provision of safe,
surgeons, who donate time to serve on
per artem fidemque prodesse, “To serve
timely, and necessary surgical care.
87
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✓ Comfort
The manifestations of surgical outreach
undertaken
by
ACS Division of Education
ACS
medical students from countries outside the U.S. and Canada.
members and supported through
The Division of Education has
The ACS Program for Accreditation
OGB encompass clinical care, educa-
developed a broad range of educa-
of Education Institutes (simulation
tional partnerships, and professional
tional programs and products that
centers) includes a number of insti-
exchange and collaboration toward
have been extremely well received
tutes that have been accredited by ACS
increasing surgical capacity, quality,
by international surgeons. Each year,
outside the U.S. and Canada. There are
and delivery. In addition, the OGB
the Clinical Congress attracts eminent
two ACS-accredited Education Institutes
community is committed to the
surgeons and surgeons-in-training from
in Sweden, and one each in the United
research and advocacy efforts needed
around the world. Their participation
Kingdom, France, Greece, Israel, and
to inform and address the unmet
in the Clinical Congress enriches the
China. Institutions from Italy and Saudi
burden of surgical disease and to
meeting immensely. Of special note is
Arabia have expressed interest in being
implement long-range solutions.
the Latin American Day session that
accredited, and their applications will
With its significant international
includes renowned surgeons from Latin
be reviewed once they are received.
membership and deep international
American countries. Speakers from
professional ties, there is a legacy
Mexico and Argentina are scheduled
of collaboration among surgeons in
to deliver presentations during this
different countries. Thousands of ACS
program at the 2012 Clinical Congress,
Fellows are involved in supporting
and much of the session is conducted in
After several Latin American ACS
surgical colleagues around the
Spanish, as well. In addition, abstracts
chapters established their own commit-
globe as well as in working to meet
are routinely submitted by international
tees on trauma in the late 1980s, the
the needs of surgical patients and
surgeons for the Poster Presentation
College established guidelines for the
strengthening the infrastructure and
and the Video-based Education sessions
formation of international committees
educational systems required for long-
at the Clinical Congress.
on trauma. Over time, these have been
ACS Committee on Trauma (COT)
term solutions. In doing so, they are
The renowned Surgical Education and
organized into several regional commit-
both educated and enriched by the
Self-Assessment Program™ (SESAP™)
tees: Latin and South America; Europe
opportunities and experiences.
remains popular with international
and Africa; Australia/New Zealand/
In times of disaster, as well as for
surgeons and surgical trainees. SESAP
Asia; the Middle East; and Canada.
everyday needs, OGB provides commu-
13™ has more than 100 subscribers
nity, coordination, collaboration,
from outside the U.S. and Canada.
Within these regions, the COT’s educational and professional develop-
information, inspiration, and needed
A number of international ACS
ment programs are in various stages
resources to surgeons engaged in this
members submitted applications for
of implementation. The committee’s
work. To date, OGB has worked with a
admission to the renowned annual
flagship course, the Advanced Trauma
community of more than 100 interna-
Surgeons as Leaders course in May
Life Support® Course (ATLS®), estab-
tional partner organizations to facili-
2012, and surgeon leaders from
lished in 1980 to foster the develop-
tate the recruitment of surgeons for
Argentina and Pakistan participated in
ment of proper triage and treatment
more than 300 volunteer opportunities
the course.
techniques, has become the standard
in 74 countries. Online resources are
The division’s e-learning programs
that has transformed trauma care
supplemented by preparatory courses
have also generated considerable
around the world. In the late 1980s,
teaching skills on surgery in low
interest in the international surgical
ATLS materials were translated into
resource settings and different cultures
community. Furthermore, the popular
Spanish to facilitate the promulga-
or systems. The program is committed
Residents as Teachers and Leaders
tion of the course in Latin America.
to meeting disparate circumstances
course held in April 2012 included
To date, ATLS has trained more than
by understanding surgical needs and
two participants from the United Arab
1 million surgeons in 63 countries,
their contexts and with an ongoing
Emirates. Additionally, the Medical
including recent inaugural courses in
commitment to quality, collaboration,
Student Program offered at the Clinical
Iran (December 2011) and Rwanda
and humanitarian principles.
Congress has traditionally attracted
(October 2011).
89
The Advanced Trauma Operative
of Veterans Affairs program for moni-
Management® (ATOM®) course, devel-
toring and improving the quality of
oped in 2001 by Lenworth Jacobs, Jr.,
surgical care, ACS NSQIP is used today
In establishing the ACS one century
MD, FACS, is a surgical simulation
by the American University of Beirut
ago, Franklin Martin, MD, FACS, and
that has, to date, trained more than
Medical Center in Beirut, Lebanon;
his colleagues had the promotion of
2,300 surgeons worldwide. In 2005,
Shaikh Khalifa Medical City in Abu
the highest standards of surgical
a collaboration between the ACS and
Dhabi, the United Arab Emirates; and
care as their primary objective. Since
the West African College of Surgeons
the Imperial College Healthcare NHS
then, the College has provided more
resulted in the establishment of an
Trust of London, England. More broadly
than 250 international scholars from
ATOM course at the Korle Bu Teaching
focused efforts are under way to bring
around the world the opportunity to
Hospital in Accra, Ghana; ATOM has
ACS NSQIP to hospitals in Saudi Arabia
visit the annual Clinical Congress
since trained surgeons from 12 West
and Japan.
and selected surgical institutions; it has developed a volunteerism
African countries. Today, ATOM is available at 39 sites worldwide—in North
Conclusion
ACS Board of Governors (B/G)
platform for international outreach and has trained trauma surgeons all
America, West Africa, Europe, and the Middle East. In November 2011, an
International Fellows have been
over the world. The College also has
inaugural ATOM course was delivered
members of the College’s Board of
helped in developing quality assur-
in Asunción, Paraguay.
Governors since 1925, representing
ance programs for medical centers
Two other Committee on Trauma
members in their respective countries.
in Beirut and Abu Dhabi, and it has
courses are now offered internation-
All Governors, domestic and interna-
produced educational prog rams
ally. The Disaster Management and
tional, have the same basic duties and
of interest to surgeons around the
Emergency Preparedness course, which
serve as the official communications
world. In fact, the ACS’ founders
trains surgeons and acute care profes-
link between the Fellows and the Board
might have expected as much from an
sionals in mass casualty response, was
of Regents. In addition, International
organization that has never imposed
held for the first time in Jeddah, Saudi
Governors aid in the selection of the
any boundaries on its mission to
Arabia, May 27 to May 28, 2012. The
committees organized within their
promote the highest standards of
Rural Trauma Team Development
areas and aid in investigating special-
surgical care. Q
Course (RTTDC), designed to teach rural
case applicants for Fellowship. Once
receiving facilities the fundamental
an international country obtains a
elements of injury resuscitation, was
Governor, it is then that Governor’s
Fabrizio Michelassi, MD, FACS, is
held in Santa Cruz, Chile, in April 2012,
responsibility to form a chapter; once a
a board certified general surgeon
drawing students from throughout the
chapter has been formed, the Governor
with a strong expertise in the
country and faculty from all over South
becomes an ex officio member of the
surgical treatment of gastrointes-
America. The course was conducted in
governing group of the chapter.
tinal and pancreatic cancers as well
Spanish, and a Latin American team
In 2002, the B/G established the
as inflammatory bowel disease. A
of physicians is in the process of trans-
International Activities Subcommittee,
clinician, researcher, and teacher,
lating the RTTDC manual.
which was added to the College’s
Dr. Michelassi is the Lewis Atterbury
Chapter Activities (now Chapter
Stimson Professor and Chairman,
Relations) Committee, with the purpose
Department of Surgery and Surgeon-
of examining strategies, programs, and
in-Chief at New York Presbyterian/
activities to enhance the College’s rela-
Weill-Cornell Medical Center.
ACS Division of Research and Optimal Patient Care (DROPC) In recent years, ACS’ highest profile
tionship with its international chapters
quality assurance program, the ACS
and Fellows, identifying strategies
National Surgical Quality Improvement
for recruiting international surgeons
®
®
Program (ACS NSQIP ), has gone inter-
for Fellowship in the College, and
national. A standardized risk-adjust-
increasing educational opportunities
ment model adapted from a Department
for the College’s international members.
Acknowledgements The author is indebted to Kathleen M. Casey, MD, FACS, Yuman Fong, MD, FACS, and Ajit K. Sachdeva, MD, FACS, FRCSC, for their contributions to this chapter.
91
Progress in Cancer Surgery by MURRAY F. BRENNAN, MD, FACS
More than 100 years ago, in July 1907, William Stewart Halsted presented his paper on the results of radical operations for the cure of carcinoma of the breast.1 That dissertation, focused on the radical approach to carcinoma of the breast, described his results from resecting the breast, the pectoralis muscles, and removing the axillary and supraclavicular lymph nodes. Halsted concluded, “Fortunately, we no longer need the proof which our figures so unmistakably give that the slightest delay is dangerous” and “It is interesting to note how late the metastasis occurred in these cases with undetected axillary involvement; another argument for wide operating.” Despite his presumed familiarity
of growth and spread for individual
accompanied by a major reduction
with the lymph node drainage of the
cancers were defined. It became clear
in the mortality of large and compli-
2
that there was no single, defined
cated procedures such as esophagec-
he also concluded that, “the liver
pattern that could be applied to all
tomy and pancreatectomy. Much of
may be invaded by way of the deep
cancers. Some cancers such as breast
this was driven by focused attempts
fascia, the linea alba, and round liga-
regularly metastasized to lymph
by individual surgeons and institu-
ment.” This aggressive and radical
nodes, whereas others such as soft
tions to improve quality of the opera-
approach to surgery was perpetuated
tissue sarcoma rarely did so. This
tion and to decrease morbidity and
by others including those at Memorial
disease-based knowledge allowed
mortality. This has been supported
Sloan-Kettering Cancer Center, where
us to modify surgery appropriately.
by a number of studies confirming
radical treatments for gastric cancer
More importantly, with increasing
the relationship between institutional
and even more extensive operations
knowledge of the lesser need for
and surgical volume on operative
– such as internal mammary node
radicality, an overall focus on func-
mortality.4,5 Unfortunately, despite
removal for breast cancer3 – were
tion, as opposed to radical extirpative
t he i mprovement i n operat ive
advocated five decades later.
breast described by Sappey in 1874,
procedures, became the goal. This
mortality, survival for comparably
In the last f ive decades, such
has allowed us to avoid amputation,
staged solid tumors from surgery
radical procedures have been aban-
preserve limbs, preserve sphincters,
alone has only minimally improved.
doned or modified. The evolution
and aim for both improved quality of
Overall apparent improvements in
of less radical operations occurred
life without loss of surgical efficacy
survival from surgery alone are
as knowledge and understanding
and cancer-specific survival.
predominantly due to earlier diag-
of cancer as a disease evolved.
This change from routine radi-
nosis and improved patient selection.
Initially, this was due to observa-
cality to more conservative but
The subsequent demise of patients
tions of natural history, and patterns
still complete resection has been
with localized disease at the time
94
We now enter a crucial time where the evaluation of outcome can be expected to be much more realistic. When “significant and meaningful” differences in outcome have to be established, critical review of what justifies a meaningful result and a willingness to selfcritique will become mandatory if we are to sustain the advances made in the last 100 years.
management. It is clear that appropriate juxtaposition of what were formally seen as adjuvant modalities of radiation and chemotherapy can, when placed proximal to a surgical procedure, provide improved outcome and a decrease in the necessity for radicality, without increasing operative mortality or morbidity.8 We now enter a crucial time where the evaluation of outcome can be expected to be much more realistic. When “significant and meaningful” differences in outcome have to be established, critical review of what justif ies a meaningful result and a willingness to self-critique will become mandatory if we are to sustain the advances made in the last 100 years. We are now in a position to look at populations. Evaluations will depend not just on single patient outcome but on the quality of that outcome a nd t he persona l a nd
of initial operation results from
initially focused on the minimization
financial cost of such outcome to
subsequent recog nition of meta-
of the morbidity of the perioperative
the individual and society. We look
static disease. While death from
period, mainly driven by decrease
beyond overall improvement for the
uncontrolled local progression does
in wound incision size, to further
individual patient to the impact on
occur, e.g., in retroperitoneal soft
studies validating that the mini-
cadres of patients, looking not only
tissue sarcoma, most deaths from
mally invasive approach provides
at those who benefit from our cancer
solid tumors are due to metastatic
the same oncological procedure as
care but at the personal (and finan-
disease. Importantly, this aware-
an open approach. It should be no
cial) cost to those who do not benefit.
ness has allowed focused attempts
surprise that if a surgical procedure
We look at the potential benefits to
at resection of isolated or confined
is identical whether by an open or
those that still fail, recur, or die, and
metastatic disease. This is most
minimally invasive approach, then
to those who do not benefit because
dramatically seen in resection of
long-term outcome should be the
they were not going to recur or die
colorectal metastasis to liver, where,
same. This thinking has developed
following their initial procedure.
in selected cases, long-term (>10
to where randomized clinical trials
We are challenged to look not only
w ith minimally invasive surgery
at the end result but at the time
versus open surgery are progres-
point of initiating therapy to predict
years) cure has been obtainable.
6
Concom ita nt w it h t hese technical advances has been a focus
7
sively available for review.
who will and will not benefit. There
on “data driven care.” No longer
With the advent of meaningful
are clear opportunities to do this:
are the opinions of the surgeon left
chemotherapy and the increased
Clinically based nomograms 9 and
to stand alone without support of
sophistication of radiation therapy,
molecular signatures that are both
data from thoughtfully constructed
we now have a synthesis of cancer
prognostic and predictive of response
prospective databases or random-
care that is focused on disease
are increasingly becoming available.
ized clinical trials. These studies
management rather than discipline
Where such cannot be predicted, we
96
will progressively move to surro-
After 21 years as Chairman of the Department of Surgery at Memorial
gate indicators of likely response by
Sloan-Kettering Cancer Center, Dr. Murray Brennan presently holds the Benno
predictive biomarkers or metabolic
C. Schmidt Chair in Clinical Oncology and is Vice President for International
(PET) responses.
Programs and Director of the Bobst International Center at the same institution.
Addressing the societal issues of operations performed in the latter years of life—where 32 percent have an operation in the last year, 18 percent in the last month, and 8 percent in the last week of life—challenges us to evaluate our intentions and the meaningfulness of surgical procedures within the context of cancer care.10 Su rgeons can be proud of the contributions they have made to cancer care in the last 100 years and now have the great opportunity, with constructive self-critique, to focus on societal as well as indiv idua l dema nds to ensu re sa fe, equal, and meaningful cancer care to all patients. Q
References 1. Halsted WS. The Results of Radical Operations for the Cure of Carcinoma of the Breast. Ann Surg 46:1-19, 1907. 2. Sappey MPC. Anatomie, Physiologie, Pathologie des vaisseaux Lymphatiques consideres chez L’homme at les Vertebres Paris, A. Delahaye and E. Lecrosnier, 1874. 3. Urban JA, Baker HW. Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain; a new procedure for primary operable cancer of the breast. Cancer 5:992-1008, 1952. 4. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128-37, 2002. 5. Begg CB, Cramer LD, Hoskins WJ, et al. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280:1747-51, 1998. 6. Tomlinson JS, Jarnagin WR, DeMatteo RP, et al. Actual 10-year survival after resection of colorectal liver metastases defines cure. J Clin Oncol 25:4575-80, 2007. 7. Nelson H, Sargent D, Wieand S, et al. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. N Eng J Med 350:2050-2059, 2004. 8. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 355:11-20, 2006. 9. Kattan MW, Leung DH, Brennan MF. Postoperative nomogram for 12-year sarcoma-specific death. J Clin Oncol 20:791-6, 2002. 10. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 378:1408-13, 201.
City of Hope salutes the world’s top doctors. And what a great bunch of Fellows. The American College of Surgeons has been teaching doctors the highest standards of practice and the latest advances in medicine for 100 years. This commitment means life-saving care for millions of patients – past, present and future. We appreciate all the Fellows, men and women alike, for helping to make the world a healthier place. cityofhope.org
I chose Guthrie
for the collaboration. Joseph Scopelliti, MD CEO, Guthrie Health
â&#x20AC;&#x153;
My very first day here, I sensed that Guthrie was a different place. Thirty-six years later, its core values of patient-centeredness, teamwork and excellence continue to help us achieve optimal outcomes for patients. Physicians who join Guthrie find an inclusive and rewarding
â&#x20AC;?
environment in which they thrive.
Where compassion and excellence come together to make a meaningful difference in the lives of those we serve. Every person. Every time. Our Vision Founded in 1910 by Dr. Donald Guthrie— who brought the Mayo Clinic model to Sayre, PA—Guthrie Health System is among the most respected systems in the country. More than 100 years later, we continue to honor Dr. Guthrie’s vision of service, stability and continuous improvement. With our integrated medical delivery system, connected by a robust electronic health record, we embody a model of strong patient care.
We are fiscally stable, with a robust A+ bond rating. Our capabilities continue to grow as we enhance our physical facilities—revitalizing and remodeling with new campuses for our Corning and Troy hospitals—and continue to pursue research, education and new technologies. We consistently rank among the best for quality.
Innovation has always been a cornerstone of our identity. In addition to providing the full spectrum of specialty and subspecialty care, we are focused on three predominant health concerns that affect humanity: cardiovascular disease, cancer and musculoskeletal disorders. This results in a comprehensive service that few others in the country have implemented.
Patient-centeredness drives all that we do. Our advanced technologies, rarely found in rural facilities, attract the highest-caliber physicians who also share our commitment to compassion. Our network of regional hospitals and offices provides unparalleled access to internal medicine, family medicine and specialty medicines across the southern tier of New York and the northern tier of Pennsylvania. Quite simply, Guthrie is an extraordinary healthcare system where physicians who value patient-centeredness, teamwork and excellence forge fulfilling medical careers.
The philosophical approach to patient care in a group practice is one of cooperation and collaboration centered on the best possible outcomes for patients. Guthrie physicians enjoy an environment where they regard other physicians as colleagues, not competitors.
Why Physicians Choose Guthrie
If your skills and values align with ours, you may be one of the uniquely qualified providers we seek to help us expand our scope of services to ensure the best possible care and access for all those we serve. Discover more about Guthrie and our career opportunities at www.ichoseguthrie.org/Careers/ACS or by calling 1-800-724-1295. Scan here to view his video.
Find Guthrie Physician Recruitment:
Historical Achievements in Cardiothoracic Surgery by JOHN E. CONNOLLY, MD, FACS
During the American College of Surgeons’ (ACS) century of existence, many surgical advances have been made. L ung resection for pulmonary tuberculosis was the starting point of modern thoracic surgery led by Richard Overholt and J. Maxwell Chamberlain in North A merica. During World War I, the management of open chest wounds was first established, and during World War II, the surgical treatment of empyema began. In 1933, Evarts Graham used a tourniquet to perform the first pneumonectomy for carcinoma of the lung. In 1939, Churchill and Belsey performed the first segmental lung resection. Finally, in 1950, Ivor Lewis first reported both an abdominal and a chest approach for esophagectomy. During the ACS century, many advances were also made in cardiac surgery by ACS Fellow surgeons. Of note was the first successful ligation of a patent ductus arteriosus by Robert Children’s Hospital in 1938, while his Chief, William Ladd, was out of town. We are all born with a patent ductus.
John Gibbon and his wife with the IBM heart-lung machine.
If it does not close by itself after birth, congestive heart failure and infective
Well, surgeons at that time were
1944. Gross did the same procedure
endarteritis may ensue. Three or four
simply not used to working around the
in 1945. In 1945, Alfred Blalock at the
surgeons had tried unsuccessfully to
great vessels just outside the heart!
Johns Hopkins Hospital performed the
close it. When you think about it now,
Next was the f irst successful
so-called “Blue Baby” operation. A blue
the procedure was just to pass a tie
resection of coarctation of the aorta
baby is one whose pulmonary artery
around a vessel outside the heart.
by Clarence Crafoord of Sweden in
is congenitally narrowed, limiting
100
PHOTO COURTESY OF THE UNIVERSITY OF MINNESOTA
Gross, Chief Resident at the Boston
adequate oxygen to the lungs. Dr. Helen Taussig, the “founder” of pediatric cardiology, had noted that blue babies who have an open ductus live longer than those without. Therefore, she suggested to Dr. Blalock to divide the left subclavian artery and anastomose it to the left pulmonary artery. Suddenly the very blue and squatting child became pink! These three operations between 1938 and 1954 were the beginning of closed cardiac surgery. In 1950 –51, Wilfred Bigelow of Toronto was studying the use of hypo-
Richard DeWall (left) and Vincent Gott, colleague, pictured with the DeWall Oxygenator.
PHOTO USED WITH PERMISSION OF DR. RICHARD DEWALL / UNIVERSITY OF MINNESOTA ARCHIVES USED WITH PERMISSION FROM DR. JAMES V. MALONEY
thermia in cardiovascular surgery. His experiment was to anesthetize
cardiac surgeon at the University
collaborated with the Chairman
a dog and pack it in ice until its
of Minnesota, reported performing
and CEO of IBM®, Thomas Watson,
temperature fell from 36˚F to 30˚F.
Bigelow’s hypothermic technique
and five IBM engineers to develop a
Next, the sternum was opened and
on a 5-year-old child in 1952. This
sophisticated heart-lung machine.
both superior and inferior cavae were
was the first direct vision open heart
The first few patients that he used it
clamped, causing asystole. Then the
operation in the world!
with were unsuccessful. In 1953, he
right atrium was opened, while in a
John Gibbon, Professor of Surgery
performed the world’s first successful
dry field an atrial septal defect was
at Jefferson Medical College in
open heart operation, using the IBM
closed with a running suture. At
Philadelphia, PA, and his wife had
extracorporeal circulation machine
that time, Bigelow was looking for
been working for 10 years to develop
for 26 minutes to close a congenital
a suitable patient on whom to try
a heart-lung machine so that open
atrial septal defect. Dr. Gibbon did a
his hypothermic procedure. But to
heart operations could be performed
few more cases with the IBM machine
his surprise, F. John Lewis, a young
under direct vision. He eventually
unsuccessfully, and then gave up open heart surgery altogether. At that time, a young surgeon named Walt Lillehei, who was the Chief of Cardiac Surgery at the University of Minnesota, did not think much of the complicated IBM machine. He proposed that a patient’s father or mother be used as the “oxygenator.” In spite of the danger to both the patient and parent, Chief Surgeon Owen Wangensteen said, “go ahead, I have great confidence in you.” Dr. Lillehei proceeded to perform 45 such cross-circulation operations to close ventricular septal defects, losing only a few patients and no parents. At the same time, Lillehei instructed a young surgical assistant, Richard DeWall, to devise a much simpler oxygenator than
Walt Lillehei’s Cross Circulation.
the IBM machine. What he produced
101
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was called a Bubble Oxygenator. It was simple to construct in the research laboratory. With the Bubble Oxygenator, Lillehei then proceeded to successfully perform every type of congenital open heart operation. His experience with the DeWall Oxygenator did more to promote cardiac surgery than any other surgeon did at that time or even later. A discovery that really revolutionized cardiac surgery occurred in 1958. Mason Sones of the Cleveland Clinic was a pediatric cardiologist by René Favaloro and Donald Effler
training, but was working in the X-ray
PHOTO COURTESY OF DR. JOHN E. CONNOLLY
Department. At that time, cardiologists believed that coronary artery occlu-
may not occur. Subsequently, William
back together.” Shumway said, “Let’s
sive disease was generalized and as
Gay and Paul Ebert reintroduced
try it.” The next thing they did was to
such would not be surgically treatable.
low concentration potassium arrest,
transplant a dog’s heart, which, as
Also, they believed that if you intro-
which allowed surgeons to perform
expected, was rejected within five days
duced dye into a coronary artery, it
coronary artery bypass surgery in
because there were no antirejection
would kill the patient. Well, one day
a still, bloodless field, an important
drugs available at that time. During
Sones was performing a left ventricu-
medical advance of the 20th century.
those five days, either Shumway, Stover
logram. As he pulled the catheter back
Two thousand such operations are
(the lab technician), or Lower stayed
into the aorta, unbeknownst to him it
performed every 24 hours worldwide.
day and night with the transplanted
slipped into the right coronary artery.
It is performed effortlessly with low
dogs. Five transplanted dogs lived for
When he injected 40 cc of dye, asys-
risk in all age groups.
two to six days with completely normal
tole occurred. It was corrected by the
The first human lung transplant was
function! Death came with rejection.
patient’s cough. When Sones developed
performed by James Hardy on June 11,
Hearts appeared to function okay if
his picture, he surprisingly found that
1964, in Jackson, MS. The patient died
the immunologic mechanisms of the
his catheter had been in the right coro-
on the 18th day of renal failure. Only
host were prevented from destroying
nary artery, it did not kill the patient,
seven months later, Hardy attempted
the graft.
and he had a beautiful picture which
the first heart transplant in a human
Su bseq uent ly, Shu mway wa s
showed that coronary artery disease
being, under what would be considered
looking for a human candidate for
was segmental. This eventually led to
to be disastrous conditions. The patient
transplantation when Dr. Christiaan
the development of the coronary artery
was in thermal shock and the donor
Barnard surprised the world in South
bypass operation, which was a tremen-
was a small chimpanzee heart, which,
Africa in 1967 with the first human
dous development. Surgery consisted
unfortunately, gradually gave way.
heart transplant. Barnard’s donor was
of bypass of coronary artery disease
In 1961, my colleague Norman
a 25-year-old female who had been in
with a saphenous vein or internal
Shumway and I were working on
an auto accident and her heart was
mammary artery (Vasilii Kolesov in
different projects in the Stanford
transplanted into Louis Washkansky,
Leningrad) or by endarterectomy.
research lab, each with a full-time
a 53-year-old man with heart failure
René Favaloro and Donald Effler
resident. Shumway’s was Richard
who survived for 18 days. His second
were the leaders with the coronary
Lower, who was bright. One day while
transplant, Philip Blaiberg, survived
artery bypass procedure, performing
Shumway was cooling a dog’s heart,
almost two years. Many surgeons
1,573 cases in one year. In 1973, Denis
Lower said to Norm, “I wonder what
then tried transplantation with poor
Melrose induced cardiac arrest by high
would happen if we detached a dog’s
results. Eventually it was Shumway
potassium citrate, from which recovery
heart completely and then sewed it
who persisted and developed human
103
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At the Montefiore Einstein Center for Heart and Vascular Care in New York City, we develop innovative techniques and technologies to support our already excellent outcomes. In 1958, Montefiore implanted the world’s first transvenous cardiac pacemaker, and in 1960 our team performed the world’s first coronary artery bypass surgery. In 1982 we created a special technique to repair the mitral valve, and in 2011, Montefiore was among the first hospitals in the Northeast to be certified to implant a Total Artificial Heart, a lifesaving alternative that can serve as a bridge to a heart transplant. Most recently, Montefiore was among the first in the country selected to offer Transcatheter Aortic Valve Replacement (TAVR), a ground-breaking new therapy for the treatment of aortic valve disease. Awarded the prestigious three-star rating by the Society of Thoracic Surgeons, Montefiore’s heart surgeons are among the very best in the nation. The Montefiore Einstein Center for Heart and Vascular Care, pioneering cutting-edge medicine for more than 50 years.
Montefiore Einstein Center for Heart & Vascular Care
www.montefiore.org/heart 1-888-ME-HEART
Norman Shumway
has g iven an enormous boost to
ment, began to catheterize dogs and
transplant medicine.
then he and Dickinson Richards, a
In the 1950s, a young cardiothoracic
Professor of Medicine at Columbia,
surgeon, Al Starr, was asked by engineer
worked together to develop human
M. Lowell Edwards to help him build
cardiac catheterization. Cournand,
an artificial heart. Starr suggested that
Richards, and Forssmann shared the
they start with an artificial heart valve.
Nobel Prize in 1956.
They then designed what is known as
In 1948, Sir Peter Medawar, a
the Starr-Edwards Ball Valve. It was
British zoologist, was investigating
first successfully used in a human in
the use of skin grafting for extensive
1960. This was a major cardiac surgery
heart transplantation as we know
burns. He was unsuccessful until he
development. In 1971, Alain Carpentier
it today. After much trial and error,
tried grafting between littermates.
of France instituted plastic reconstruc-
lung transplantation became a reality
That discovery led Joseph Murray of
tion of the mitral valve. He and Starr
under Joel Cooper and F. Griffith
Boston to guess that kidney grafting
each received a Lasker Award in 1968
Pearson in Toronto in 1983, facili-
would be successful between iden-
for their valve advances.
tated by the use of cyclosporine and
tical twins. Thus, in 1954, he found
When the American College of
wrapping of the bronchial suture line
an identical twin brother with renal
Surgeons began in 1913, smoking
with a pedicle graft to reduce the inci-
failure who successfully accepted his
was not yet a widespread habit, but
dence of bronchial dehiscence. The
twin brother’s normal kidney. Both
it became so during World War I and
main problem with heart and lung
Medawar and Murray were awarded
has fostered much of our cardio-
transplantation now is shortage of
the Nobel Prize in Physiology or
vascular disease. It was between
organs. This has led to an increase in
Medicine—in 1960 and 1990, respec-
the ’40s and ’50s that Drs. Richard
the development of ventricular assist
tively—for discoveries that advanced
Overholt and Alton Ochsner began
devices and artificial hearts to employ
transplantation of organs.
to blow the antismoking alarm, and
until human hearts are available.
PHOTO COURTESY OF DR. JOHN E. CONNOLLY / PHOTO COURTESY OF AL STARR
Forssmann and his personal experi-
In 1970, the Swiss pharmaceu-
the Surgeon General began labeling
In 1929, a young German physician
tical company, Sandoz, discovered a
cigarette packages that “smoking may
named Werner Forssmann wanted
cyclosporine-producing fungus. The
be hazardous to your health.”
to catheterize a patient’s heart and
agent turned out to have a strong
In summary, cardiothoracic surgery
obtain pressures inside it, but his
immunosuppressive effect, and the
has made fantastic advances over the
superiors would not let him and said,
use of this substance was intro-
100 years of the American College
“You’ll kill the patient.” To prove the
duced in 1972 in humans, which
of Surgeons’ existence and future
point they were wrong, one weekend
expectations are even more unlimited.
he anesthetized his own forearm and
Hopefully, some ACS Fellows will also
passed a ureteral catheter all the
lead the fight against obesity. Q
way into his right ventricle. He then walked down several flights of stairs to the X-ray Department and had some
John E. Connolly, MD, FACS, is
dye injected into his right ventricle
the Founding Professor and Chair of
with no problem. On Monday when his
Surgery at the University of California,
Chiefs came back to town, they were
Irvine, 1965. He presently continues to
absolutely furious and said, “You will
teach there and is a researcher and
never do that again! If you do anything
author. Dr. Connolly has been very
that crazy again you’ll be out.”
active in the ACS since becoming a
In 1943, A nd ré Cou r na nd, a
Fellow in 1958, wearing numerous
pulmonary physiologist at Columbia Un iversit y
who
k new
a bout
hats including Past Chair of the Board Starr-Edwards Ball Valve.
of Regents and Vice-President.
105
Advances in the Twentieth Century: Colon and Rectal Surgery by HERAND ABCARIAN, MD, FACS
The twentieth century saw not only the birth and growth of the American College of Surgeons, but also an amazing transformation in all fields of surgical specialties including colon and rectal surgery (CRS). The following are brief highlights of a few of the accomplishments in the specialty of colon and rectal surgery during this period. 1. Colon and Rectal Cancer (CRC)
for presence of synchronous or meta-
disease. Now direct visualization of
chronous metastases without need for
the entire colon allows total examina-
unnecessary exploratory operations.
tion of the colon for mass lesions and
The two defining landmarks in the
In 1982, Bill Heald described the tech-
inflammatory diseases. Colonoscopy is
early twentieth century were abdomi-
nique of total mesorectal excision (TME)
used for diagnosis, surveillance, and
noperineal resection of rectal cancer
to reduce the risk of pelvic recurrence,
follow-up of all patients, especially
by Ernest Miles and pathologic clas-
and he and Dr. Philip Quirke demon-
those at high risk of colon cancer
sification of rectal cancers by Cuthbert
strated the importance of mesorectal
including those with inflammatory
Dukes, who was instrumental in
lymph nodes and negative circumfer-
bowel disease, familial polyposis,
demonstrating the correlation of the
ential radial margins. TME has become
and/or cancer syndromes. In these
pathologic stage of rectal cancer with
the holy grail of rectal cancer surgery
latter cases, advances in genetics of
survival. Anterior resection and low
and has had a significant impact in
CRC help to identify genetic markers
anterior resection became popular
reducing local recurrence, increasing
in familial adematous polyposis,
after World War II, but the manufac-
disease-free intervals and ultimately
Lynch syndrome, and other inherited
turing of mechanical stapling devices—
patient survival. With the advent
cancers especially in institutions
especially circular staplers—allowed
and widespread use of radiation and
utilizing inherited cancer registries.
for much lower anastomoses and
chemotherapy, preoperative treatment
Chemotherapy of colorectal cancer
avoidance of permanent colostomies
of locally advanced or bulky rectal
was originally recommended by Warren
by drastically reducing the incidence
cancers allows for resectability and
H. Cole, MD, FACS, but effective drugs
of abdominoperineal resections.
potential curability of these tumors.
were slow to develop. Formulation of
Advances in imaging technology—
Currently there are protocols studying
5-fluorouracil in the ’50s was a first
particularly computerized tomography,
the policy of close observation without
step, and the subsequent addition of
endorectal ultrasonography, and
radical surgery in cases of complete
leucovorin, inrinotecan, oxaliplatin,
magnetic resonance of the pelvis—
response to neoadjuvant therapy.
and “biologic monoclonal antibiotics”
allow for much better preoperative
In addition to advances in imaging
and antiangiogenic drugs have had a
evaluation and staging of colonic and
techniques, the invention of fiber-optic
definite impact in patients’ prognoses
especially rectal cancers. These tech-
colonoscopy in the early 1970s added
when used preoperatively or following
niques as well as PET scans make it
an invaluable addition to the diag-
resection of hepatic or pulmonary
possible to evaluate cancer patients
nostic armamentarium in colorectal
metastases from CRC. Preoperative
106
finding nearly coincided with the invention and marketing of fiber-optic colonoscopes and led to surveillance colonoscopy and target biopsies to diagnose dysplasia and offer prophylactic colectomy to patients when indicated, preventing colitis cancers. The next remarkable innovation was restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) proposed in 1978 by Sir Alan Parks Dr. Burrill Crohn (center) pictured with surgeons Gordon Oppenheimer (left) and Leon Ginzburg (right), with whom he published on regional ileitis.
and perfected by Joji Utsunomiya from Japan. This operation provides the patients with CUC an operation that would allow them to retain their
staging and individual stage directed
caused extensive morbidity and many
sphincter mechanism and avoid perma-
therapy involving neoadjuvant therapy
deaths until Bryan Brooke in the U.K.
nent ileostomy. Since the advent of IPAA
and surgery have made a real improve-
devised a simple eversion of the ileum
the patients are more amenable to
ment in prognosis of patients with CRC.
covering the serosa and exposing the
this operation, resulting in significant
It i s i mpor t a nt to note t he
normal mucosa (Brooke ileostomy).
reduction in incidence of colitis cancers.
landmark original work of Norman
Two decades later, the efforts of Rupert
Advances in the medical treatment
D. Nigro, MD, FACS, in designing a
Turnbull, MD, FACS, and Norma Gill,
of inflammatory bowel disease have
“multimodality treatment” for anal
RN, ET, at the Cleveland Clinic gave
evolved from adrenocorticotropic
squamous cell cancers. This radically
enterostomal therapy formal recogni-
hormone (ACTH) and steroids to biologic
altered the care of such patients,
tion and changed the quality of life for
immune modulators. These agents have
reduced the need for proctectomy and
millions of ostomates in the U.S. and
helped improve the prognosis of anal
permanent colostomy by 85 percent,
the world.
CD and delay or prevent the need for
and increased the five-year survival
Basil C. Morson and Lillian S. C. Pang
diversion or protectomy. Popularization
rate from 50 percent with surgery
in the U.K. described the pathology of
of small bowel strictereplasty in the ’70s
alone to more than 80 percent with
“dysplasia” in CUC and its relation-
has led to bowel conservation surgery
chemoradiation therapy.
ship to “colitis cancers” in 1967. This
in an attempt to prevent short bowel syndrome in small bowel CD.
2. Inflammatory Bowel Disease 3. Diverticular Disease THE MOUNT SINAI ARCHIVES / NIH NATIONAL LIBRARY OF MEDICINE
While chronic ulcerative colitis (CUC) had been diagnosed and differentiated
Traditionally, acute sigmoid diver-
from specific colitides, it was not until
ticulitis resulting in a phlegmon or
the 1930s that Burrill Crohn, MD, and
perforation was treated by a three-
his associates published on “Regional
stage procedure of diverting colostomy
Ileitis.” Subsequently it was recognized
and drainage, resection, and closure
that the disease may involve the entire
of colostomy. Eugene Salvati, MD, and
gastrointestinal tract and was officially
his colleagues reintroduced Hartmann’s
named Crohn’s disease (CD), with
procedure in the early ’80s as the
its own defined pathologic findings.
preferred first stage in a two-stage
Patients with CUC were treated with
operation. Later, colonic lavage was introduced in an attempt to cleanse the
proctocolectomy and end ileostomy, but serositis at the site of the ileostomy
Rupert Turnbull
colon intraoperatively, allowing primary
107
anastomosis in obstructing diverticulitis
circular stapler to excise a donut of
or cancer. Primary resection, colorectal
rectal mucosa and submucosa at the
anastomosis, and proximal diverting
apex of the hemorrhoids and elevates
ileostomy introduced by Malcolm C.
and fixes the hemorrhoidal tissue at
Veidenheimer, MD, resulted in reduced
the level of anorectal ring. This opera-
hospital and sick days and an easier
tion, when used judiciously and for
second-stage operation, i.e. closure
the correct indication (circumferential
of diverting ileostomy vs. Hartmann’s
third-degree hemorrhoids), results Bill Heald
reversal. CT-guided drainage of diver-
in comparably effective results with
ticular abscess since the early ’80s
Ferguson’s hemorrhoidectomy without
allows for subsequent single-stage
have been reported from a few centers
the significant early postoperative pain
operation and avoidance of colostomy.
in the U.S., Korea, and the U.K., cost
and disability. Other minimally inva-
Abdominal washout, drainage, and
considerations are currently seen
sive procedures such as THD (trans-
intravenous antibiotics are currently
as the major impediment in expan-
anal hemorrhoidal dearterialization)
being studied in select cases of perfo-
sion of robotic rectal cancer surgery.
have since been introduced. Sutured
rated diverticulitis aiming for subse-
Randomized trials sponsored by
hemorrhoidopexy techniques may also
quent resection without colostomy.
the American College of Surgeons
accomplish the same results in eleva-
Oncology Group (ACSOG) will go a long
tion and fixation of prolapsing and
way to yield meaningful and cred-
bleeding hemorrhoids wherever stapler
ible level I evidence in rectal cancer
and new technologies are unavailable.
surgery analogous to the COST trial
b. Anal fissure
4. Minimally Invasive Colon and Rectal Surgery The first report of laparoscopic
Anal fissure was described by Joseph-
in colon cancer resection.
colon resection was published by
Newer techniques including single-
Claude-Anthelme Récamier in 1829.
Morris Franklin, MD, in the early ’90s.
port colectomy and NOTES (natural
Efforts to overcome the associated anal
Since then, the procedure has been
orif ice translum inal endoscopic
stenosis included anal dilation and
expanded to all benign disorders, and
surgery), etc., will need further evalu-
excision of anal fissure with or without
after the publication of the Clinical
ation in randomized controlled trials
sphincterotomy. The landmark work of
Outcomes of Surgical Therapy (COST)
before attaining universal acceptance.
Dr. Stephen Eisenhammer from South
trial demonstrating equivalency of the oncologic results of laparoscopic
Africa in the 1950s documented the role of the internal sphincter in the patho-
5. Anorectal Surgery
colectomy to traditional open techAnorectal surgery has evolved into
1971, Dr. Mitchell J. Notaras described
surgery has become more popular and
an outpatient operation in recent years.
the technique of lateral internal sphinc-
used around the world in the treat-
a. Hemorrhoidectomy
terotomy, which revolutionized the as
surgical treatment of anal fissure by
less early morbidity (e.g. pulmonary
performed by William Allingham in
avoiding a midline sphincterotomy that
complications and wound infections),
the 1850s, has remained popular in
causes “keyhole deformity” and variable
fewer sick days, and earlier return
the U.K. and European countries. In
degrees of incontinence to gas and stool.
to work are some of the parameters
the U.S., closed hemorrhoidectomy,
Since the early 1990s, a succession
favoring the laparoscopic technique.
popularized by James A. Ferguson,
of chemicals has been introduced
ment of CRC. Shorter hospital stays,
PHOTO COURTESY OF THE PELICAN CANCER FOUNDATION
genesis of chronic anal fissure (CAF). In
nique, minimally invasive colorectal
Open
hemorrhoidectomy,
Laparoscopy is suitable for all
MD, in Grand Rapids, MI, has remained
to induce relaxation of the internal
colectomies, but mobilization of a
the procedure of choice. In the early
sphincter in order to avoid sphincter-
bulky rectal tumor in an obese man
’90s, Dr. Antonio Longo introduced a
otomy and possible postoperative fecal
can be truly challenging. The use
novel and revolutionary procedure,
incontinence. Nitroglycerine ointment,
of the robot facilitates proctectomy
i.e., stapled hemorrhoidopexy or PPH
calcium channel blockers, injection of
for cancer and proctopexy for rectal
(procedure for prolapse and hemor-
botulinum toxin, sildenafil, and minox-
prolapse. Although excellent results
rhoids). This procedure uses a special
idil, among others, have been tried, but
109
the incidence of persistence of pain and
or biofeedback has been helpful in
recurrence of CAF after initial relief of
management of difficult defecation
symptoms has been shown repeatedly
disorders, especially in patients
in Cochrane Reviews to be much higher
unsuitable for surgical correction.
in “medical sphincterotomy” rather
E. Anal incontinence
than lateral internal sphincterotomy,
For too long, patients with anal incon-
which remains the gold standard in treatment of CAF to this day.
tinence were condemned to a lifetime Joseph M. Mathews
NIH NATIONAL LIBRARY OF MEDICINE
c. Anorectal fistula
use of constipating agents, diapers, and, at last resort, a colostomy. Newer
The standard treatment of anorectal
recent promising entry in the field of
advances in the treatment of fecal
fistulas was and is anal fistulotomy,
sphincter sparing procedures is the
incontinence include pulsed gracilis
and St. Mark’s Hospital in London
LIFT (ligation of intersphincteric
muscle transfer (not available in the
became the mecca for treatment of
fistula tract) procedure, which has
U.S.) and artificial bowel sphincter,
fistulas in the late 1840s. Traditional
yielded excellent short-term results,
which has a modest success rate but is
treatment modalities of hemorrhoids
but awaits a larger number of cohorts
beset by mechanical failures and septic
and fistulas were imported to the U.S.
with longer follow-up periods to gain
complications. Injection of various
by Joseph M. Mathews, the father of
universal acceptance.
microspheres in the submucosa of the
colon and rectal surgery in the U.S.,
d. Anorectal physiology
anorectum has been tried, and as soon
who chaired the first department
Anorectal physiology has enhanced
as one is abandoned, another surfaces
of proctology in the country at the
the field of anorectal surgery in the
in the market. Sacral nerve stimulation
University of Kentucky and who served
last three decades. Anorectal manom-
(SNS) has shown real promise in the
as the first president of the American
etry allows measurement of sphincter
treatment of fecal incontinence and
Proctologic Society in 1899. The land-
function at rest and at squeeze
for inexplicable physiologic reason for
mark classification of Parks et al. in
in the evaluation of rest and urge
chronic constipation. The complexity of
the mid-1970s allows the surgeon to
fecal incontinence. Pudendal nerve
the procedure and the high cost of pulse
classify not only the complexity of the
terminal motor latency is a surrogate
generators mandate that this procedure
fistula but also to assess the likeli-
for electromyography of the sphincter
be done in high-volume centers.
hood of cure vs. possibility of fecal
mechanism and is used to evaluate the
The preceding is a mere snap-
incontinence. Because fistulotomy in
innervation of the external sphincter.
shot of some, but certainly not all,
transsphincteric and suprasphinc-
Endorectal ultrasonography provides
of the advances in the field of colon
teric fistulas will definitely result in
visualization of the sphincter mecha-
and rectal surgery in the twentieth
varying degrees of fecal incontinence,
nism in its entirety. Injection of
century. Human imagination and tech-
since the early ’90s multiple proce-
hydrogen peroxide into the external
nological innovations will undoubtedly
dures and techniques have been tried
opening of the fistula during ultra-
continue this phenomenal progress in
in treatment of these “high” fistulas.
sonography aids in visualization of
the twenty-first century. Q
Fibrin sealant, first autologous and
the fistulae tract and identification of
later in commercially prepared form,
the internal opening. Measurement
has had varying success rates of 30
of colonic transit time using radio
to 50 percent. This was followed by
opaque markers helps diagnose slow
Professor of Surgery at the University
introduction of a porcine intestinal
transit constipation and identify an
of Illinois at Chicago and Chairman
submucosal plug and more recently a
occasional patient who might benefit
of the Division of Colon and Rectal
polytetrafluoroethylene (PTFE) plug to
from abdominal colectomy for intran-
Surgery at the John Stroger Hospital
close the internal opening of a fistula.
sigent constipation. Defecography,
of Cook County. He is a Past President
There are also two flaps, endorectal
or dynamic proctography, permits
of the American Society of Colon and
advancement and dermal island
the accurate evaluation of the rectal
Rectal Surgeons and a Past Executive
anoplasty, utilized to obliterate the
outlet in cases of outlet obstruction
Director and President of the American
internal opening of fistulas. The most
or animus. Neuromuscular retraining
Board of Colon and Rectal Surgery.
Herand Abcarian, MD, FACS, is a
111
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Degrees of Freedom Advances in Gynecological and Obstetrical Surgery by KARL C. PODRATZ, MD, PHD, FACS
The development of gynecological and obstetric surgical procedure has not taken place in a void. As in every other field of medicine, parallel developments in the understanding of human physiology, pharmacology, nutrition, intensive care, instrumentation—even electricity—have provided the synergy to make advances possible. Nothing, however, has been more important than the imagination and determination of individual surgeons who pioneered new techniques and created new tools. Their dedication has given modern women and the specialists entrusted with their gynecological and obstetrical care greater degrees of freedom than ever before. Laparoscopy
During the 1920s and ’30s, advances
position to maximize v isualiza-
in laparoscopy were chiefly centered
tion of pelvic structures. He began
Laparoscopy (more broadly endos-
on the development of equipment
performing laparoscopic operative
copy) has its origins in the quest for
including wider angle lenses, trocars
procedures for infertility diagnoses
an efficient, minimally invasive way to
for port introduction of instruments,
in German-occupied Paris during
inspect the abdominal cavity. In 1910,
and insufflation devices. As crude as
World War II, further developing
not long before the founding of the
they were, these devices facilitated
it through the 1940s. Through his
American College of Surgeons (ACS)
the progress that would be made over
efforts, and following publication of
in 1913, Hans Christian Jacobaeus, a
the next 40 years.
his work in 1947, gynecologists began
Swedish internist, performed the first
For example, in the 1930s, a
routinely using laparoscopy for tubal
laparoscopic procedures. His paper
Hungarian internist by the name of
sterilization, lysis of adhesions in the
reported his findings in the abdominal
Janos Veress developed and improved
abdomen, aspirations of ovarian cysts,
cavities of 19 patients using an endo-
the insufflation needle invented by
and retrieval of ova from the ovaries.
scopic approach, which he subse-
Otto Goetze in 1921 by means of
In the 1950s, the simple improvement
quently termed “laparothorakoscopie.”
adding a spring that enabled safe
of illumination expanded laparoscopy.
Bertram M. Bernheim, MD, of the
insertion and insufflation (inflation) of
Palmer introduced a safer light source
Johns Hopkins Hospital, was the
the peritoneal cavity. It could also be
by placing a small quartz-electric light
first to introduce laparoscopy in the
used for draining ascites and evacu-
bulb at the tip of a laparoscope, which
United States, performing the proce-
ating fluid and air from the chest and
increased brightness and decreased the
dure at Hopkins in 1911. He actually
remains an essential tool today.
chance of burns. Fiber-optic lighting
published his experiences prior to
Perhaps the most important pioneer
technology was a natural follow-on.
learning of Jacobaeus’ work, terming
in gynecologic laparoscopy was Raoul
A wider range of gynecologic opera-
the procedure “organoscopy.” Dr.
Palmer, a French gynecologist. He
tive laparoscopic procedures were
Bernheim’s work, and his reporting
was instrumental in emphasizing
performed in Europe than in the U.S.
of a high diagnostic success rate,
the importance of monitoring intra-
in the 1960s, including the first lapa-
helped catalyze American interest
abdominal pressure during the proce-
roscopic appendectomy, performed by
in laparoscopy.
dure and used the Trendelenburg
German gynecologist Kurt Semm.
113
Semm’s laparoscopic appendectomy met with a significant amount of criticism and even disbelief from fellow surgeons, but he was undeterred. He designed an improved automatic insufflator and thermocoagulator (preventing tissue from burning during laparoscopic sterilization), further demonstrating that gynecologists were at the forefront of laparoscopy development. The treatment of ectopic pregnancies via laparoscope began in the 1970s and early ’80s, abetted by the introduction of new television, video, camera, and light-source technologies. Technological development in turn inspired new techniques, and
With the da Vinci Surgical System, a surgeon controls robotic arms from a console to perform complex and delicate procedures through very small incisions with increased vision, precision, dexterity, and control.
in 1981, the A merican Board of Obstetrics and Gynecology required laparoscopic training to be a compo-
procedures including radical hyster-
Thus the procedure wasn’t attempted
nent of residency training.
ectomy and exenteration.
until Alexander Brunschwig, MD,
The first video-laparoscopic chole-
embarked on a phase I trial.
Pelvic Exenteration
Dr. Philippe Mouret in Lyons, France.
Born in Texas and trained in Boston, France, and Chicago, Dr. Brunschwig
Five years later, Camran Nezhart
Cancer of the cervix accounted for
performed the first total pelvic exenter-
reported the first laparoscopic radical
a significant percentage of the gyne-
ation in New York in 1947. He sympa-
hysterectomy and lymphadenectomy.
cological cancers during the first half
thetically performed the procedure,
Considered the “father” of operative
of the twentieth century. Most were
considered by some at the time to be
video laparoscopy, Nezhart’s advances
treated with radiotherapy but recur-
an abusive, mutilating operation, on 22
were bolstered by use of the first robotic
rence was all too common. Typically,
terminal patients with disease confined
arm in laparoscopy to hold a camera/
the recurrent cancer invaded locally
to the pelvis. Still, Dr. Brunschwig’s
instruments in 1994. Subsequently,
adjacent organs including the rectum,
pelvic exenterations for patients
several generations of robot systems
bladder, and vagina. Chemotherapy was
with cervical and reproductive-tract
have been developed. The fully articu-
essentially unavailable and additional
cancers realized a modest salvage rate
lating instruments simulate the full
radiotherapy was ineffective. As such,
(12 percent) when other options did not
range of motion of the surgeon’s wrists
the only reasonable option was surgery.
exist. That did not prevent the surgical
and hands, and offer the advantage
The potential for survival existed if
community from criticizing him due to
of three-dimensional, high-definition
these central pelvic tumors could be
a surgical mortality rate of 23 percent.
imaging and magnification.
removed with wide margins of tissue
The initial keys to successful pelvic
The degrees of freedom now possible
clearance including surrounding
exenteration lay first in determining
inside the abdomen with robotic
organs, a procedure called pelvic
which target lesions were appro-
instruments have made a marked
exenteration. Unfortunately, it was
priate for surgery and second, in
difference in approach. Robotic
recognized that with limited contem-
finding a method of substitution for
laparoscopy now facilitates hyster-
porary antibiotics, blood replace-
urinary bladder function following
ectomy, myomectomy, ectopic preg-
ment, and intensive care, rates of
the removal of the bladder, uterus,
nancy, oophorectomy, and oncologic
survival would be prohibitively low.
vagina, and rectum.
114
©2012 INTUITIVE SURGICAL, INC.
cystectomy was performed in 1987 by
Along with others, Dr. Brunschwig
These pioneering advances have been
new cases of ovarian cancer will be
helped identify lesions suitable for
complimented by further advances
diagnosed in 2012 and approximately
surgery and sought solutions suitable
in bladder substitution (the Kock and
15,500 deaths are anticipated. While
for urinary diversion. Eugene Bricker,
Miami pouches), better diagnostic
chemotherapy and some biological
MD, who had been involved with pelvic
techniques, and the employment of
agents are important treatments,
exenterations at Barnes Hospital in St.
robotics. Though pelvic exenteration
surgery remains central in the diag-
Louis, MO, in the 1940s, reported his
remains a very extensive procedure for
nosis, staging, and primary treatment
success with the construction of an
women undergoing it, there has been
of this disease. Fallopian tube and
ileal conduit that afforded low-pres-
a substantial improvement in longevity
primary peritoneal cancers present
sure drainage of urine into an appli-
with five-year survival rates approxi-
in similar fashion and are likewise
ance attached to the abdominal wall.
mating 55 to 60 percent. There has like-
managed with cytoreductive surgery.
In 1950, an ileostomy patient by the
wise been a dramatic improvement in
These cancers spread in a similar
name of Herman W. Rutzen constructed
the quality of life for those undergoing
manner, primarily through exfo-
a prototype of a rubber bag that could
the procedure, with new techniques
liation. Cells exfoliated from the
effectively form a watertight seal with
in pelvic floor reconstruction, colonic
surface of these cancers are carried
the skin. Dr. Bricker tried the so-called
reanastomosis, neovaginal reconstruc-
throughout the peritoneal cavity
“Rutzen bag” on two patients at the
tion, and continent urostomy.
by the abdominal f luid. The cells
Veterans Administration Hospital in St. Louis with results so promising
com mon ly seed the d iaph rag m,
Cytoreductive Surgery
that he suspended his own work on
omentum, and multiple other organs as well as the peritoneum and serosal
a bladder substitute. Ruzten’s device
Epithelial ovarian cancer accounts
surfaces of the bowel. As tumors
and Dr. Bricker’s application of it had
for the majority of deaths from cancers
grow, more cells are progressively
a major, positive impact on morbidity
of the female reproductive tract in the
shed, expanding the tumor burden
with pelvic exenteration.
U.S. According to estimates, 22,280
within the abdominal cavity. Patients
The College of American Pathologists is honored to partner with the American College of Surgeons to achieve optimal cancer care for patients. The CAP congratulates ACS on 100 years of
Congratulations improving quality in surgery, trauma, and cancer care.
cap.org
Thank you
for helping us create an exceptional hospital. ACS Fellows, youâ&#x20AC;&#x2122;ve helped advance the quality of health at Henry Mayo. With your help, weâ&#x20AC;&#x2122;ve created an entirely new hospital with expanded Cardiovascular Services, Spine Surgery and Joint Replacement programs, and a NICU, new ER, OR, helipad, and ICU. We appreciate your choice of Henry Mayo Newhall Memorial Hospital. Thank you again for helping transform health care in Santa Clarita.
Physician Relations:
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henrymayo.com
frequently present with malignant
successful procedure was pioneered
ascites and pleural effusions.
in 1900 by Howard Kelly, MD, a uro-
Cytoreductive surgery refers to the
gynecologist at Johns Hopkins. Dr. Kelly
surgical excision of tumor and tumor-
performed a plication (folding) of the
involved organs with the intent of
bladder neck and proximal urethra by
minimizing the amount of residual
means of a deep mattress suture and
disease remaining at the completion
anterior colporrhaphy (repair of the
of the operative procedure. Optimal
anterior vagina after plication). In 1914,
cytoreduction is removal of all visible disease. At a minimum for women
Dr. Kelly presented a detailed analysis Howard Kelly
having completed childbearing, this
plication” remained the standard of
requires removal of the ovaries,
verified. Combined with more effective
uterus, fallopian tubes, omentum, and
chemotherapy, the procedure currently
The next significant advance
regional lymph nodes. With advanced
results in survival rates approaching
emerged in 1949 when Drs. Victor
disease, excision of the peritoneum,
100 months if all macroscopic disease
Marshall, Andrew Marchetti, and
spleen, bowel, and other adjoining
can be removed. As before, the larger
Kermit Krantz introduced the cysto-
organs may be necessary.
care for more than 50 years thereafter.
the remaining tumor mass, the lower
urethropexy and colposuspension
Prior to the 1970s, cytoreductive
the survival interval. But today, gyne-
procedure, also referred to as the MMK
surgery was not considered a viable
cological oncologists approach ovarian
procedure. The MMK procedure (in
procedure. Because of the limits of
cancer much more aggressively,
simple terms, bladder neck suspension/
contemporary chemotherapy, patients
resulting in survival rates improved by
support surgery) was subsequently
who presented with advanced ovarian
a factor of three to four over the 1970s.
modified in 1961 by Vanderbilt Medical
cancer (typically 70 percent) were not considered curable. For women who demonstrated extensive disease
School professor John C. Burch, MD.
Surgery for Stress Urinary Incontinence
throughout the abdominal cavity, surgery was generally limited to removal of the primary tumor site.
NIH NATIONAL LIBRARY OF MEDICINE
of outcomes for 20 patients. The “Kelly
Dr. Burch’s modification involved placing surgical sutures at the bladder neck and anchoring them to the Cooper
C hronic ailments have benefited
ligament. Gynecological surgeons used
from the development of gynecolog-
both the MMK and Burch procedures
But in the early 1970s, C. Thomas
ical surgical procedures, too. Stress
in the decades that followed, with SUI
Griffiths, MD, studied the effect of
Urinary Incontinence (SUI) has long
cures nearing 85 percent.
tumor “debulking” on survival in
been a source of physical, emotional,
More recently, “sling” procedures
102 patients with advanced ovarian
and social distress for women that
have become the surgical interventions
cancer. He reported that surgical cyto-
surgery has sought to alleviate. SUI
of choice for SUI. The sling is basi-
reductive procedures were associated
is essentially the loss of varying
cally a narrow ribbon, typically made
with improved survival rates. Despite
amounts of urine from movements
of synthetic material, which is placed
skepticism, Dr. Griffiths demonstrated
that increase pressure within the
beneath the urethra in minimally inva-
that if all tumor tissue in the abdomen
abdomen and on the bladder, such
sive fashion with minute incisions and
could be removed, patients had a
as coughing, sneezing, or exercising.
inserted via a trocar. The sling place-
survival rate of 39 months. If the
Technically, it stems from the loss of
ment augments deficient pelvic floor
tumor could be reduced to 5 milli-
support of the urethra and bladder
muscles by providing a hammock of
meters or less, patients survived 29
neck. It is generally caused by changes
support under the urethra.
months on average. If the remaining
commonly associated with pregnancy,
A variety of slings, including the
tumor was between 5 and 15 millime-
childbirth, strenuous work-related
tension-free transvaginal tape (TVT)
ters, the survival rate was 18 months.
activities, and loss of estrogen support.
and transobturator tape (TOT) types,
As a result of Dr. Griffiths’ work, the
Surgical techniques for the cure of
are currently in use, and studies have
value of cytoreductive surgery was
SUI were not introduced until the late
shown them to be approximately
recognized and, over the years, further
nineteenth century. The first truly
85 percent effective. More recent
117
ADVANCING
THE SCIENCE OF SURGICAL CARE Science. Skill. Commitment. The University of Florida Department of Surgery.
SCIENCE When patient care presents mysteries to solve, UF surgeons look to the laboratory for answers. Our surgeons are dedicated to bringing scientific discoveries from the lab to the operating room to improve care for patients.
SKILL We are training the next generation of surgeon-scientists to be lifelong learners and always seek inventive solutions to clinical problems. In fact, our general surgery residents spend additional years of training focused on research.
COMMITMENT Progressing education, furthering discovery, translating findings, and providing innovative quality surgical care…this is our mission, our commitment, as an academic surgery department.
5NIVERSITY OF &LORIDA $EPARTMENT OF 3URGERY s surgery.med.ufl.edu/acs
developments aim to minimize the
by interrupting blood supply in fetal
lower urinary tract obstruction, lesions
operative procedure as much as
puppies. The experiment established
of the thorax) met the criteria for fetal
possible to reduce complications.
the pathogeneses of neonatal intestinal
surgery that were set by consensus
atresia and, as importantly, demon-
during this period and endorsed by
strated the feasibility of simulating
the International Fetal Medicine and
human birth defects by appropriate
Surgery Society. As a result, very few
fetal manipulation.
open fetal procedures were attempted
Fetal Surgery The delicacy and complexity of childbearing have meant that obstetrical
The 1960s and ’70s saw experi-
in the following decades, and by the
surgical practices have historically
mental fetal surgery used to simulate
1990s, a shift to in utero endoscopy
been limited to post-birth procedures.
human congenital anomalies and for
was under way, particularly in Europe.
With the advent of fetal surgery or
the study of normal developmental
Minimally invasive endoscopic fetal
fetus-in-utero intervention, a funda-
physiology and the pathophysiology
surgery poses less risk to the fetal
mentally new (still nascent) channel of
of congenital defects. Experimental
patient and mother. The first clinical
obstetrical surgery has opened.
fetal surgery in primates proved more
fetoscopic surgeries were interventions
The practical drivers of such change
difficult as uterine contractility and
on the umbilical cord and placenta.
have been technological. The devel-
preterm labor were more difficult to
Clinical trials also demonstrated
opment of safe, non-invasive fetal
control. However, advances in surgical
the potential of fetoscopic therapy
imaging, monitoring, and sampling
and anesthetic techniques and in the
for twin-twin transfusion syndrome
techniques has led to an increasing
pharmacologic control of labor made
(disproportionate blood supply).
number of fetal anomalies diagnosed
experimental manipulations of the
Future fetal interventions are likely to
prior to birth. While some of these
primate fetus possible, setting the
remain minimally invasive and center
anomalies were understood before
stage for human fetal procedures.
on prenatal gene therapy and stem cell
the application of these technolo-
The procedure that inaugurated
treatments. Recent trials in the prenatal
gies, acceptance of the potential of
hu ma n fet a l i nter vent ion wa s
treatment of open spina bifida (myelo-
fetal su rg ical and /or fetoscopic
performed by New Zealand surgeon
meningocele) at the Children’s Hospital
interventions accelerated after such
Sir William Liley, who attempted to
of Philadelphia, Vanderbilt, and UCSF
approaches became more adaptable.
transfuse the fetus in utero in 1963.
have shown promise as well.
Physiologic observation of the
His successful intra-abdominal infu-
The advancement of the surgical arts
mammalian fetus began with the
sion of blood ameliorated Rh disease
and their compliments in the century
examination of animal (guinea pig)
in a fetus expected to die before birth.
since the founding of the ACS have
fetuses in the nineteenth century. By
In 1981, the first open fetal surgery
not only improved the mortality of
1920, the first scientifically successful
was undertaken at the University of
patients but raised their quality of life
nonhuman fetal procedures had been
California, San Francisco (UCSF) by
as well. New technologies, techniques,
performed, studying aspects of fetal
a team including Michael Harrison,
and clinical philosophies have given
movements and experimental in utero
MD. In the operation, a vesicostomy
modern gynecological and obstetrical
manipulation. In the 1930s and ’40s,
was placed in a fetus with a urinary
surgeons greater degrees of freedom
observation of and operations on the
obstruction. Though the fetus did not
than their predecessors envisioned. Q
lamb fetus gained momentum, proving
survive, the procedure was a technical
the most productive fetal experimental
success and was complimented by the
model for decades thereafter.
first successful sonographically guided
Karl C. Podratz, MD, PhD, FACS, a
In the 1950s, South African
placement of a fetal urinary catheter at
gynecologic oncologist, is the Joseph
surgeons Dr. Christiaan Barnard (who
UCSF the same year. The fetus survived
I. and Barbara Ashkins Professor of
performed the first successful human
this less extensive intervention and the
Surgery Emeritus at Mayo Clinic in
heart transplant) and Dr. J. H. Louw
adult continues to communicate with
Rochester, MN. He served three terms
produced intestinal atresia (narrowing
the university team today.
as a member of the Board of Regents
or absence of portions of the intestine)
Despite these successes, few condi-
similar to that seen in human fetuses
tions (congenital diaphragmatic hernia,
of the American College of Surgeons (2003–2012).
119
Neurosurgery and the American College of Surgeons by EDWARD R. LAWS, JR., MD, FACS, DMEDCH NAPLES (HON), FRCSED (HON), FRCPSG (HON)
In 1913, the year that the American College of Surgeons (ACS) was founded, Harvey Williams Cushing (1869-1939), the pioneer of the “Special Field of Neurological Surgery,” was recruited to the newly opened Peter Bent Brigham Hospital as Moseley Professor of Surgery at Harvard. In those days, most of the very few surgeons who performed neurosurgical procedures were general surgeons who had agreed to take on the occasional neurosurgical case. Some specialization in surgery had
problems. Their expertise in this area
to Johns Hopkins for surgical training,
already occurred before World War I,
was recognized by membership in
Cushing took along a Roentgen tube
and there were surgeons who concen-
the Society of Neurological Surgeons,
and made the first X rays there,
trated their surgical practices in the
founded by Cushing in 1920. These indi-
including an image of a bullet lodged
areas of head, eyes, ear, nose, and throat
viduals included Edward W. Archibald of
in the spine. After spending a year
(HEENT), orthopaedics, gynecology and
Montreal, Charles Bagley of Baltimore,
abroad, he came back to Baltimore
obstetrics, and urology. Other surgical
Charles A. Elsberg of New York City,
and introduced intraoperative blood
specialties developed over time as
Charles H. Frazier of Philadelphia,
pressure monitoring and the concepts
surgical practice expanded and tech-
Albert E. Halstead of Chicago, Allen B.
of the Cushing reflex (bradycardia
nology and surgical science advanced.
Kanavel of Chicago, George Heuer of
and respiratory depression related to
Neurosurgery was one of these.
Baltimore, Dean Lewis of Chicago, and
increased intracranial pressure), and
Howard C. Taylor, Jr., of New York City.
the Cushing ulcer (gastric ulcer related
served in World War I had developed
Drs. Kanavel and Halstead deserve
to stress). By 1909 he had established
major experience in the treatment of
special mention. They had become
basic principles of pituitary physiology,
neurological injuries, and the imme-
experts, like Cushing, in transsphe-
and began his large series of successful
diate postwar years were character-
noidal pituitary surgery. Drs. Elsberg
operations for pituitary adenomas.
ized by many changes in medicine
and Taylor were pioneewrs in spinal
and technology. This surely provided
neurosurgery.
Many of the surgeons who had
Cushing’s experience in World War I established the principles of manage-
an impetus for surgical innovation and
Dr. Cushing, President of the
ment of head wounds, which have
specialization, and for the central posi-
American College of Surgeons in
been refined during subsequent armed
tion of the ACS as an effective voice
1920–1921, contributed in many
conflicts. He actively worked on intraop-
and source of education and ethical
ways to the advance of surgery and
erative fluid replacement, methods and
practice for all surgeons.
neurosurgery over the past century
principles of hemostasis, and the possi-
Among the Founders of the American
and more. As a medical student at
bilities of blood transfusion. Along with
College of Surgeons were a number
Harvard, he and a classmate, E. Amory
other surgeons, he had developed an
of prominent general surgeons who
Codman, introduced the first anaes-
operation on the Gasserian ganglion for
also operated on some neurosurgical
thesia record. When he decided to go
the treatment of trigeminal neuralgia,
121
AHEAD.
Science moves forward. Fields evolve. And careers are not static. If youâ&#x20AC;&#x2122;re interested in putting your leadership skills to work, the Congress of Neurological Surgeons is interested in you. The CNS offers the insight, innovation and information that pave the way to your future. Hone your leadership skills, advance your education and further your career by joining the one organization focused on fresh ideas and the future of neurosurgery.
Think ahead. We are. For more information about member beneďŹ ts or to apply today, visit www.CNS.org.
Congratulations ACS on 100 years of improving the care of the surgical patient!
Phone: 847-240-2500 Toll Free: 1-877-517-1CNS info@1cns.org www.cns.org
From the more than 8,100 members of the American Association of Neurological Surgeons (AANS) to our colleagues at the American College of Surgeons (ACS), we congratulate you on your 100th anniversary. Best wishes for your continued success.
Figure 1. Neurosurgeon Presidents of the American College of Surgeons. Top row, from left: Harvey Williams Cushing, Howard Christian Naffziger, and Loyal Davis. Bottom row, from left: Charles George Drake and Edward Raymond Laws, Jr.
and pursued operations for the treat-
active in the College, helping to develop
The introduction of antibiotics in
ment of epilepsy and brain tumors.
surgical specialty representation and
the late 1930s was important for all
involvement, which continues to the
of surgery, as was the discovery and
present day (Table 1).
synthesis of cortisone.
Cushing’s pupil and coworker at
PHOTOS COURTESY OF THE AMERICAN COLLEGE OF SURGEONS ARCHIVES
Johns Hopkins, Walter E. Dandy (1889–1948), was responsible for a
There are many milestones in the
In the 1950s, dexamethasone was
major advance in neurosurgery. With
evolution of contemporary neurosur-
introduced as a means of decreasing
his colleagues in the experimental
gery. Cushing and W. T. Bovie intro-
intracranial pressure. At the same
surgical laboratory, he discovered the
duced electrocautery in 1927. That
time, new principles of neuroan-
physiology of the cerebrospinal fluid
same year, Cushing published his
aesthesia were developed, making
(CSF) circulation. In 1919, based on the
authoritative book on meningiomas,
intracranial surgery safer and more
observation of the ability to image free
classifying these benign tumors and
effective. That decade saw the intro-
air in the peritoneal cavity on X ray,
establishing the principles of their
duction of CSF shunting procedures,
Dandy introduced ventriculography,
surgical management.
wh ich revolut ion i zed ped iat r ic
replacing the CSF with air and thereby
In 1927, Egas Moniz of Portugal
neurosurgery. It also included the
visualizing intracranial structures and
introduced arteriography, setting the
application of stereotactic surgery to
their distortion by intracranial lesions.
foundation for the diagnosis and treat-
the treatment of tremor. Stereotactic
With the impetus from these early
ment of cerebrovascular disease. Over
surgery, now based on sophisticated
advances, neurosurgery has progressed
the subsequent years, endovascular
imaging, has evolved to deep brain
steadily over the past 100 years. Dr.
surgery has evolved and angiography-
stimulation (DBS) with indications
Cushing, as the first neurosurgeon to
based interventions continue to be
not only for movement disorders, but
be President of the ACS, and many of
more and more effective and more
also for epilepsy and some psycho-
his trainees and colleagues remained
frequently employed.
logical conditions.
123
TABLE I
Other leaders in this paradigm
Neurosurgeon Leaders of the American College of Surgeons
shift for neurosurgery were R. M. Peardon Donaghy of Burlington, VT, Leonard Malis of New York City, Gazi
Presidents Harvey Williams Cushing, MD, FACS, Boston, MA
Yasargil, then of Zurich, Switzerland, 1921–22
Robert Rand and Theodore Kurze of Los Angeles, and Albert Rhoton of
Howard Christian Naffziger, MD, FACS, San Francisco, CA
1938–39
Gainesville, FL.
1962–63
the CT scan (1970s) and the MRI scan
Subsequently, the introduction of Loyal Davis, MD, FACS, Chicago, IL
(1980s) revolutionized neurosurgical Charles George Drake, MD, FACS, London, Ontario
1984–85
Edward Raymond Laws, Jr., MD, FACS, Charlottesville, VA
2004–05
diagnosis and treatment. Computerbased image guidance and the introduction of the operating endoscope (another collaborative phenomenon
Neurosurgeon Regents of the ACS (All of the above, and:) William Feland Meacham, MD, FACS, Nashville, TN Edward Louis Seljeskog, MD, FACS, Rapid City, SD Martin B. Camins, MD, FACS, New York City, NY
Neurosurgeon Secretary of the ACS
with otorhinolaryngology) have further advanced the field, and have opened up new areas of endeavor. The collaborative nature of the adoption of microneurosurgery and minimally invasive endoscopic anterior skull base surgery emphasize the fact that so many of our subsequent advances result from multidisciplinary collaboration, an integral
W. Eugene Stern, Jr., MD, FACS, Los Angeles, CA
aspect of the educational programs of the ACS, and of its role in keeping
Neurosurgeon Vice-Presidents of the ACS
the “House of Surgery” together. Presently, neurosurgery collaborates with many of the other surgical disci-
John E. Raaf, MD, FACS, Portland, OR
plines on a regular basis. These include: Henry Gerard Schwartz, MD, FACS, St. Louis, MO
UÊ Neurotrauma and critical care – acute care surgery, ortho-
Eben Alexander, Jr., MD, FACS, Winston-Salem, OR
paedic surgery, ophthalmologic surgery, maxillofacial surgery;
Richard Lee Rovit, MD, FACS, New York City, NY
UÊ Cerebrovascular surgery – vascular surgery, interventional/
Julian Theodore Hoff, MD, FACS, Ann Arbor, MI
endovascular surgery; UÊ Brain tumor surgery – surgical neuro-oncology, neuropa-
The introduction of microneuro-
using and improving the operating
thology, radiation oncology;
surgery in the late 1960s marked a
microscope, neurosurgeons rapidly
UÊ Skull base surgery – otorhi-
major paradigm change. Spurred on by
adopted microneurosurgery, techni-
nolaryngology–head and neck
surgical pioneers like Julius Jacobson,
cally and conceptually. The almost
surgery, plastic surgery;
who introduced neurosurgeons to
simultaneous introduction of precise
microsurgical technique, and by otolo-
bipolar cautery was a significant part
surgery, physiatry, rehabilitation
gists and ophthalmologists who were
of the success of microsurgery.
medicine, spinal instrumentation;
124
UÊ Spine surgery – orthopaedic
Edward R. Laws, Jr., MD, FACS,
is a member of the American Surgical
i ÌÊ` Ã À`iÀÊ iÕÀ }Þ]Êi« i«-
DMedCh Naples (Hon), FRCSEd (Hon),
Association, and is a member of the
Ì }Þ]Ê«ÃÞV >ÌÀÞ]Ê iÕÀ À>` }ÞÆ
UÊ Õ VÌ > Ê iÕÀ ÃÕÀ}iÀÞÊqÊ Ûi-
FRCPSG (Hon), is a graduate of Princeton
Institute of Medicine of the National
UÊ *iÀ « iÀ> Ê iÀÛiÊÃÕÀ}iÀÞÊqÊ
University and the Johns Hopkins
Academy of Science.
ÀÌ «>i` VÊÃÕÀ}iÀÞ]Ê > `Ê
Medical School and its neurosurgical
ÃÕÀ}iÀÞ]Ê« >ÃÌ VÊÃÕÀ}iÀÞÆ
training program. He has held endowed
UÊ *i` >ÌÀ VÊ iÕÀ ÃÕÀ}iÀÞÊqÊ«i` >ÌÀ VÊ
chairs at the Mayo Clinic and the
ÃÕÀ}iÀÞ]ÊVÀ> v>V > ÊÃÕÀ}iÀÞÆÊ> `
University of Virginia, Charlottesville,
UÊ -ÌiÀi Ì>VÌ VÊÀ>` ÃÕÀ}iÀÞÊqÊ
was Chair of Neurosurgery at George
À>` >Ì Ê« ÞÃ VÃ]ÊÀ>` >Ì Ê
Washington University, Washington,
V }Þ]Ê iÕÀ À>` }Þ°
DC, and currently is Professor of
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Surgery at Harvard Medical School and
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Brigham and Women’s Hospital, where
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he directs the Pituitary/Neuroendocrine
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Center. During his surgical career he
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has operated upon more than 7,800
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brain tumors, of which 5,500 have been
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pituitary lesions.
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Dr. Laws has served as President of
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the American College of Surgeons, the
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Congress of Neurological Surgeons, the
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American Association of Neurological
i}iÊ vÊ-ÕÀ}i ðÊQ
Surgeons, and the Pituitary Society. He
References Cushing H. The physician and surgeon. SGO. 1922;35:701-710. Cushing H. Surgical and end results in general. SGO. 1923;36:303-308. Davis L. Credo. Bull Amer Coll Surg. 1963;36:25-28;52. Drake CG. Fellowship: the benchmark for American Surgery. Bull Amer Coll Surg. 1984 Dec;69(12):6-10. Greenberg SH, ed. A History of Neurosurgery. Park Ridge, IL: AANS; 1997: 626pp. Laws, ER. Harvey Cushing and the unity of surgery. Bull Amer Coll Surg. 2004 Dec;89(12):8-12. Naffziger, HC. Metamorphosis of the surgeon. SGO. 1940;70:374-378. Scarff, JE. Fifty years of neurosurgery 19051955. In: Davis L, ed. Fifty Years of Surgical Progress 1905-1955 as reprinted from Surgery, Gynecology and Obstetrics. Chicago, IL: Franklin Martin Memorial Foundation; 1955: 303-399.
Through the Lens: A Century of Innovation in Ophthalmic Surgery by BARRETT G. HAIK, MD, FACS
A century ago, ophthalmic surgeries would not have been popular topics for casual conversation. Procedures involved large incisions and long recuperation periods that often involved immobilization in devices for several days. Complication rates were high and visual rehabilitation limited. However, due to the determination of innovative ophthalmic pioneers, the past 100 years have witnessed tremendous advancements in intraocular surgery. The first surgical procedures to
Herein, I shall discuss five key areas
cure blindness were devised more
of innovation that have most dramati-
than 2,000 years ago. The opera-
cally revolutionized ophthalmic surgery
tions to remove cataracts from the
over the past century.
visual axis utilized thorns and forged needles, and were surrounded by great
Intraocular Lens
mystique. Despite a very high rate of failure, successes were so dramatic
For eyesight to be possible, light
that early surgeons were treated with
entering the human eye must first be
the greatest respect and honored
refracted at the air-tear interface of the
throughout the land. Over the ensuing
cornea and then focused by the crystal-
20 centuries, cataract surgery has
line lens onto our retinas. Next, photo-
undergone extraordinary advances,
receptors within the retina convert that
later devised methods for removing
especially in the past 100 years.
light into electrical impulses of infor-
the cataractous lens, but there was a
The nineteenth century set the stage
mation, which are transmitted through
problem: What would take the place
for modern surgery with the introduc-
the optic nerve to our brains, where the
of the lens? Removing an opaque lens
tion of germ theory and sterile surgery
perception of vision is created. When
meant condemning a patient to half-
by German physician Robert Koch and
we are born, the lens is clear as glass.
inch-thick glasses that did a poor job
British surgeon Baron Joseph Lister,
But, as the lens ages, it begins to lose
of replacing the lens’ ability to bend
after whom Listerine® was named. These
its flexibility and undergoes natural
light. Innovation was needed, and it
discoveries dramatically improved the
changes to its structure that cause
took one brilliant man to change the
safety of surgical outcomes, and, coupled
yellowing and opacification, ultimately
course of ophthalmology.
with major improvements in anesthesi-
leading to a decreased ability to see.
During World War II, ophthalmolo-
ology and the refinement of vital surgical
For a long time, the only way to deal
gist Harold Ridley, MD, was treating
instruments such as the lancet blade,
with a visually significant cataract
eye injuries in Royal Air Force pilots.
have resulted in much safer and less
was for a surgeon to stick a needle
He noted that when fragments of
invasive procedures that can treat a
into the eye and displace the lens out
acrylic plastic from cockpit canopies
wider variety of diseases and yield better
of the visual axis. With the advance
were embedded in patients’ eyes, they
outcomes for surgery patients.
of ophthalmic surgery, physicians
were tolerated without inflammation,
126
NIH NATIONAL LIBRARY OF MEDICINE
Robert Koch
rejection, or any apparent toxicity. He wondered, what if he made a lens from this acrylic to insert in the eye? It was a bold idea with limited acceptance from his colleagues. He pressed on, however, and introduced the first intraocular lens (IOL) at the end of 1949. “In doing so, he changed the practice of ophthalmology,” note Drs. David J. Apple and John Sims in their biography of Ridley for Survey of Ophthalmology. “Not only [did] Ridley’s invention
Steve Charles, MD, FACS, uses an operating microscope for retinal surgery.
PHOTO BY STEVE MOSER, OPHTHALMIC PHOTOGRAPHER, UNIVERSITY OF TENNESSEE MEDICAL GROUP
provide superior visual rehabilitation to cataract patients for generations to
few key advances highlight the path
come, but also, without his having real-
to where we are today.
Each incremental improvement in microsurgical tools and techniques is
ized it, the IOL has been a major factor
In 1956, José I. Barraquer, MD, of
built upon its predecessors, allowing
in changing the way ophthalmology is
Buenos Aires, Argentina, pioneered
for the implementation of new tech-
practiced.” For his remarkable accom-
the idea of adapting surgical micro-
niques and refinement of old ones.
plishments in ophthalmic medicine, Dr.
scopes for suspension from the
As a result of the past 100 years of
Ridley was knighted Sir Harold Ridley
ceiling, an approach ophthalmolo-
progress, most major eye surgery in
by Queen Elizabeth II in February 2000.
gists needed in order to keep their
developed nations around the globe
Initially, a patient had to be close to
patients lying in a supine position.
is done with operating microscopes,
legally blind before a surgeon would
This enabled proper stabilization and
facilitating new surgical techniques
perform cataract surgery because
positioning of patients, which was a
and improving patient outcomes.
early IOLs were associated with higher
key prerequisite to numerous future
complication rates. There were also
innovations in ophthalmic surgery.
Phacoemulsification
concerns over their long-term effects
In the 1960s, Richard C. Troutman,
on eye health. Over the years, however,
MD, of New York approached German
In the 1960s, Charles Kelman, MD,
continued refinement in IOL materials,
manufacturer Zeiss Oberkochen to
couldn’t turn off his brilliant mind
shape, and surgical method led to their
develop a zoom microscope with vari-
even while in the dentist’s chair. He
widespread acceptance with significantly
able ranges for use in his practice and
was fascinated with the ultrasonic
better outcomes than leaving patients
at New York Hospital. When he demon-
device that cleaned his teeth and
aphakic. Following the introduction of
strated it at an American Academy of
began asking himself, if sound waves
foldable IOLs, the age of small-incision
Ophthalmology meeting in 1965, the
can break up plaque, why couldn’t
cataract surgery was born, and today’s
implications of what he had achieved
they do the same to a cataract? At
ophthalmic surgeons are able to operate
were obvious and he was met with
that time, cataract surgery involved
on patients as soon as they feel limited by
immediate acceptance and praise.
cutting 180 degrees around the eye
their vision. What was once a risky and
Subsequent advances have included
before removing the lens with a
imperfect procedure has thus evolved
variable wavelengths of illumination,
freezing cryoprobe. Recovery was
into a low-risk and highly satisfying
integrated laser capabilities, voice-
lengthy and postoperative complica-
surgery for both patient and surgeon.
activated adjustments, improved depth
tions were borderline routine.
Microsurgery
of focus, high-definition and 3-D video
In 1967, Dr. Kelman introduced
recording, and conferencing. These
phacoemulsification, using ultrasonic
advances facilitate the creation of online
energy to emulsify the lens and then
The introduction of microscopy
surgical libraries, real-time education
aspirate it through a tiny vacuum. It
created the field of microsurgery and
in adjacent or distant viewing sites, and
was a very crude procedure in the
revolutionized ophthalmic surgery. A
innovative telesurgical applications.
beginning with limited support from
127
100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to
2012 2 100 years 1912 to 2012 2 100 yearss 1912 to 20 012 10 00 years 1912 to 2012
MedStar Health celebrates the yearss 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years American College of Surgeons’ 1912 2 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 2 1Centennial 00 years 1912 to 2012Anniversary. 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100
100 years 1912 to 2012 100 years 1912 to 2012 2 100 years 1912 to 2012 100 yearss 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 191 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1 years 1912 to 2012 100 years 1912 to 2012 100 yea 1912 to 2012 100 years 1912 to 2012 100 y
2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 years 1912 to 2012 100 Years of Quality Care Since the College’s founding by Dr. Franklin H. Martin, you have partnered with healthcare institutions across the United States to enhance and ensure the safe care of surgical patients, while improving quality in surgery, trauma and cancer care.
We join you in celebrating this milestone of contributions to millions of people through the years, and we salute all of our surgical fellows. With knowledge and compassionate care, MedStar Health looks ahead with the American College of Surgeons to create further healthcare breakthoughs— all centered on the patient.
medstarhealth.org
PHOTOS BY JOE MASTELLONE, OPHTHALMIC PHOTOGRAPHER, UNIVERSITY OF TENNESSEE MEDICAL GROUP
Fundus photo showing scatter laser surgery for treatment of diabetic retinopathy.
separates from the retina. It was once
The foot-pedal-controlled aspiration
believed that touching the vitreous of
system was developed by Drs. Conor
the eye risked retinal detachment and
O’Malley and Ralph Heintz in 1971.
total loss of vision. Because of this,
Then, in the early 1980s, Steve Charles,
surgically removing the vitreous was
MD, FACS, introduced xenon endopho-
always considered dangerous and
tocoagulation, in which a fiber-optic
foolhardy. But then, in 1968, David
probe is positioned near the retina after
Kasner, MD, reported successful
a vitrectomy to treat retinal breaks, stop
extraction of diseased vitreous in a
retinal bleeding, coagulate neovascu-
his colleagues. That he was able to
case of amyloidosis, becoming the
larization, or manage a number of other
pioneer such a radical new approach
first surgeon to demonstrate that
complications, dramatically improving
is nothing short of amazing. It is said
removal of diseased or prolapsed
surgical outcomes. Numerous innova-
that he secretly performed his first
vitreous is tolerated by the eye.
tive vitreoretinal surgeons have contin-
phacoemulsification test on a blind
However, it was Robert Machemer,
ually improved the designs of these
man behind a closed door with a sign
MD, at Bascom Palmer Eye Institute
tools to include variable flow control,
that read, “Contaminated Room—Do
who buried the erroneous notion once
disposability, refined ergonomics, and
Not Enter.”
and for all. In 1969, he invented a
other remarkable advancements that
Today’s cataract patients have
miniaturized, motor-driven cutter
have paved the way to modern vitreo-
Dr. Kelman to thank for his persis-
and, working with Jean-Marie Parel,
retinal surgery.
tence. Like me, my father was an
PhD, a year later, a suction cutter that
Again, what was deemed impossible
ophthalmologist, and I remember as
would fit into a small hole and act as
a century ago has become routine.
a child rounding on his postopera-
a guillotine to aspirate the vitreous
These pioneers have established
tive patients in the hospital where he
jelly. Coupled with continuous infu-
removal of vitreous as a safe and reli-
worked and seeing dozens of cataract
sion of solution, th is tech n ique
able procedure, leading to hope for
patients whose heads were immo-
marked the beginning of a revolution
millions of patients suffering from
bilized by sandbags for four or five
in vitreous microsurgery.
vitreoretinal diseases. Although it is
days. Dr. Kelman changed all that. By
impossible to quantify exactly how
contrast, today’s cataract surgery is
many patients have had their vision
an outpatient procedure with a short
saved or restored by vitrectomy, the
recovery period and rare complica-
enormity of its impact is unmistakable.
tions. Modern phacoemulsification devices and our surgical techniques
Lasers
are extremely sophisticated, shunning the 4-pound hand pieces of the
More than a dozen types of lasers are
late 1960s and 1970s for a constantly
used in modern ophthalmic surgery
evolving set of tools that will continue
for different types of procedures. The
to be modified to yield even better
precursor to the ophthalmic laser was
outcomes for our patients.
the photocoagulator, invented in 1949 by Gerhard R. E. Meyer-Schwickerath of West Germany, whose experiments
Vitrectomy
resembled those of Dr. Frankenstein. Most of t he eye’s volu me i s
He observed numerous patients who
composed of a substance termed the vitreous. Like the lens, vitreous changes with age. When we are born, it is gelatinous and flexible, but as we age it liquefies and eventually
were blinded by staring at the sun, Hamilton Eye Institute vitreoretinal disease specialist Edward Chaum, MD, PhD, uses a laser to repair damage caused by diabetic retinopathy.
and he hypothesized that this power, if carefully harnessed, could be used to destroy diseased tissue. He would bring patients to a room on the top
129
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floor of his clinic, where the ceiling
to LASIK and photorefractive kera-
opened. On sunny days, he would
tectomy (PRK), which remain tremen-
use a series of mirrors to direct and
dously popular elective surgeries for
magnify the sun’s rays to treat—
those patients wishing to do away
and burn—areas of the retina. The
with corrective lenses.
technique proved very effective for
The femtosecond laser marks the
diabetes complications and was useful
next major advancement driven by new
for certain aneurysms and tumors
laser technology. As this safer and more
in the eye. Today, ophthalmologists
effective transpupillary laser system
use a variety of laser wavelengths to
is perfected and fully integrated into
treat retinal diseases such as diabetic retinopathy. Hundreds of thousands of diabetic patients have had their vision saved by retinal photocoagulation. In the 1950s, xenon lamps began to
Aaron N. Waite, MD, a skilled ophthalmic surgeon, uses an Nd:YAG laser to perform a peripheral iridotomy for angle closure glaucoma.
be used as the light source for photo-
cataract surgery, we will see postoperative outcomes improve beyond even the excellent results currently achieved by modern vitreoretinal surgeons.
Conclusions
PHOTO COURTESY OF THE HAMILTON EYE INSTITUTE
coagulation, eliminating the need for a hole in the roof. When the ruby laser
her laser beam precisely cut or vapor-
Thanks to the creativity and perse-
was invented at the end of that decade,
ized without damaging surrounding
verance of innovative ophthalmic
it was found effective in producing
tissue, solving a difficult complication
surgeons, the past 100 years have seen
adhesive chorioretinitis, but was not
of modern cataract surgery: following
remarkable developments in technology
useful in treating vascular diseases.
cataract removal and intraocular lens
and technique that have led to reduced
However, as laser science rapidly devel-
placement, the capsular bag containing
recovery times and improved outcomes
oped, so did its ophthalmic surgery
the new man-made lens may grow
for patients. World-changing advances
applications. Francis L’Esperance, MD,
gradually opaque. Before the YAG
have been made in the areas of intra-
conducted the first photocoagulation
laser, ophthalmic surgeons did not
ocular lenses, microsurgery, phaco-
with an argon ion laser at the Edward
have a safe, non-incisional treatment
emulsification, vitrectomy, and laser
S. Harkness Eye Institute in 1968,
to restore vision lost as a result of this
surgery. Modern surgery is performed
which was highly successful and led
secondary posterior capsular opacifica-
in ways unimaginable a century ago. As
to widespread applications for treating
tion. Now, a 5-minute YAG procedure
we train the next generation of ophthal-
an array of vitreoretinal diseases. In
restores this lost vision without a
mologists to lead us into the future, one
1971, the krypton laser was found to
surgical incision in the eye.
wonders what new developments may unfold over the next 100 years. Q
be even more effectively absorbed by
Another wave of innovation began
pigments of the eye, but producing the
with the excimer laser, patented by
beam was technologically difficult and
Steven L. Trokel, MD. This laser is
cost prohibitive.
capable of reshaping corneas to
For the past 17 years, Dr. Haik
The development of the yttrium-
correct nearsightedness and farsight-
has served as Hamilton Professor
aluminum-garnet (YAG) laser in 1978
edness. It was originally used by IBM®
and Chair of Ophthalmology at the
was the next revolutionary step in
to cut silicone chips at its New York
University of Tennessee Health Science
the development of laser eye surgery.
facility in the 1970s. Rangaswamy
Center. He is the Founding Director
When Danièle S. Aron Rosa, MD, first
Srinivasan, PhD, James Wynne, PhD,
of the world renowned Hamilton Eye
presented her results, she was widely
and Samuel Blum, PhD, who worked
Institute, a comprehensive, verti-
criticized and rejected by colleagues.
in the IBM research labs in 1982,
cally integrated center of ophthalmic
Over a decade, however, her work
recognized its potential in medical
excellence. He is also Director of the
was finally accepted and she became
applications, but it was Dr. Trokel
Division of Ophthalmology in the
an internationally renowned figure
who first applied the excimer laser
Department of Surgery at St. Jude
in ophthalmology. Instead of burning,
to cornea surgery. This paved the way
Children’s Research Hospital.
131
Orthopaedic Surgery 1913 to 2012 100 Years of Evolution, Invention, and Innovation By DAVID G. MURRAY, MD, FACS
Orthopaedic surgery was well organized as a specialty by 1913, but in the latter years of the nineteenth century it was largely associated with “splints, straps, and buckles.” Most surgical procedures fell into the realm of the general surgeons, with orthopaedists providing supporting dressings or braces as well as setting fractures or caring for infections or lacerations. With the advent of the twentieth century, this began to change. One of the prominent orthopaedic
wounds, irrigating with iodine, and
continued to involve plaster cast immo-
entrepreneurs was Fred H. Albee, MD,
packing with Vaseline gauze. After
bilization after reduction, but the hip
who introduced bone grafting in 1915.
dressing, a plaster cast was applied
began to attract the attention of the
In addition, his several inventions at the
and the patient triaged back to the
more aggressive surgeons.
time included a bone mill and a unique
U.S. The cast was not to be windowed
fracture table. He pioneered the stabili-
or changed for several weeks unless
zation of tuberculous spines by means
absolutely necessary for sepsis. Most of
of inserting tibial bone grafts into the
the time the underlying wounds were
split spinous processes of the affected
clean and healing when the cast and
spine to achieve a solid fusion. He had
dressings were eventually removed.
a lengthy career with major involve-
Many limbs were saved by the “Orr
ment in World War I, where it was said
Method,” which continued to be used
(perhaps by him) that he performed half
for the treatment of osteomyelitis
of the bone graft operations required in
several decades after the war. The ’20s saw orthopaedic surgeons
Massive injuries to the extremi-
becoming more aggressive in the
ties during World War I presented a
surgical management of disabilities
major challenge for the medical staff.
and deformities. The residuals of
Amputations were frequently required
polio epidemics demanded a variety
and serious infections were almost
of surgical approaches to improve the
the rule rather than the exception. An
usefulness of involved extremities as
orthopaedic surgeon from Nebraska,
well as the spine. Techniques for tendon
H. Winnett Orr, promoted a treatment
transfers, joint fusions, limb length-
protocol that involved immediate
ening or shortening, etc., dominated
cleansing and debridement of the
the literature. Fracture management
132
Smith-Petersen-type acetabular cup for hip replacement surgery.
SCIENCE MUSEUM/SCIENCE & SOCIETY PICTURE LIBRARY
treating injured soldiers.
arthroplasty” procedure, which he developed, became the standard for treating arthritis of the hip for the next three decades. Willis Campbell, MD, of the fledgling Campbell Clinic in Memphis, TN, created a metallic prosthesis to cover the femoral side of the arthritic knee, drawing inspiration from Dr. Smith-Petersen’s success with the hip. Unfortunately, the knee is a more complex joint than the hip and the Campbell attempt at arthroplasty was unsuccessful. Other concepts, including hinges, also failed. Further attempts at imaginative solutions Sterling Bunnell
were put on hold by the advent of
PHOTO COURTESY OF STERLING BUNNELL MEMORIAL HOSPITAL, PETER CARTER, MD, COLLECTION AND TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN
World War II, when orthopaedic In 1925, Marius Smith-Petersen, MD,
driving force behind the formation
of Boston devised a three-flanged nail
of a new organization, the American
The war years were not without
for fixing a fracture of the femoral neck.
Academy of Orthopaedic Surgeons
advances that affected orthopaedic
A slender guide wire was inserted into
(AAOS). The AAOS was created to be
practice. Streptomycin drastically
the femoral head with X-ray control
inclusive of all board-certified ortho-
changed the course of treatment for
and the nail, which had a longitudinal
paedic surgeons, with a commitment to
tuberculosis of the spine, historically
hole down the center, was driven in
promoting continuing education across
a condition creating major difficulties
over the wire, which was then removed.
the specialty. The new organization was
for the orthopaedic surgeon. Likewise,
Fred Knowles, MD, in Fort Dodge, IA,
spectacularly successful, eventually
penicillin profoundly altered both the
designed a pin that was threaded at
maturing into the largest association
incidence and management of osteo-
the end, with a hub halfway down the
of orthopaedic surgeons in the world.
myelitis. Otherwise, trauma manage-
surgeons were called up in droves.
shaft. A groove in the pin just beyond
The 1930s turned out to be a
ment occupied the surgical skills of the
the hub provided a weak point so that
watershed decade for the specialty.
large number of orthopaedic surgeons
when the pin was inserted to the hub
In 1936, Charles Venable, MD, and
serving in the various theaters of
against the bone, and the fractured hip
Walter Stuck, MD, introduced the
World War II. The novelty of creating
stabilized, a little stress on the rest of
use of a cobalt, chromium, and
new inventions or procedures tempo-
the pin would break it off, leaving only
molybdenum alloy called Vitallium
rarily took a back seat to the everyday
a tiny slit in the skin to be closed. It
in surgery. Vitallium turned out to
challenges of battlefront surgery.
was a very early example of “mini-
be not only strong and durable but,
During this time, Sterling Bunnell,
mally invasive surgery.” A number of
most importantly, completely inert
MD, devoted his talents to supervising
designs, modifications, or adaptations
in the physiologic environment of the
and organizing the treatment of inju-
emerged relatively quickly in the next
human body. This metal immediately
ries and other problems involving
few years and the fracture of the hip,
became the springboard to opening
the hand. In 1944, he authored
which previously was a catastrophic
up the entire field of orthopaedic
the classic textbook Surgery of the
injury in the elderly person, became
implants. Dr. Smith-Petersen, who
Hand. His enthusiasm for the field
a manageable event with predictable
had been searching for a material
attracted others, and in 1946, the
restoration of function.
that could be interposed in the hip
American Society for Surgery of the
In 1933, the venerable American
to form a new joint surface, suddenly
Hand (ASSH) was inaugurated. This
Orthopaedic Association became the
found one in Vitallium. The “cup
was the first subspecialty, or special
133
The Department of Surgery
We share with the American College of Surgeons the commitment to teach medical students, residents, fellows and surgeons in a manner which inspires quality, promotes the highest standards and strives for the best outcomes for our patients. We seek to create new knowledge to the benefit of all while at the same time train the surgical leaders of tomorrow.
The Alpert Medical School of Brown University Department of Surgery congratulates the American College of Surgeons on their 100th Anniversary
interest, society to be formed within the overall fabric of the AAOS. (A number of others emerged, eventually leading to the formation of the Council of Musculoskeletal Specialty Societies [COMSS] in 1984, as advisory to the Board of the AAOS.) Hand surgeons quickly grew in numbers and diversity of interests. Alfred Swanson, MD, of Grand Rapids, MI, was one of several concentrating on the development of replacements for damaged finger joints. Silastic spacers proved to be the most durable and well tolerated. His devices, Swanson prostheses, became the standard for the time and are still the choice for many hand surgeons. James Urbaniak, MD, of Duke University pursued the replantation of digits after an early experience
Ignacio Ponseti
with salvaging a severed thumb. He subsequently reported a number of
his patient’s knee. The operation was a
orthopaedists were able to direct
successful replants. This led to his
success! The ultimate MacIntosh knee
their attention toward other prob-
development of educational courses
prosthesis, originally manufactured
lems. At the time, congenital disloca-
to acquaint a large number of ortho-
in acrylic, was subsequently made
tion or subluxation of the hip was a
paedic surgeons with the techniques
of Vitallium and became one of the
known entity but was often missed
for repairing tiny vessels. His example
common devices for treating arthritis
in the nursery, precluding effective
has been responsible for the presence
of the knee well into the ’60s.
closed reduction at a later age. Dr.
of an operating microscope in the oper-
PHOTO COURTESY OF THE UNIVERSITY OF IOWA
ating room of every hand surgeon.
Mark Coventry, MD, of the Mayo
Robert Salter of Toronto devised an
Clinic pursued a different tack.
osteotomy of the pelvis just above the
The 1950s brought back the quest
Eschewing prostheses and taking
acetabulum, which allowed the socket
for a solution for the arthritic knee.
advantage of the fact that usually
to be reoriented to cover the femoral
Perhaps apocryphal, but quite possibly
one compartment of the knee was
head. When done early enough, it
factual considering the times, is the
more arthritic than the other, he
allowed the socket to remodel around
story of the MacIntosh device. As it is
created a wedge-shaped osteotomy
the head, creating a normal joint. He
told, Dr. David MacIntosh of Toronto
of the tibia just below the weight-
reported successes in patients up to
was taking a break from a very diffi-
bearing surface which, when closed,
the age of 12. The Salter osteotomy
cult case involving a large defect in the
realigned the knee so that the major
remains the treatment of choice for
lateral plateau of an arthritic knee. As
weight bearing was transferred to the
missed congenital hip dislocations to
he was tapping out his cigarette, he
better-preserved side. His theory was
the present time. Fortunately, careful
noticed that the acrylic ashtray was
that the operation would “buy time”
exam in the nursery has made this
oval in shape with two shallow depres-
before a more definitive operation was
procedure much less common.
sions, much like the surface of a tibial
necessary. Still, he was committed to
Another condition encountered in
plateau. Energized, he appropriated
pursuing a more permanent solution.
the nursery is the congenital club foot.
the ashtray, cleaned and sterilized it,
The Salk vaccine closed the door
Descriptions of the deformity date back
sawed it in half, and filled the defect in
on polio in 1955 and pediatric
to antiquity, but effective methods
135
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who had devised an arthroscope for inspecting the interior of the knee. Impressed with the potential of this instrument, Dr. Jackson came back to Toronto, bringing the first arthroscope to the North American continent. He promptly began extoling its possibilities and inviting anyone interested to visit him. The problem with the instrument was a tiny light bulb on the end for illumination that had a propensity for bending out of position or breaking off entirely, necessitating an open operation to search for an elusive bulb. At that point, industrial engineers took over and very soon a fiber-optic arthroscope was on the market, along with instruments for operating through tiny nicks in the skin. Arthroscopic surgery took off like a rocket. The Arthroscopy Association of North America was formed in 1981, and by 1992 had more than 1,000 members. The use of the arthroscope expanded to include Robert Jackson
procedures on the shoulder, hip, ankle,
PHOTO COURTESY OF THE AMERICAN ORTHOPAEDIC SOCIETY FOR SPORTS MEDICINE
and the small joints of the wrist. for treating the problem with splints,
streptomycin, but spinal problems
In 1974, a Los Angeles Dodgers
manipulations, and braces were never
in the form of scoliosis still plagued
pitcher blew out his elbow, a career-
very effective. In the ’60s, Dr. Ignacio
teens and preteens. Casting, fusions,
ending injury. He came under the
Ponseti in Iowa City, IA, developed a
and braces at best stabilized the
care of Fran k Jobe, MD, of the
serial cast system concluding with
deformity but did little to correct
Kerlan-Jobe Orthopaedic Clinic in
cutting the Achilles tendon through
it. In the late ’50s, Paul Harrington,
Los Angeles. As an expert in surgery
a tiny slit. At this point, the foot was
MD, in Houston, TX, devised a system
of the upper extremity, Dr. Jobe was
corrected and maintained in that
involving a rod and hooks that could
not aware of any standard repair for
position with a brace or shoes until
be implanted in the curved spine and
this injury. Accordingly he devised
stable. Almost simultaneously, several
”jacked” out to straighten the curve.
a complex reconstruction involving
pediatric surgeons were working on
A fusion could be done at the same
ligament grafting. His patient recov-
procedures to correct the foot in a
time so the devices could be removed
ered, and with intensive physical
single operation. Comparisons of the
eventually and the correction main-
t herapy, ret u r ned to t he Major
two approaches over time led to the
tained. This innovation stimulated
Leagues in 1976 to win 164 more
conclusion that the Ponseti method
a flurry of approaches for straight-
games. Dr. Jobe, whose exceptional
produced better results with fewer
ening or stabilizing the spine, but
surgical talents may be exceeded
complications. Working into his 90s,
Harrington rods remain the work-
only by his modesty, insisted that his
Dr. Ponseti was teaching his method
horse for treating the scoliotic curve.
operation be known by the name of
to surgeons from all over the world.
In 1964, Dr. Robert Jackson of
his patient, Tommy John. During the
Pott’s disease of the spine was
Toronto was doing a fellowship in
preparation of this manuscript, Phil
a th i ng of the past, than ks to
Japan with Dr. Masaki Watanabe,
Humber of the Chicago White Sox
137
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Geisinger Congratulates the American College of Surgeons “ I am proud of this great organization. I am proud of its distinguished traditions, of its meritorious accomplishments, of what it clearly promises for the future as a momentous force in American surgery. ” - Harold L. Foss, MD, speech to Clinical Congress, 1953 Surgeon-in-Chief and Superintendent, Geisinger, 1915-1958 President, American College of Surgeons, 1952-1953
Expert medicine. Leading-edge options.
threw only the 23rd perfect game
British surgeon Sir John Charnley
implanted with cement. Dr. Gunston’s
in the history of baseball. Humber
was responsible for one of the most
publication in 1971 was the first to open
had had his career resurrected by
innovative and most widely productive
the door to the potential for cemented
Tommy John surgery in 2005.
advances in the history of orthopaedic
knee prostheses. Immediately, possi-
Not all proposals, innovations, and
surgery. With intensive background
bilities began to be explored in the
inventions turned out to be successful.
research and the introduction of two
U.S. The initial hypothesis was that if
The concept of dissolving the inter-
new materials (bone cement and high-
the total knee was being replaced, the
vertebral disc by enzymatic activity
density polyethylene) into the system,
replacement didn’t have to look like a
originated with Lyman Smith, MD, in
he perfected the total hip replacement
knee. Designs were bold, unique, and
1964. Using chymopapain, he demon-
in 1958. In the early ’60s, the world
imaginative. As it turned out, the closer
strated its effectiveness in vitro and in
of orthopaedic surgery was beating a
the prosthesis resembled the actual
animals. In the 1970s, experimental
path to his doorstep in Wrightington,
knee, the better it worked. Among
work began with humans. Initial
England. Orthopaedic surgeons from
the first to concede this point were
results were encouraging. By the
the U.S. arrived in droves to observe
Dr. John Insall and Dr. Chit Ranawat
1980s, pressure was mounting from
and take notes to bring back home. At
of the Hospital for Special Surgery in
the orthopaedic community to release
this point, the FDA entered the picture,
New York. Their final “Total Condylar”
this material for clinical use. In a
declaring the procedure “experimental,”
prosthesis design became the template
combined effort by the AAOS and the
based largely on the introduction of
for successful knee replacement.
American Association of Neurological
bone cement. Prior to approval, the
The success with hips and knees
Surgeons, a series of comprehensive
FDA required two years of closely docu-
opened the door for joint replacement
courses, including didactic material
mented experience with the operation,
surgery to include shoulders, elbows,
and hands-on practice with models,
including the cement, at 50 selected
and ankles. Results have varied, of
was organized. (This was not the first
sites. This process only confirmed the
course, but improvements in design,
time the two specialties had worked
safety and efficacy of the procedure.
fixation, and techniques have continued
together on the spine. In 1934, neuro-
Subsequently, total hip replacement has
to the present time.
surgeon William Mixter and ortho-
become the most common and the most
As the Clinical Congress of the ACS
paedic surgeon Joseph Barr together
consistently successful operation in the
approaches, an assessment of the
per for med t he f i rst successf u l
history of the specialty.
coincident century in the history of
removal of a ruptured lumbar disc.)
As large numbers of these cases
orthopaedic surgery would suggest
In November 1982, the FDA finally
were accumulating, it appeared that
that the pure excitement, and some-
released chymopapain for clinical
the bone cement was the weakest
times turbulence, associated with
use. The immediate reaction of both
link in the system. It occasionally
innovation and invention has subsided
orthopaedic surgeons and neurosur-
failed and was difficult to remove. In
to a more refined effort biased toward
geons was explosive. Strict indica-
the ’80s, the development of porous
modification and adjustment, in the
tions promulgated by the educational
coating of the prostheses to permit
continuing pursuit of the ever elusive
courses were exceeded and the results
fixation by boney ingrowth helped
goal of perfection. Q
were understandably mixed. After
solve the problem. The development
the initial enthusiasm abated, usage
could be attributed to a coordinated
moderated and eventually became
effort by industry and orthopaedic
David G. Murray, MD, FACS,
limited to symptomatic demonstrable
surgeons, including William Harris of
was Professor and Chairman of the
disc herniations. A few years later, the
Boston and Jorge Galante of Chicago.
Department of Orthopedic Surgery at
procedure was rarely used. In 2003,
Charnley did not include the knee
Upstate Medical University in Syracuse,
the FDA placed chymopapain on the
in his arthroplasty efforts. A Canadian
NY, from 1966 to 2000. He is a Past
“Discontinued Drug Product List,”
orthopedic surgeon, Frank Gunston,
President of the American Academy
adding that it was “discontinued from
working in England with Charnley
of Orthopaedic Surgeons (1982–1983),
marketing for reasons other than
seized the opportunity to create a total
and a Past President of the American
safety or effectiveness.”
knee prosthetic design, which could be
College of Surgeons (1997–1998).
139
Milestones in Otolaryngology–Head and Neck Surgery From leaders to lasers, the field of otolaryngology–head and neck surgery has impacted surgery in more ways than most patients— and fellow surgeons—would guess. by GERALD B. HEALY, MD, FACS, FRCSENG (HON), FRCSI (HON)
The history of otolaryngology–head and neck surgery probably begins with the Egyptians in 1550 B.C., with a suggestion of treatment for deafness and aural discharge. Practically, however, Americans owe today’s advances to the Civil War. Surgeons returning from the battlefields realized the war wounds of various body parts—limbs, eyes, ears, head and neck structures, etc.—were more than one surgeon could master. The medical community began to value the concentration by surgeons on specific anatomical areas, and modern specialization was born in the United States. The first otolaryngology specialty
required to have a vision and hearing
different training than an understudy
organization began in 1868 with the
test. By 1912, this Academy was the
in Berlin working with a different
founding of the American Otological
largest specialty society in the country.
professor in the same field. However,
Society, followed in 1879 by the
The American College of Surgeons
as Europe headed toward World War
American Laryngological Association.
(ACS) was founded just a year later,
I, the physical danger to travel elimi-
In 1896, the American Academy of
and almost immediately it began to
nated these training opportunities for
Ophthalmology and Otolaryngology
shift the national focus to the local-
American surgeons.
(AAOO), a joint specialty organiza-
level surgeon. This approach greatly
tion devoted to surgery of structures
influenced AAOO decisions as well.
above the clavicle, excluding the brain, was founded.
A History of Firsts
Within the United States at that time, standards were even looser: You could
In the early 20th century, training was
call yourself whatever specialist you
an informal affair. A famous European
wanted as our country had no specific
surgeon would label himself a guru—
license or certification structure. The
likely gaining know-ledge by dabbling
“Flexner Report” commissioned by the
with corpses and dissecting cadavers—
Carnegie Foundation in 1910 at the
AAOO was a true pioneer. In 1909, it
and an aspiring surgeon would ask if he
urging of Theodore Roosevelt would
began to push hard for vision, hearing,
could spend time learning, one-on-one,
become the template of academic
and nasal breathing examinations for
from the surgeon in London, Paris, or
teaching centers. This led to the stan-
children in schools. Today, of course,
Vienna. However, those who went to the
dardization of medical education and
every school-age child in America is
professor in London might get totally
residency training.
140
A s these t wo perfect stor ms produced a formalized education system, the AAOO was founding the first two certifying boards in all of medicine: ophthalmology in 1916, with otolaryngology following in 1924. Historically, this was not a popular direction; physicians grumbled and complained. However, otolaryngology leadership discussions centered on visionary people saying, “We must make sure our surgeons are qualified to do what they claim.” Thus the certification process began and all of medicine was enlisted to participate. Education has remained an important cornerstone of the specialty. Otolaryngology was the first specialty to start what’s known as “lifelong education” among residents and practitioners through a home study course. The A AOO collaborated with the ACS in 1940 to launch this program for residents and practitioners to augment what they were learning in the hospital setting. Educators felt
Chevalier Jackson
NIH NATIONAL LIBRARY OF MEDICINE
it was critical to teach more basic science that was applicable to the
otolaryngology was one of the first
benefited patients and their care-
areas being focused on in patient care.
two pathology registries at the Armed
givers in both specialties.
By 1970, otolaryngology was the first
Forces Institute of Pathology (AFIP).
specialty to start a comprehensive,
Facial plastic surgery in the head
annual self-assessment exam (now
and neck region also gained interest
the cornerstone of the maintenance
as patients returning from World
The father of modern endoscopy
of certification process): This was a
War II w ith signif icant cosmetic
was Chevalier Jackson, MD, an
voluntary program to evaluate how
defects began to seek treatment from
otolaryngologist from Philadelphia.
you compared with peers in relation
surgeons skilled in head and neck
Between the turn of the century and
to procedures and treatments. Today,
surgery. As these areas of interest
the late 1940s, he was the premier
lifelong learning/continuous profes-
grew and ophthalmology expanded,
instructor in teaching techniques for
sional development is a requirement
it became apparent the two special-
the removal of foreign objects from
of all surgical certifying boards.
ties had very divergent interests in
the air and food passages of children
Surgical Gifts
After World War II, otolaryngology
modern medicine. The specialty of
and adults. In addition, he pioneered
became heavily involved in addressing
eye care became very sophisticated
the treatment of caustic ingestion
head and neck cancer surgery; today,
and complex, as did the care of the
and forced government agencies
with our colleagues in general and
remaining structures of the head
to mandate the labeling of caustic
plastic surgery, we care for a majority
and neck. Thus the specialties split
products. Dr. Jackson also standard-
of these cancer patients in America.
into two separate organizations in
ized tracheotomy as a safe surgical
In support of this anatomical region,
the 1960s. This decision g reatly
procedure for airway obstruction. His
141
innovations became the precursor of
endoscopes to access the sinuses and
modern treatment of air and food
thus create options for surgical inter-
passage diseases by otolaryngologists,
vention. David W. Kennedy, MD, popu-
thoracic surgeons, pulmonologists,
larized the technique in the United
and gastroenterologists.
States soon thereafter, and today
Other specialty accomplishments
external sinus surgery is rarely done
include preservation /conservation
unless there is a rare complication of
surgery of the larynx. Previously,
the endoscopic approach.
laryngeal cancer led surgeons to
Access to the skull base has evolved
remove the entire organ and the art
with innovative surgical techniques.
of verbal communication was lost. But
Today, otolaryngologists, together
in the late ’60s, Joseph Ogura, MD,
with colleagues in neurosurgery and
of St. Louis pioneered partial resec-
plastic surgery, give new hope to
tion surgery to prevent this drastic
patients with tumors in this complex
outcome, and today this procedure is
anatomical region.
the standard worldwide. Surgical lasers have also become
Strides in Otology
an important surgical development of the modern era. Otolaryngology
Surgeons began working in the
was in the forefront in the first use of
ear and mastoid in Europe in the
surgical lasers, thanks to the Boston
David W. Kennedy
and M. Stuart Strong. Their publication, Laser Surgery of the Vocal Cords:
Advancements in Nasal and Sinus Surgery
attempted. In the pre-antibiotic era, ear infections often progressed to mastoiditis and frequently to intra-
An Experimental Study With Carbon
COURTESY OF THE AMERICAN ACADEMY OF OTOLARYNGOLOGY–HEAD AND NECK SURGERY
mid-1800s—very crude operations usually done to relieve infection were
University team of Drs. Geza Jako
Dioxide Lasers on Dogs, detailed a
Nasal surgery certainly was the
cranial infection. Drainage was the
methodology to use a microscope and
purview of otolaryngologists from the
only treatment, and crude methods
laser attachment to visualize and treat
beginning of the specialty. It included
(by today’s standards) using hammer
lesions of the larynx transorally. This
reconstructive surgery, surgery for
and chisel were used to open the ear
was a major breakthrough because it
chronic infection, and surgery to
and mastoid.
magnified structures and provided a
remove tumors. In the era before
Major developments changed this
laser delivery system, making trans-
antibiotics, sinus infections—thanks
approach. First came the evolution
oral endoscopic surgery of the larynx
to their proximity to the brain—were
of more refined instruments. Otologic
possible. Jako and Strong opened the
potentially very lethal problems.
surgeons soon learned that the dental
airway to micro-minimally invasive
Intracranial infection secondary to
drill powered by electricity could
surgery so that patients didn’t have to
sinus pathology was potentially fatal.
be useful in opening the ear and
suffer invasive neck operations.
Methods to clear sinus pathology
mastoid. Next came the operating
More recently, the National Institute
evolved from the late 1800s through
microscope in the 1920s, which
of Deafness and Other Communication
the late 1970s, with most operations
otologists used to magnify the middle
Disorders was established as a result
taking an external approach. The
ear and the tiny ossicles behind the
of the urging and efforts of the otolar-
surgeon would make an incision
eardrum, thus allowing reconstruc-
yngology–head and neck surgery
somewhere on the patient’s face and
tion of the hearing system. This led to
community; it became a full institute
enter the sinuses by that route.
stapedectomy in 1956, an operation
at the National Institutes of Health
I n t he 1970 s, D r. Hei n z R.
that revolutionized the treatment
during the Reagan Administration,
Stammberger (an Honorary Fellow
of deafness. Otolaryngologists truly
bringing hope to millions of hearing-
of the ACS), an Austrian otolaryn-
became the first micro surgeons with
and speech-impaired patients.
gologist, revolutionized the use of
this evolution.
143
Life Works Here THE DEPARTMENT OF SURGERY AT DARTMOUTH-HITCHCOCK MEDICAL CENTER is a vibrant, growing and dynamic academic surgical program built on a long-standing tradition of clinical excellence, teaching and research. We are actively involved in transforming surgical care by constantly striving to maximize value for our patients, our students and trainees, and to the overall population that we serve. As the only academic medical center and tertiary referral center for the State of New Hampshire, the Department of Surgery at Dartmouth-Hitchcock Medical Center provides an extensive variety of surgical services. Our Department has twelve highlyproductive surgical sections. Additionally, we have seven post-graduate training programs and fellowships in Vascular and Minimally-Invasive Surgery that consistently attract top candidates from around the country. Every one of our 100 faculty is actively involved in teaching at the undergraduate or graduate medical level and our Department serves as the focus for surgical education for the Dartmouth academic community and the Geisel School of Medicine at Dartmouth. The Geisel School of Medicine is the country’s 4th oldest medical school and has an established reputation as one of the greatest. Our faculty is increasingly attracting funding for clinical and basic research, and there are several exciting areas within our Department where new techniques and processes are evolving. We offer many exciting patient care, learning and research opportunities in every major surgical discipline, and encourage you to find out more. Send a CV to: surgery@dhphysicians.org
Dartmouth-Hitchcock Clinic is an affirmative action, equal opportunity employer. Women and minorities are encouraged to apply.
dartmouth-hitchcock.org
THE
BEST AND BRIGHTEST THE
At Sanford Health, every day we honor our own commitment to health and healing so that we can improve the human condition. Today, Sanford Health honors The American College of Surgeons’ commitment to the best quality and brightest outcomes. From the surgeons at Sanford Health, congratulations to The American College of Surgeons for 100 years of service. 100-11395-4596 8/12
Antibiotics obviously played a major role in reducing the need for surgery in the first place, and so did the insertion of ear tubes. Ear tubes were actually developed by Dr. Adam Politzer in Austria in 1861. But—as is common with new ideas—the public at that time thought Politzer’s idea of inserting a tube into the eardrum to equalize pressure on either side was too radical. However, after World War II, otolaryngolog ists asked whether tubes could be used to prevent children from suffering ear infections. Beverly A rmstrong, MD, thought about using Politzer’s idea to see if we could turn that process around.
Capt. David Thompson performs an ear tube surgery on a young hospital patient.
The rest is history. Tube insertion in children is one of the most frequent
certainly our specialty, too, crossed
offers both medical and surgical oppor-
operations in the world. However,
lines with many other disciplines. But
tunities, enjoying a wide diversity.
w ith the emergence of resistant
the idea that only one group should
This need to be ambidextrous on
bacteria, the original problem of the
hold the answers is archaic, selfish,
both sides of patient care has created
pre-antibiotic era is beginning to
and not good for patients. We have
a proud number of leaders in medi-
rear its ugly head again. There are
thankfully resolved that attitude
cine—from deans of medical schools to
more mastoid operations being done
today. We’re working together to
presidents of societies and academies
now than 20 years ago. It could very
make everyone a better surgeon to
like the ACS. But no matter the acco-
well be the next surgical challenge
help all patients.
lades and honors on the wall, otolar-
for our profession to tackle.
yngologists continue to search for the
Modern otology’s major break-
that approximately 40 to 50 percent
next surgical breakthrough to share
through, of course, is the cochlear
of otolaryngology involves treating
with our colleagues. Otolaryngology–
implant for the deaf. Robert K. Jackler,
patients medically without doing
head and neck surgery and its deep
MD, at the Stanford University School
surgery, and that’s an important
heritage is a proud member of the
of Medicine has tracked the origin to
distinction to some other surgical
House of Surgery. Q
American otolaryngologists working
disciplines. For students who are only
in California.
interested in technical intervention,
Standing Out, Standing Apart U.S. NAVY PHOTO BY JOURNALIST SEAMAN ERICA MATER
Still, it’s important to point out
otolaryngology is not appropriate. For
Gerald B. Healy, MD, FACS,
instance, a patient with a history of
FRCSEng (Hon), FRCSI (Hon), is the
nasal obstruction may visit an otolar-
emeritus Gerald B. Healy Chair
Otolaryngolog y–head and neck
yngologist. Many times the problem
in Otolaryngology and emeritus
surgery has become an integral part
is secondary to allergy, and if you
Surgeon-in- Chief at Children’s
of “the House of Surgery”—all the
treat the allergy effectively, surgery
Hospital Boston. He is a Professor of
surgical disciplines coming together
is unnecessary. A child with an ear
Otology and Laryngology at Harvard
under one virtual roof: the American
infection doesn’t receive ear tubes as
Medical School. He was Executive
College of Surgeons—collaborating
the first treatment. We don’t resort
Director of the American Board of
for the common goal of trying to make
to surgery until the patient has had
Otolaryngology (1998–2004) and
life better for our patients. The past
medical treatment that may include a
President of the American College of
saw many turf wars in surgery, and
course of antibiotics. Thus the specialty
Surgeons (2007–2008).
145
The Large and the Small of It Advances in Pediatric Surgery by THOMAS V. WHALEN, MD, MMM, FACS
Looking back on his career, former U.S. Surgeon General C. Everett Koop, MD, FACS, reflected that prior to the 1960s, children “did not get a fair shake in surgery.” The reasons were many but chiefly because surgeons, Dr. Koop remembered, were frightened of children. “They distrusted the ability of
children injured in the fateful Halifax
coup. Nevertheless, the operation set
anesthetists to wake children up after
Explosion of 1917 inspired him to
a precedent for surgical correction of
putting them to sleep, a position not
focus on pediatrics and keep accurate
congenital cardiac malformations and
far from that of many anesthetists.
medical records of symptoms, surgical
pediatric surgery in general.
The younger and smaller the patient,
procedures, and outcomes. In 1927, he
The clinical material that Dr. Ladd
the more significant the hazard.”
became surgeon-in-chief at Children’s
and others had been recording for years
The hazards were significant to be
Hospital in Boston. There he estab-
at Children’s was compiled by Dr. Gross,
sure. Before the 1940s, the survival
lished the first pediatric surgical
and in 1941 a book was published,
rate for infants born with defects
training program, which produced
Abdominal Surgery of Infancy and
like esophageal atresia and tracheo-
the man many regard as the father of
Childhood, by Ladd and Gross.
esophageal fistula (incomplete forma-
American pediatric surgery.
It was the first pediatric surgery
tion of the trachea and esophagus in
Robert E. Gross, MD, was born in
text, and while it featured material
the womb) was zero percent. There
Baltimore, MD, and graduated from
on infants and children, the prevailing
was no curative surgery for common
Harvard Medical School in 1931 before
contemporary surgical emphasis was
congenital problems like patent ductus
residency at Peter Bent Brigham
on the period from birth to infancy.
arteriosus (PDA—the failed closing
Hospital and later Children’s Hospital
Venturing into small humans to
of a blood passage from the right to
in Boston under Dr. Ladd. Despite
operate was daunting given the tech-
the left side of the heart). Congenital
having vision in only one eye, he was
nology of the time, but a handful of
diaphragmatic hernia (through the
a talented and bold surgeon. Both
surgeons were willing to try.
foramen of Bochdalek) had 85 percent
qualities were demonstrated when
Cameron Haight, a California-born,
mortality within 24 hours of birth and
he successfully ligated (tied together/
Harvard-educated surgeon at the
8 percent overall survival from birth.
closed) a patent ductus arteriosis in a
University of Michigan was one. In
7-year-old girl in August 1938.
1941, he performed the first successful
As serious as these defects were, a number of surgeons like Dr. Koop real-
Dr. Gross had carefully planned this
staged repair of esophageal atresia
ized they were potentially correctable
operation by practicing it in the post-
and tracheoesophageal fistula (TEF).
operative conditions and that the quality
mortem room and animal laboratory
The implications of the successful
of surgical care available to infants and
but famously did it when his mentor,
procedure were huge.
children was simply not good enough.
Dr. Ladd, was on summer vacation. Dr.
Esophageal atresia, TEF, and intes-
The first to really act to create
Ladd surely would not have permitted
tinal atresia essentially created respi-
a pediatric surgical specialty was
Dr. Gross to undertake the proce-
ratory complications resulting in death.
William E. Ladd, MD, a Boston, MA,
dure, and, though it was a success, he
Typically, the proximal blind end of the
surgeon whose experience treating
never forgave Gross for the surgical
esophagus would quickly and always
147
experience gained during World War II, suggested a need for recognition of the pediatric surgical field. This became a reality at the 1948 annual meeting of the American Academy of Pediatrics (which had itself formed in 1930) in Atlantic City, NJ. There, pediatric surgeons came together to form the Surgical Section of the Academy recognized by the AAP in 1949. Dr. Gross and Dr. Koop along with others from the “Boston School” of pediatric surgery were a driving force in formation of the Surgical Section, which facilitated both collegiality and peer discussion at a time when pediatric surgeons were spread across a handful of locations from Boston and Philadelphia to San Francisco. Annual gatherings had increased importance in an era when simple transcontinental phone calls were expensive and not universally available. The Surgical Section was also a forum—though an imperfect one— from which to gain recognition as a viable surgical sub-specialty apart C. Everett Koop examines an infant.
from general surgery or pediatrics.
In 1948, the first successful surgical
an article for the journal Annals of
the trachea and the lungs. Worse yet,
repair of a fetal abdominal wall defect
Surgery, the inclusion of the Surgical
the distal end would bring stomach
was accomplished when Dr. Gross
Section within the AAP was a difficult
acid up into the trachea and the lungs.
reported successfully excising the
marriage, the result of which was
That would set up an intense chemical
omphalocele sac and covering it with
that “for the next 20 years the estab-
pneumonitis followed by bacterial
skin grafts. An omphalocele (rupture)
lished surgical fraternity considered
pneumonitis from the saliva.
is a birth defect in which the infant's
pediatric surgeons to be the technical
Adding to these complications, there
intestine or other abdominal organs
operative arm of the pediatricians,
was no way to feed affected babies
fail to retract into the abdominal cavity
not real surgeons!”
because intravenous parenteral nutri-
in utero and stick out of the umbilicus
An illustration of prevailing attitudes
tion was not developed (by Stanley
(navel). In babies with an omphalocele,
was that through the 1960s, pediatric
Dudrick, MD, FACS, and associates
the intestines are covered only by a
surgeons were not allowed to have inde-
in Philadelphia) until 1968. Following
thin layer of tissue and can be easily
pendent admitting privileges for children
Dr. Haight, Dr. Gross subsequently
seen. Prior to this surgical procedure,
at a majority of children’s hospitals.
performed the first single-stage repair.
little could be done for newborns with
These patients had to be admitted by a
As a result, the survival rate for full-
this and other associated birth defects.
pediatrician. A pediatric surgeon could
term babies with these conditions has
These adva nces a nd out side
participate and operate but only when
climbed to nearly 100 percent.
148
developments, some stemming from
asked by the attending pediatrician.
NIH NATIONAL LIBRARY OF MEDICINE
As J. Alex Haller, MD, recounted in overfill with saliva that would spill into
But surgeons with pediatric training
Section of the AAP that formed in 1966
the work of established pediatric
were coming into positions of respon-
and was headed by William Clatworthy,
surgeons and a second generation of
sibility throughout the United States.
MD, of Columbus Children’s Hospital.
surgeons developing new techniques.
Through the 1950s and ’60s, Dr. Gross
Under Dr. Clatworthy’s leadership, the
One of these was Dr. Dudrick, a
trained 69 pediatric surgeons, many of
directors of approximately 20 unregu-
University of Pennsylvania School of
whom founded training programs in
lated training programs for pediatric
Medicine graduate and general surgeon
medical centers around the country,
surgery in the U.S. and Canada estab-
who, in 1964, pioneered research into
joining others from the broader Boston
lished criteria for training that included
a specialized central venous feeding
School. Dr. Gross defined the format
board certification in general surgery
technique known as intravenous hyper-
of training to be a three-year pyramid
and two additional years of specialized
alimentation (IVH), or total parenteral
for residents with previous training. To
training in children’s surgery.
nutrition (TPN). The development and
assure continuity, Dr. Gross staggered
Meanwhile, the first issue of the
subsequent clinical application of TPN
the start of the residents’ training,
only publication dedicated to pedi-
in pediatric surgery were confirmed
which included a first-year junior resi-
atric surgery—the Journal of Pediatric
when an infant with malrotation and
dency, a second-year senior residency,
Surgery—appeared in February 1966.
midgut volvulus (rotation of the gut and
and a following year as chief resident.
Before its publication, pediatric
its constituents—small bowel, cecum,
As a result, an increasing number
surgeons had to review either non-
ligament of Treitz—and twisting of
of pediatric surgery training programs
surgical pediatric literature or general
abdominal blood vessels) survived
“self-declared” in hospitals across the
surgical literature for relevant infor-
corrective surgery despite severe short
country. Oversight was provided by a
mation. The Journal’s editor-in-chief
bowel syndrome with the use of TPN at
voluntary committee of the Surgical
was Dr. Koop and it brought together
the Children’s Hospital of Philadelphia.
Children’s Hospital of Wisconsin congratulates the American College of Surgeons for providing a century of support in advancing and improving children’s surgical care and standards. The Pediatric Surgical Program at Children’s Hospital of Wisconsin in Milwaukee is one of the largest in the nation and includes all pediatric surgical specialties. We have expertise in traditional and minimally invasive general and thoracic procedures. Our program has achieved national recognition in surgical outcomes and
Visit chw.org/surgery.
120681
training pediatric surgeons.
Department of
Surgery 8 OE 4USFFU 4JPVY 'BMMT 4%
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Another advance in the surgical treatment of congenital abdominal wall defects was achieved in 1967 when S. R. Schuster, MD, reported the first staged closure of gastroschisis at Boston Children’s Hospital. Gastroschisis is a small, abnormal opening adjacent to the umbilicus from which the fetal bowel hangs out uncovered in the amniotic fluid. The defect was untreatable until Dr. Schuster described a method involving plastic IV bags sewn to the abdominal
The 1948 annual meeting of the American Academy of Pediatrics.
NIH NATIONAL LIBRARY OF MEDICINE
wall and then together into a silo covering the exposed bowel. Each day
of general surgical residency. They
produce the latest in instrumentation
thereafter, the silo would be squeezed
would then become board eligible
in a timely fashion. Such is the case
progressively tighter, putting more
and certified in the general surgical
with robotics. While robotic pediatric
bowel back into the abdominal cavity
field whereupon they were required
procedures have been tried, they have
while expanding the cavity to accom-
to do an additional two years of
not caught on widely because acqui-
modate it. This progressive staged
pediatric surgery residency to be
sition and maintenance costs are
closure was subsequently modified
eligible for pediatric surgery boards.
high and the single-source provider
and today the use of manufactured
Today, the ABS has separate certifi-
of surgical robotics lacks sufficient
pre-formed, sterilized silos has
cates numbering only four; pediatric
market incentive to produce special-
made a leap in the treatment of large
surgery was the first, followed by
ized robotic instrumentation.
omphaloceles and gastroschisis, with
vascular surgery, surgical critical
By the early 1980s, the next pedi-
much reduced mortality rates.
care, and advanced surgical oncology.
atric surgical advance had been
The establishment of new pediatric
Though developments in pediatric
demonstrated and it represented a
surgery training programs nation-
surgical techniques and training
paradigm shift. Michael Harrison,
wide combined with the training of
progressed steadily, the development
MD, had only recently completed
more pediatric surgeons provided
of instruments and other specialized
his pediatric surgery residency at
impetus for the formation of an inde-
medical devices has lagged. This
Children's Hospital Los A ngeles
pendent American Pediatric Surgical
is chiefly because of the relatively
when in 1981, along with colleagues
Association in 1970 with Dr. Gross as
small commercial market for pedi-
from the University of California,
the first president. With their own
atric surgical devices as opposed to
San Francisco (UCSF), he performed
specialty training requirements and
demand for adult surgical instrumen-
fetal surgery for hydronephrosis, a
an independent surgical organization,
tation. For example, the increasingly
condition in which a baby’s ureters
pediatric surgeons were in position to
commonplace laparoscopic removal
are blocked and urine is not made
ask the American Board of Surgery
of gallbladders in adults in the
effectively, leading to kidney damage.
(ABS) to recognize the discipline
1980s was not immediately adopted
Operating in utero, though concep-
with a special certificate. This it did
by pediatric surgeons because the
tually possible, was met with signifi-
in 1972, further establishing the
instruments were simply too large
cant skepticism. Though the first
legitimacy and distinction of pediatric
to be effective in the small children
fetus did not survive, Dr. Harrison
surgery as a sub-specialty.
operated upon.
showed that the process was tech-
Finally, in 1973, the ABS delineated
The market dynamics of pediatric
nically feasible. The procedure was
the certification process for pedi-
surgery are such that there has not
complimented by the first successful
atric surgeons who were required to
been enough profit incentive for the
sonographically guided placement of
undertake a minimum of five years
medical device manufacturers to
a fetal urinary catheter at UCSF the
151
Department of Surgery YaleSurgery.org
Here’s to the next 100 years. Times change. But our shared commitment to high standards and better outcomes will always be the same. We’re proud of the partnership we’ve forged with the American College of Surgeons over the years. And no matter what the future holds, we will always be there supporting the vital role you have in improving the quality* of patient care. *Quality of care is a major focus for University of Utah Health Care, which recently ranked in the top 10 nationally by University HealthSystem Consortium.
laparoscopically, as is pediatric appendectomy. Though rare i n infants, appendicitis is prevalent enough in children to make it the second most frequently performed pediatric surgery. Despite trailing usage in adult surgery, robotics are beginning to become more accepted in the pediatric field; benefits (less scarring, greater precision, magnified vision) are being demonstrated in places like Seattle Children’s Hospital, where John Michael Harrison
Meehan, MD, and Thomas Lendvay,
PHOTO COURTESY OF UCSF FETAL TREATMENT CENTER
MD, are performing novel procedures same year. That fetus survived this
Around the same time Dr. Harrison
less extensive intervention and the
was pioneering fetal surgery in
As the ACS celebrates a century of
adult continues to communicate with
California, Alberto Peña, MD, laid
improving the vitality and quality
the university team today.
using the da Vinci Si Surgical System.
the foundation for greatly improved
of life of Americans, it’s fitting and
The focus of fetal intervention
surgical treatment of another congen-
personally gratifying to note that pedi-
shifted to congenital diaphragmatic
ital defect: imperforate anus. In these
atric surgeons represent the highest
hernia (CDH), a hole, usually in the
cases, the opening to the anus from
percentage of ACS Fellows of any disci-
left side of the diaphragm, such that
the rectum is missing or blocked. The
pline. Equally satisfying is the fact that
abdominal content is forced up into
rectum may end in a blind pouch or
the first female president of the College,
the chest, squeezing the lungs, which
may have openings to the urethra,
Kathryn Anderson, MD, FACS (2005
don’t develop normally, resulting in
bladder, base of the penis or scrotum
through 2006), is a pediatric surgeon.
significant difficulty breathing. By the
in boys, or vagina in girls.
Back in the early 2000s, the ACS
early 2000s fetal surgical emphasis
Though rare, the defect was only
recognized that among its 18-strong
had shifted to minimally invasive
partially treatable until Dr. Peña
Board of Regents, some disciplines
techniques including endoscopic and
undertook elegant anatomic studies to
were not represented. Wisely, they
image-guided manipulation.
delineate all of the different muscles of
added three additional Regents, one of
Recent trials in the prenatal treatment
the anal sphincters and improvised the
whom was to be a pediatric surgeon. It
of open spina bifida (myelomeningo-
posterior sagittal approach, an opera-
has been my pleasure to take on this
cele) are showing promise as well. More
tion using a muscle stimulator to, in
role since 2003, and when my term
broadly, it has only been over the past
an open fashion, bring the anus down
finishes in October of this year, the
10 to 15 years that minimally invasive
into the middle of the appropriate anal
College will draw a new Regent from
instrumentation has been sufficiently
sphincters. Though now in his 70s, Dr.
our ranks, reinvigorating the Board
perfected and commercially adopted as
Peña is still operating at Cincinnati
and advocating in all things—large
to allow widespread utilization.
Children’s Hospital. His work dramati-
and small—for pediatric surgeons. Q
A n interesting offshoot of Dr.
cally improved the potential for normal
Harrison’s pioneering work was the
bowel function and stool discharge in
finding that there was essentially no
babies with this defect.
Thomas V. Whalen, MD, MMM, FACS,
scarring left from incisions to the fetus
Today, the most common pedi-
completed his fellowship in Pediatric
once the baby was born. This has given
atric surgical procedure is inguinal
Surgery at the Children’s Hospital of
rise to a continuing scientific investiga-
hernia (IH) repair. IH affects from 0.5
Los Angeles in the early 1980s. He is
tion of fetal healing and the factors that
to 5 percent of all male infants. The
currently Chief Medical Officer at Lehigh
allow for scar-less healing.
procedure is frequently performed
Valley Health Network, Allentown, PA.
153
Plastic Surgery A Story of Innovation BY MARY H. MCGRATH, MD, MPH, FACS
Entering the twentieth century in the U.S., there were no plastic surgeons as we now think of the specialty. Small flaps for facial repair were done occasionally, full thickness skin grafts were used, and the renowned German surgeon Karl Ferdinand von Graefe performed the first cleft palate repair and published Rhinoplastik in 1818. It is believed that the use of the word “plastic” as applied to this type of surgery dates from that time. The word “plastic” is derived from the Greek word “plastikos,” meaning “to mold.” At the outbreak of World War I
including tubed pedicle flaps to
By the time World War II broke
in 1914, there were a handful of
transfer soft tissue and maxillofacial
out, the scope of plastic surgery was
surgeons with modest experience
procedures that revolutionized the
ready to change. During this conflict,
with reconstructive techniques but
treatment of facial skeletal deformity.
treatment of complicated fractures of
no trained corps to treat the devas-
American casualties, initially treated
the extremities and facial skeleton,
tating maxillofacial wounds associ-
and stabilized on the Continent, were
nerve and tendon injuries, paraplegic
ated with trench warfare. Combat
transported home to military hospitals
pressure sores, frostbite, and severe
in Europe produced unprecedented
in the U.S., where the new specialty
burns fell to the plastic surgeon. The
numbers of appalling facial injuries,
was to take shape in North America.
specialty gained stature during the
and a hospital in Sidcup, England, was
The techniques and clinical experi-
war, and when the military plastic
taken over to treat such wounds. It
ence of the battlefield entered civilian
surgeons returned to civilian life,
was in this crucible that the specialty
care, and surgeons began to treat
they brought the skills to deal with a
of plastic surgery was born.
previously irreparable defects and
changed civilian population. People
When the United States entered
expand the limits of care. Particularly
were no longer willing to accept
Europe’s trenches in 1917, a St. Louis,
notable were advancements in skin
congenital defects and facial scars
MO, surgeon, Vilray P. Blair, was sent
grafting, flap construction and delay,
and were prepared to undergo elective
to England with orders to form a U.S.
and awareness of aesthetic outcomes.
surgery to correct these problems.1
military subsection for the treatment
With growing maturity and dispersion
Technical and scientific advances
of maxillofacial injuries. Working with
of the specialty during the 1920s and
soon followed with the introduction of
the English surgeons, Dr. Blair saw
1930s, plastic surgeons began profes-
successful human organ transplanta-
an advantage to partnering dental
sional organizations for the sharing of
tion by Joseph E. Murray, MD, in 1954
surgeons with their knowledge and
knowledge. By 1937, plastic surgery
for which he later received the Nobel
skills with general surgeons in the
had emerged as a distinct specialty,
Prize (Figure 1); the deltopectoral axial-
treatment of soldiers with facial inju-
and the American Board of Plastic
pattern flap by Vahram Y. Bakamjian,
ries. Together, these teams made rapid
Surgery was founded in that year. The
MD, in 1965; craniofacial surgery by
advances and this war experience is
motto on the American Board of Plastic
Paul Louis Tessier in 1967; micro-
described in Harold Gillies’ classic book
Surgery certificate, Ad formam func-
surgical transfer by Harry J. Buncke,
Plastic Surgery of the Face, published
tionem felicitatemque restituendam,
Jr., MD, in 1972; and autologous flap
in 1920. Remarkable surgical innova-
translates as “For restoring form, func-
breast reconstruction in 1978. The
tions arose from wartime devastation,
tion, and well-being.”
pace of innovation has never slowed.
154
a colleague in neurosurgery, devised an intracranial approach to the orbits to mobilize and relocate them medially without damaging either the eye or the brain. This was accomplished successfully in several patients, and when the work was reported at an international meeting in Rome in 1967, the enormity of what Dr. Tessier had done was recognized immediately.2 Over the ensuing years, his concepts led to the creation of the subspecialty of craniofacial surgery, which is now performed by multispecialty surgical teams at craniofacial centers around the world. Dr. Tessier was an honorary member of the American College of Surgeons (ACS) and was presented with the ACS’ Jacobson Innovation Award in 2000. Figure 1. Joseph E. Murray, MD, FACS, (left) of Boston receiving the 1990 Nobel Prize in Physiology or Medicine for his work on organ transplantation.
With the fundamental breakthrough of craniofacial surgery came a richness
JAN COLLSI/SCANPIX
of techniques, ideas, and concepts that With growing sophistication, plastic
impairment and has to face serious
continued to expand as plastic surgery
surgery has matured into areas of
social prejudice when navigating
evolved over subsequent years. The
specialization, of which some are:
through everyday life. Effective
treatment of facial trauma was forever
congenital, maxillofacial, breast
techniques for repair of cleft lip and
changed with the use of extensive
surgery, hand surgery, head and neck
palate had evolved by 1960 when the
subperiosteal dissection through
surgery, skin and soft tissue, aesthetic
Parisian plastic surgeon, Dr. Tessier,
coronal and intraoral approaches,
surgery, body contouring, wound care,
was consulted by a patient with a
direct interosseous osteosynthesis
microsurgery, and burn care. As a rela-
facial deformity unlike any that had
of fractured bones through these
tively small specialty, plastic surgeons
ever been treated. He described it
exposures, and extensive primary
quickly learn about innovations in each
as “prodigious exorbitism with a
bone grafting. Early efforts to correct
of these areas and readily adapt for
monstrous aspect” with severe maxil-
craniofacial asymmetry or deficiency
their own practices the new ideas devel-
lary hypoplasia, exposed eyes, and
relied on a variety of skeletal onlay
oped through the clinical and research
respiratory obstruction. Drawing on
grafts stabilized with wires. Later, the
experience of fellow plastic surgeons.
his experience with facial fractures
development of rigid skeletal fixation
With the breadth of exposure that this
and anomalies, Dr. Tessier worked on
devices and plating systems helped to
collaboration brings, the momentum of
dry skulls and cadavers to delineate
stabilize osteotomy segments more
innovation is not surprising. New solu-
approaches to the problem, and when
accurately and permit more exten-
tions for perplexing clinical problems
he was ready, successfully operated
sive bone grafts. To avoid the need to
are constantly evolving.
on his patient, completely freeing the
remove some of these fixation devices,
facial skeleton from the cranium,
plating systems composed of resorb-
advancing it by 25 mm, and securing it
able biomaterials were constructed.
Craniofacial Surgery
by the novel use of bone grafts. At the
Distraction osteogenesis techniques
The indiv idual w ith craniofa-
same time, he was caring for patients
are used to actively move osteotomy
cial deformity may have functional
with orbital hypertelorism and, with
segments of the mandible or maxilla
155
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while bone induction gradually fills the gaps or lengthens the bone as would natural growth. The process of presurgical workup and procedural planning now takes advantage of advanced craniofacial imaging techniques with three-dimensional modeling and surgical simulation that permit better prediction of surgical outcomes and more accurate information for the patient about risks and benefits. Based on 30 years of experience in multidisciplinary North American trauma units, today the basic principle for managing facial injury is early, definitive treatment as soon as THE FIGURE IS THE FRONT-PLATE FROM VOLUME 4, PEDIATRIC PLASTIC SURGERY, IN PLASTIC SURGERY, 2ND EDITION. MATHES SJ (ED). SAUNDERS ELSEVIER: PHILADELPHIA, 2006
consistent with the patient’s general cond it ion. Ea rly recon st r uct ion improves the quality of the result and reduces the residual deformities that may affect function and appearance. One area of special interest is postnatal growth of the facial structures since children with facial injuries may have posttraumatic facial deformity as a result not only of displacement of bone structures caused by the fractures, but also of faulty or arrested development stemming from the injury. Ongoing inves-
Figure 2. This figure shows some of the surgical approaches and techniques used to treat cleft lip, cleft palate, craniofacial microsomia, velopharyngeal dysfunction, craniosynostosis, hypertelorism, and other facial anomalies.
tigation into the molecular biology of craniofacial bone may lead to an understanding of the etiopathogen-
Microsurgical Free Tissue Transfer
became two of the most important flaps in plastic surgery at that time. As it happened, the design principle
esis of craniofacial deformity. There is a wide spectrum of cranio-
By the early 1970s, the design of tube
of these new flaps was soon to fuse
facial deformity: soft tissue and
pedicle flaps for soft tissue transfer
with another body of innovative work
bone, congenital and developmental,
had changed as plastic surgeons real-
to produce a momentous advance.
traumatic, and tumor resection. For
ized that the inclusion of an identifi-
Simultaneously, Dr. Buncke was
each of these, complex aesthetic and
able artery to nourish the flap would
working in California to develop tech-
functional problems call for individu-
enhance its survival. Flaps with a
niques for vascular reattachment of
alized surgical interventions based
known arterial, or axial, circulation
severed digits. Working with vessels
on fundamental concepts (Figure 2).
supplanted older random pattern
as small as 1 mm in size, he devel-
The volume of activity and the pace of
flaps. The deltopectoral axial-pattern
oped minute metallicized tip sutures,
continuous improvement in this area
flap described by Dr. Bakamjian in
modified delicate instruments for
are striking, and are likely to continue
1965 and the groin flap based on the
use in his procedures, and in March
in the search for an anatomically
superficial circumf lex iliac artery
of 1964 reported the first successful
perfect reconstruction.
described by Ian McGregor in 1972
rabbit ear replantation to the Plastic
157
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Surgical Research Council meeting.
thrombosis can occur when kinking
In 1966, he performed the first great
or compression of vessels by hema-
toe-to-thumb transplant in the rhesus
toma or edema leads to decreased
monkey. Shigeo Komatsu, MD, and
inflow. Even with a technically perfect
Susumu Tamai, MD, did the first
anastomosis, there can be failure of
human digital replantation in 1968.
reperfusion in an ischemic organ after
Dr. Buncke perfected his techniques,
reestablishment of blood supply. This
and by 1969 he was ready to perform
is termed the no-reflow phenomenon
microsurgery in the human; he and
and the mechanism is thought to be
Donald McLean, MD, transferred the
due to endothelial injury, platelet
omentum by microvascular techniques
aggregation, and leakage of intravas-
to fill a large scalp defect. From there,
cular fluid; the severity of this effect
Dr. Buncke went on to many micro-
correlates with ischemia time.
vascular “firsts,” among them a great
Microvascular flap transfer remains
toe-to-thumb transfer, serratus muscle
technically demanding, with re-explo-
transfer for facial paralysis, and
ration rates ranging from 6 to 25
tongue replant. In 2004, Dr. Buncke was presented with the ACS Jacobson
PHOTOGRAPH IS FROM THE ARTISTRY OF RECONSTRUCTIVE SURGERY: SELECTED CLASSIC CASE STUDIES. BRENT B (ED). CV MOSBY CO: ST. LOUIS, 1987, PAGE 726
Innovation Award for his pioneering work with microsurgery (Figure 3). The two streams of innovation
Figure 3. Harry J. Buncke, Jr., MD, FACS, has been called “the Father of Microsurgery” for his contributions in the history and development of reconstructive microsurgical procedures.
converged at this point. An under-
percent. The use of pharmacologic agents for postoperative anticoagulation is not a uniform practice for elective microvascular transfers since they can increase the chance of hematoma, and even a small collection near
standing of vascular territories and
the anastomotic site can obstruct the
axial flap design existed at the same
and the donor site deformity that will
fragile vessels. Postoperative moni-
time that the frontier of successful
be created with regard to function and
toring is critical since rapid identifi-
anastomosis of vessels with the small
aesthetic appearance.
cation of ischemia allows immediate
diameter of most axial flap vessels
Initially a technical feat of note,
intervention, and salvage rates vary
was reached. Now the door was open
microvascular surgery rapidly became
between 54 to 100 percent in different
for the transfer of skin flaps that were
an integral part of plastic surgery,
series. A number of devices are
completely disconnected from their
an essential element in residency
used for flap monitoring, including
circulatory sources. A microvascular
training programs, and a technology
temperature probes, pulse oximetry,
free tissue transfer, also called a free
that dispersed around the world and
photoplethysmography, handheld
flap, brings distant tissue with a pedi-
into many surgical specialties. Over
pencil Doppler probes (low frequency
cled arterial and venous supply from
time, outcomes have improved to
continuous ultrasonography), and
another part of the body to be anasto-
the point where tissue survival rates
implantable Doppler probes.
mosed to vessels at the recipient site to
for free tissue transfers exceed 95
Microvascular tissue transfer has
reestablish blood flow. The transferred
percent. Getting to this point required
made it possible to bring healthy tissue
tissue may be skin, fat, muscle, fascia,
years of incremental improvements.
to lower limb defects with exposed
bone, nerves, small bowel, large bowel,
Technical precision is required to
bone and orthopedic hardware,
or omentum as needed to reconstruct a
avoid anastomotic failure due to
vascularized fibula to a mandible with
given defect. The goal is to transplant
faults such as narrowing of the lumen,
osteoradionecrosis, and innervated
tissue as similar as possible to replace
sutures tied too loosely so that media
muscle to reanimate the paralyzed
missing components. Selection of tissue
of the vessel is exposed in the gap and
face. Hundreds of surgical procedures
for transfer depends on the size, compo-
clot forms, sutures tied too tightly that
based on this technology have been
sition, and functional capabilities of the
tear through the vessel, or too many
described; it is truly the case that if
tissue needed, technical considerations
sutures with subendothelial expo-
it can be imagined, it can be done. In
such as vessel size and pedicle length,
sure and clot formation. Secondary
addition, the principles and techniques
159
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of microsurgery are under continual refinement. Areas of emphasis include identification of tissue transfers that better suit the needs of the recipient site and minimize donor site sequelae. The latter has led to minimally invasive and endoscopic techniques for harvesting flap tissue through smaller incisions. It has also led to the description of tissue transfers such as perforator flaps that preserve functional muscle and fascia at the donor site and suprafascial free flaps that require supermicrosurgery techniques. Supermicrosurgery is the anastomosis of smaller caliber vessels ranging from 0.3 to 0.8 mm in diameter and means that a flap can be elevated PHOTOGRAPH IS FROM MENICK FJ. DISCUSSION: SIMPLIFYING CHEEK RECONSTRUCTION: A REVIEW OF OVER 400 CASES. PLAST RECONSTR SURG. 2012 JUN;129(6):1300-3
anywhere on the body that a discrete tiny perforator vessel can be identified. With this “freestyle flap,” tissue can be harvested from better concealed parts of the body, but the use of 12-0 nylon sutures with 50- to 30-μm needles can make this “freestyle reconstruction” difficult to learn.3
Restoration Based on Aesthetic Principles Plastic surgery holds dear the belief that optimal reconstructive surgery has an aesthetic component. The dual goals of reconstructive surgery are preservation of life and limb AND restoration of form and function. Over the decades, the conviction that a superior reconstruction should be
Figure 4. (Above, left) This teenager’s nose, orbit, and right cheek were obliterated by a shotgun blast. (Above, right) A cheek flap with a triangular cervical extension is designed, (below, left) and the cheek skin component is advanced to resurface the anterior cheek. (Below, right) The result after facial and nasal repair. Surgical procedures included skin grafting of the right cheek and eyelids, a radial forearm microsurgical free tissue transfer for nasal lining, rib grafts to provide nasal skeletal structure, a three-stage pedicle forehead flap for total external nasal reconstruction, and two cheek skin flaps.
aesthetically correct has driven the search for better methods to reach
to treat specific defects (Figure 4). The
axis of blood supply. The option of
these goals. Merely replacing lost
evolution of muscle and musculocuta-
using muscle as a potential flap was
tissue with a shapeless blob outlined
neous flaps, fascia and fasciocutaneous
noted because muscles have inde-
by scar—viable though it may be—
flaps, tissue expansion, and fat injec-
pendent, intrinsic blood supply. In
does not restore a patient’s identity or
tions have added new dimensions to
1972, Miguel Orticochea, MD, made
satisfy the wish to look normal. This
the plastic surgeon’s skills.4
an important additional observation
means that employing a single surgical
By the early 1970s, the plastic
when he described musculocuta-
approach to a problem is not enough; a
surgery community was familiar
neous perforating vessels supplying
spectrum of procedures may be needed
with the idea of moving tissue on its
a cutaneous territory on superficial
161
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The Eastern Association for the Surgery of Trauma congratulates the American College of Surgeons on its
th
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ACS fellows receive a 20% discount. Use discount code ACS2012. Register at www.amwa-doc.org/join-renew. Eleni Tousimis, MD, FACS, ACS Member and AMWA Board Member Chief Breast Surgery Associate Professor of Clinical Surgery Director of Fellowship Program Georgetown University Hospital
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Congratulations to the American College of Surgeons on their 100th Anniversary.
muscles. He designed a musculocuta-
f lap, the radial forearm f lap, and
temporary prosthesis that is gradually
neous flap, which is a muscle flap with
scapular flap. One of the most useful
enlarged by adding fluid; this expan-
an attached skin island. Appreciated
features of a fasciocutaneous flap is
sion increases the surface area of
immediately, this was the impetus for
that it can be distally based. Unlike
the overlying soft tissue. Over time,
a vigorous 10-year period of contri-
a muscle flap where the dominant
it is not just stretching but actual
butions, among them the definition of
pedicle is closest to the heart, the blood
growth of the skin flap that creates
the cutaneous territories of superfi-
flow in the fascial plexus is multidirec-
an increase in the surface area with
cial muscles, the anatomy of muscles
tional. This means that a flap distally
accompanying increases in collagen
including each one’s arc of rotation,
based on the calf can be rotated to
and ground substance. Expanders
and the application of muscle and
cover the foot and ankle. This obvi-
should be placed under tissue that
musculocutaneous flaps for breast,
ates the need for a free microvascular
best matches the lost tissue. Filling
chest, extremity, and head and neck
transfer and has become a standard
of the expander is initiated about two
reconstruction. Scores of flaps were
for foot coverage. Another advantage
weeks after surgery and continued
described, and breadth of treatable
of the fasciocutaneous flap is that it
at weekly or biweekly intervals. The
deformities increased exponentially.
can confer sensibility if a sensory
patient is ready for the second surgical
Compared with skin f laps, muscle
nerve is included.
procedure when the expanded tissue
flaps are less bulky, less stiff, and
The latest addition to the armamen-
is adequate to produce the desired
more malleable to conform to wounds
tarium of flaps is the perforator flap
effect. At the second surgery, the
with irregular three-dimensional
first described about 10 years ago.
skin is incised through the old scar,
contours. They have more robust blood
An improvement over the musculo-
the expander removed, and the
supply and demonstrate superiority in
cutaneous and fasciocutaneous flaps,
expanded f lap advanced over the
wounds compromised by irradiation
it relies on evidence that neither a
defect. It is important to confirm that
or infection. The vascular anatomy
muscle nor a fascial plexus of vessels
the expanded tissue will replace the
is predictable and easily identifiable,
is necessary for flap survival provided
defect before excising the defect. If
and the muscle can be put into use as
the single muscu locutaneous or
it is not sufficient, this is handled by
a functional unit for a dynamic tissue
fasciocutaneous vessel is care-
subtotal resection of the defect and
transfer. A major consideration with
fully dissected out and preserved.
leaving the expander in place for
muscle flaps is whether the loss of
Advantages include preservation
a second round of expansion.5 The
function at the donor site is accept-
of functional muscle and fascia at
advantages of expansion are the
able. In an effort to limit the func-
the donor site and versatility of flap
provision of matching tissue for recon-
tional loss associated with use of an
design with regard to including as
struction, normal sensibility of the
entire muscle, methods of functional
little or as much tissue as required.
transferred tissue, a donor defect that
preservation have been devised. If
The disadvantages are the difficult
is negligible, and enhanced success
some portion of the muscle chosen as
dissection needed to isolate the perfo-
of pre-expanded traditional f laps
the flap is left innervated and attached
rator vessels, anatomic variability
due to enhanced vascularity. Tissue
at its insertion and origin, function
of position and size of perforator
expansion also can be combined with
is preserved after transfer of the
vessels, short pedicle length avail-
other reconstructive techniques. For
remainder of the muscle.
able, and the fragile nature of these
example, expander placement in
small blood vessels.
either the subcutaneous or submus-
In the 1980s, the observation of
cular plane can facilitate later repair
septocutaneous perforating vessels
Even as work was ongoing to find
to the overlying skin circulation led
flaps to fit specific needs with less
to the description of fasciocutaneous
bulk and less donor site morbidity,
Lipotransfer, or autologous fat
flaps. By including the deep fascia and
another technique was maturing.
injection, is an area of current
its regional fascial vascular system,
Tissue expansion uses a mechanical
interest in plastic surgery. In the last
specif ic f laps could be designed
stimulus to induce tissue growth in
few years, autologous fat injections
and some have come into wide use,
order to create soft tissue for recon-
for volume restoration have shown
including the anterior lateral thigh
structive use. It involves implanting a
the surprising benefit of appearing
of abdominal wall hernias.6
163
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to reverse atrophic skin changes and
The Future of the Specialty
Mary H. McGrath, MD, MPH, FACS, is Professor of Surgery in the Division
soften areas of scarring. Fat grafting is a technique-dependent procedure
Pla st ic su rger y cont i nues t o
of Plastic Surgery and Associate
where atraumatic handling and
evolve w ith new approaches for
Chair of the Department of Surgery
methodical layering of the autologous
the care of people with congenital
at the University of California, San
fat is emphasized for long-lasting
and acq u i red deform ities. With
Francisco. She is a member of the
results. An unexpected finding is that
therapeutic advances in medicine
Board of Commissioners for The
in addition to volume restoration, fat
and surgery, new problems emerge
Joint Commission and a member of
grafting seems to have a rejuvenative
that call for novel reconstructive
the Plastic Surgery Residency Review
effect on the skin itself. When fat is
techniques. Challenged by these
Committee. She was First Vice-
injected beneath depressed scars, not
difficult problems, plastic surgery
President of the American College
only the indentation but the character
continues to look for ways to treat
of Surgeons in 2008 and is a former
of the skin itself appear to improve.
life- and limb-threatening problems
member of the ACS Board of Regents
With reports of the transforma-
and at the same time restore form,
and former Vice-Chair of the Board
tive power of fat grafted in areas of
function, and well-being. Chest wall,
of Regents.
radiation damage, chronic ulcers, and
abdominal wall, and perineal recon-
other defects, there is much interest
struction are progressing rapidly,
in documenting the extent and identi-
and defects that were incapacitating
7
a decade ago are now correctable.
With the ongoing advances in recon-
Lower extremity salvage after devas-
structive and aesthetic surgery, it is
tating injury is commonplace. With
no longer necessary to be limited to a
the advent of new specialties such
single surgical approach to a problem.
as bariatric surgery, entirely new
As illustrated by Frederick J. Menick,
needs for plastic surgery emerge.
MD, in Figure 4, procedures are
Old techniques, such as perforator
combined to effectively treat specific
flaps, continue to evolve and supply
defects on an individualized basis.
more perfect ways to reconstruct
This integrated approach means
defects. Facial transplantation is
that an advanced technique such as
an option for a select number of
microvascular tissue transfer may be
severely d isf ig u red i nd iv idua ls,
feasible, but a simpler approach with
for whom it can provide a better
tissue expansion may produce a supe-
functional and aesthetic outcome
rior result for a defect where color,
than conventional reconstructive
thickness, and texture are important.
methods. From empiric observa-
A musculocutaneous flap may restore
tions come new techniques such as
lost bulk, but fat injections can be
fat grafting, which may revolutionize
added to perfect the contour at the
clinical practice. From the research
margins of the flap. Selecting the best
laboratory come tissue engineering,
treatment modality requires a system-
gene therapy, and stem cell work
atic approach to patient care through
that will change reconstruction in
the key phases of management. The
unforeseeable ways in the future.
steps in this surgical decision making
The search continues for the most
process are: defect analysis, assess-
reliable, durable, and aesthetic ways
ment of surgical options, identifica-
to, as Gaspare Tagliacozzi wrote in
tion of surgical goals, execution of
1597, “restore, repair, and make
the operative procedure, and result
whole those parts ... which fortune
fying the mechanism of these effects.
analysis or outcome evaluation.
8
References 1. McCarthy JG. Introduction to Plastic Surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders Co; 1990:1-68. 2. Jones, BM. Paul Louis Tessier: Plastic surgeon who revolutionized the treatment of facial deformity. J Plast Reconstr Aesthetic Surgery. 2008;61(9):1005-1007. 3. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg. 2009;123(1):230-235. 4. McGrath MH, Pomerantz J. Plastic surgery. In: CM Townsend, RD Beauchamp, BM Evers, KL Mattox, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia: Elsevier Saunders; 2012;1916-1951. 5. Argenta LC, Marks MW. Principles of tissue expansion. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2006;539-567. 6. Tran NV, Petty PM, Bite U, Clay RP, Johnson CH, Arnold PG. Tissue expansion-assisted closure of massive ventral hernias. J Am Coll Surg. 2003;196(3):484-488. 7. Rigotti G, Marchi A, Galiè M, Baroni G, Banati D, Krampera M, Pasini A, Sbarbati A. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119(5):1409-1422. 8. Mathes SJ, Nahai, R. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchhill Livingstone; 1997: 10-36. 9. Tagliacozzi G. De Curtorum chirurgia per Insitionem. Venice: Gaspare Bindoni; 1597.
has taken away.”9 Q
165
History of the Committee on Trauma “He who wishes to be a surgeon should go to war.”—Hippocrates by DONALD D. TRUNKEY, MD, FACS
The most widely read previous history on the Committee on Trauma (COT) was authored by George W. Stephenson, MD, FACS, and published in the Journal of the American College of Surgeons in 1979. It would be impudent and even crass for me to attempt a history as complete and well-written as Dr. Stephenson has presented. I have to comment, however, on his title, “The Committee on Trauma: Its Men and Its Mission.” In 2012, the appropriate title would be, “The Committee on Trauma: Its Men and Women and Its Mission.” My effort will be to give some background that begins in the late 1800s and introduces societal needs, and to trace the evolution of trauma care during this period of time through military conflicts to the present. In addition, I will conclude with comments on the committee’s efforts since Dr. Stephenson ended his history in 1980. Antiseptic Surgery: A Fundamental Difference in the Care of Fractures
each day that the number of such germs
healed. Lister used carbolic acid not
is insignificant compared to those in the
only in the wound but also sprayed the
dust on the surface of objects or in the
atmosphere around the operative field
clearest of ordinary water.”
and table. Other antiseptics such as
In 1878, Louis Pasteur presented
It was a Scottish surgeon, Joseph
a paper on the theory of germs and
Lister (1827–1912), who introduced a
Ironically, Lister’s theories were most
its application to surgery before the
systematic, scientifically based anti-
strongly opposed in his own country but
Academy of Medicine in Paris. He stated,
sepsis in the treatment of wounds in the
were adopted by Continental surgeons
“If I had the honor of being a surgeon,
performance of surgical operations.
in Europe, especially those in Germany.
impressed as I am with the dangers of
He made Pasteur’s findings a prag-
In 1876, Lister traveled to the United
exposure to the germs and microbes
matic adjunct to all surgical sepsis.
States, where he spoke about his anti-
scattered on the surface of all objects,
Lister learned of Pasteur’s method of
septic dressings at the International
particularly in hospitals, not only would
destroying bacteria by excessive heat,
Medical Congress in Philadelphia, PA.
I use only perfectly clean instruments,
but he knew that would not be possible
The presentation lasted three hours,
but after washing my hands with the
in surgical procedures. He turned to
but post-meeting, American surgeons
greatest care and submitting them to
chemical antisepsis and experimented
remained unconvinced of the meth-
a rapid flaming, which would cause no
with using chloride and sulfides, but
od’s efficacy. As late as 1883, at the
more discomfort than a smoker feels
finally decided to use carbolic acid.
first official meeting of the American
in passing a burning coal from one
He instilled carbolic acid into wounds
Surgical Association (ASA), more
hand to the other. I would never use
but learned that it could be equally
speakers opposed Listerian practices
water which had not been submitted
effective in decreased concentration.
than supported them.
to a temperature of 110–120 degrees
In 1865, he successfully employed this
Another attempt was made by
[Celsius]. All this is practical. In this
process in the case of a compound
European surgeons to convince
way, I would have to fear only the germs
fracture in the tibia of an 11-year-old
the United States that operative
in suspension in the air around the
boy. He found that the fracture had
management of fractures was appro-
[patient’s] bed but observation shows us
united and that the sore was entirely
priate, particularly if conservative
166
Dakin’s solution were also used.
management failed. Sir Arbuthnot
non-operative methods of reposition
Lane, a British surgeon, visited the
used are entirely inadequate. 3) That
United States and advocated open
when proper, non-operative methods
treatment and internal fixation of frac-
are used, good results are obtained.”
tures. This generated the same type
It took Scudder a significant amount
of controversy that followed the ASA
of time to come to the conclusions
meeting in 1883. The ASA committee
that he presented in his Oration on
that heard this presentation demurred
Fractures. Operative management of
and asked to continue gathering infor-
fractures did not get total acceptance
mation using a report it had devised. Incredibly, an irony was in the
in the United States until the end of Charles Scudder
NIH NATIONAL LIBRARY OF MEDICINE
making. In May 1922, Charles Scudder,
World War II; German surgeons had treated U.S. prisoners of war by opera-
MD, appeared before the American
and of that amount, $20 million was
tive internal fixation using Kuntscher
College of Surgeons (ACS) Board of
paid for the treatment of fractures.”
rods. All had successfully healed and
Regents and presented the problem
He articulated one other advance-
of traumatic surgery and fractures in
ment, which was direct and indirect
particular. This led to organization
research into the processes of repair,
of the Committee on Fractures. Dr.
involving physical, chemical, physi-
Scudder was appointed as the first
ological, and pathologic studies. In
chairman and immediately organized
closing his oration, Scudder was terse:
his committee with appointment of 12
“Twenty years ago, at the time of the
There were several societal issues
of his members as area chairmen and
popularization and exploitation of the
that would impact the Committee
66 as local chairmen. Scudder did not
operative treatment of fractures, I said
on Fractures and subsequently the
embrace Listerian antisepsis and was
in Atlantic City, in opening the discus-
Committee on Trauma. In the 1880s,
lukewarm on open repair of fractures.
sion of Sir Arbuthnot Lane’s paper: ‘We
Otto von Bismarck, the minister presi-
Dr. Scudder delivered the first
are not ready for the popularization of
dent of the Kingdom of Prussia, insti-
Oration on Fractures (which evolved
the operative fracture treatment in the
tuted social legislation that included
into the annual Scudder Oration) in
country. We should advance fracture
the first system of socialized medicine
October 1929. He prefaced his paper
treatment by developing non-operative
as well as accident insurance. The
by stating, “Many problems which
methods.’ Gentlemen, time has proved
health care system, which served as
arise in the treatment of fractures are
that opinion expressed in 1909.” He
a model for other countries, placed
yet unsolved. Let me enumerate a few:
then went on to say, “I believe the situ-
emphasis on trauma care (although
1) The securing of accurate records of
ation in this country is changed and is
a formalized statewide trauma care
clinical observations, which can serve
as follows: The operative treatment of
system in Germany would not come
as the basis for dependable conclu-
fractures has become a firmly estab-
into fruition until 1975).
sions. 2) The understanding of the
lished practice. It is based upon neces-
Prior to World War I, the No. 1
relation of fractures to industry. 3) The
sity, asepsis, and a clearer knowledge
cause of compound fractures (open)
necessity for sound, ethical practices.
of the pathology of repair. It is a safe
was industrial accidents. (Motor
4) The further development of new
and sound treatment. It is no longer
vehicle accidents did not contribute
methods of treatment. 5) The proper
a method of last resort. It is often the
to mortality and morbidity until much
treatment of the rapidly increasing
method of primary choice. The results
later. The first mortality was in New
number of bizarre and complex types
of such operative treatment when safe-
York City on Sept. 13, 1899, when
of fractures, the results of railroad,
guarded and carried out by compe-
Henry Bliss was struck by an electric-
motor vehicle, and airplane accidents.
tent men are brilliant.” He closed
powered taxicab and killed.) Even
During 1928, about $41 million was
by saying, “My theses tonight are: 1)
after World War I, industrial accidents
spent by the railroads of the country
That surgeons must demand the early
were a leading cause of traumatic
for the treatment of personal injuries,
treatment of fractures. 2) That the
injury. In Stephenson’s history on the
internal fixation plates and rods were finally accepted.
Accident Hospitals and Trauma Centers
167
THE STRENGTH TO HEAL U.S. Army would like to congratulate the American College of Surgeons on their 100th year anniversary. Surgeons are passionate about patient care and contributing to medical knowledge. Army surgeons share the same pride and dedication of their civilian counterparts and have taken the lead in ground-breaking research, such as extreme trauma. If you want to learn alongside some of our countryâ&#x20AC;&#x2122;s leading practitioners performing unprecedented medical techniques and procedures, take advantage of continuing education and professional conferences, and experience the pride that comes with serving our great nation and the Soldiers dedicated to protecting it, take a close look at U.S. Army Health Care Team. Stop by the Army booth #1231 to talk with a member of the U.S. Army Health Care Team or visit us at healthcare.goarmy.com/acs
Š2012. Paid for by the United States Army. All rights reserved.
COT, he points out that Dr. Frederick
and Philadelphia General Hospital.
Besley was able to get information
Others including Charity Hospital in
from the National Board of Casualty
New Orleans, Parkland Hospital in
Insurance Underwriters that showed
Dallas, Los Angeles County Hospital,
that in 1927, there were 23,000 indus-
Cook County Hospital, San Francisco
trial accidental deaths out of a total
General Hospital and Harborview
of 95,500 accidental deaths. There
Hospita l i n Seat t le were early
were 3,250,000 non-fatal industrial
providers of this trauma care.
accidents; 115,000 employees with permanent partial disabilities; and
Otto von Bismarck
World Wars I and II
1,150 more totally disabled, at a total cost of $1 billion. This emphasizes
years earlier, was scheduled for
I believe it is safe to say that the
that the COT has had a need to docu-
closure, but Gissane made a powerful
United States military has always
ment injuries and to use this informa-
argument to keep it open and use it
had an influence on the treatment of
tion in developing strategies that can
as an accident hospital. Thus, the
civilian trauma, by virtue of medical
reduce disability and return workers
Birmingham Accident Hospital was
advances pioneered on battlefields as
to gainful employment.
born and has arguably been labeled
well as through its efforts—force orga-
as the first civilian trauma center.
nization and evacuation practices—to
LIBRARY OF CONGRESS
Such numbers suggested there was a need for hospitals or centers to treat
Dr. Freeark in modest fashion
decrease the time between injury and
traumatic injuries specifically. Bob
referred to the first and only accident
treatment. Many of the members of
Freeark’s Scudder Oration gave an
hospital in North America as the
the ASA, the ACS, and specifically the
early example of an accident hospital,
Maryland Institute for Emergency
COT have served in the armed forces.
one founded by Lorenz Böhler, an
Medical Services, established in
It is noteworthy that in April 1917,
Austrian surgeon. During World War I,
Baltimore in 1968. Although this is
Sir Arthur Balfour and a British mili-
Böhler treated many wounded soldiers
true, Freeark and Bill Blaisdell, MD,
tary mission came to the United States
who had sustained at that time what
in San Francisco both established
to discuss the pressing needs of the
were considered uniformly disabling
trauma services in the county hospi-
allies. He pleaded, “Send us doctors.”
and even fatal gunshot fractures of
tals in which they worked and turned
Britain had too few physicians for its
the extremities. Following the war,
them into legitimate trauma centers.
civilian and military requirements
he endeavored to establish a hospital
In 1966, Cook County Hospital, under
and since the main battlefield was
to care for the victims of traumatic
Dr. Freeark, took care of thousands of
along the Somme River, the French
injury—now due to industrial accidents
patients. Similarly, Dr. Blaisdell over
physicians were overwhelmed. The
(in most cases) rather than combat—
a 12-year period made San Francisco
regular army hospital units at that
where prompt commencement of
General Hospital the only trauma
time could not answer the plea, but
treatment could better the chances for
center in the city of San Francisco.
fortunately, a number of 500-bed Red
positive outcomes. Working with the
The center exists to this day and treats
Cross base hospital units were trained
Workman’s Compensation Board, he
approximately 3,500 cases annually.
and ready for service. Six of these units
established after several years a ward
There is no question that the estab-
(base hospitals 2, 4, 5, 10, 12, and 21)
for the treatment of patients injured at
lishment of trauma centers and public
were ordered to France in May 1917
work. His results were so impressive
hospitals and ultimately university
to support the British Expeditionary
they developed other accident hospi-
hospitals was a stroke of genius since
Force (BEF). The first unit to go was
tals throughout the whole of Austria.
they combined critical care with
George Criles’ base hospital number
Dr. Freeark also mentioned a
teaching and research. A number of
4 from Western Reserve in Lakeside
second pioneer, an Australian by the
these public hospitals included Boston
Hospital in Cleveland. It left New York
name of William Gissane. In 1941,
City Hospital, Bellevue Hospital in
on May 8, and on May 25 assumed
The Queen’s Hospital in Birmingham,
New York City, Shock Trauma in
responsibility for British General
England, which had been built 100
Baltimore, Grady Hospital in Atlanta,
Hospital number 9 at Rouen, France.
169
We’re practicing
BIG MEDICINE in a (pretty darn amazing) small town.
What makes the Department of Surgery at the University of Vermont and Fletcher Allen the first choice for surgeons like James Hebert, Susan MacLennan and Bruce Tranmer? Some might say it’s being a part of a team of nearly 100 surgeons who make up our 13 surgical divisions. Others would say that it’s our focus on academic medicine; the way we strive to foster leading-edge research and innovation; and our strong commitment to putting our patients first. But, the one thing we’d all agree on is that we work, and live, in one of the most amazing towns in the country. UVM.edu/Medicine/Surgery
Harvey Cushing’s base hospital number 5 (Harvard University) at BEF General Hospital number 11 suffered the first U.S. military losses to hostile action. A German bombing raid on the night of Sept. 4, 1917, killed 1st Lt. William T. Fitzsimmons, MC and several enlisted men. Another eight hospitals—6, 8, 9, 15, 17, 18, 27, and 39—joined the British Expeditionary Force.
Walter B. Cannon
A World War II blood transfusion.
Soon after reaching Europe, the early hospitals doubled to 1,000-bed
Offensive of September to November
were utilized, studies were conducted
units. However, there were no accom-
1918 was the American Expeditionary
on primary suture and delayed primary
panying additional personnel. By July
Forces’ largest of the war. The
suture, X-ray machines were used in
1918, only eight of the required 52
Offensive reflected the magnitude of
combat, and increased importance
evacuation hospitals were in France
the medical department’s challenges,
was placed on orthopedic surgery and
to support the 26 combat divi-
but it also stretched an already
physical therapy and rehabilitation.
sions. Evacuation hospitals took the
badly extended medical force to the
Drugs including penicillin and
wounded from the field hospitals for
breaking point. In the course of the
sulfa were introduced in the interwar
initial treatment, stabilization, resus-
operation, 69,832 American and 2,635
years and were a major advance in
citation, and life-saving surgery and
German wounded were treated along
treating infection. They would influ-
passed them by hospital train to the
with 18,864 gas victims and 2,029
ence the care of the wounded both in
rear for more definitive care. Lacking
shell-shock cases for a total of 93,360
peacetime and in war. During World
evacuation hospitals, Merritte Ireland,
casualties. Another 68,760 medical
War II, sulfonamide, sulfathiazole,
MD, the chief surgeon, had to impro-
cases were admitted to hospitals,
sulfadiazine, and others continued as
vise from the existing base hospitals,
many of them with influenza.
drugs for infection. However, the real
NIH NATIONAL LIBRARY OF MEDICINE
often with negative consequences.
Another innovation to support the
revolution was in penicillin, which
In the summer of 1918, Ireland took
American Expeditionary Force was
entered large-scale military distribu-
personnel from the 46 base hospitals
the establishment of five Navy hospi-
tion in 1944. This wonder drug proved
and organized shock and surgical
tals in order to transport casualties
to be the most effective weapon in the
teams to augment the stressed evacua-
back to the U.S. Although hospital
military’s age-old battle against wound
tion hospitals. This solved one problem
ships were protected under the Geneva
infection. Even in the war in the Pacific,
but created another by removing
Conventions, Navy officials noted the
where there were multiple indigenous
surgical personnel when they were
German government did not abide by
diseases, advances were made in
most needed to care for wounded
these agreements, as evidenced by the
treating malaria with synthetic quinine
arriving from the front. Despite
fact that several British hospital ships
called Atabrine. Just as in World War I,
adverse conditions, it was the medical
were sunk by torpedo or shelling.
the frequent use of plasma and whole
and surgical personnel in the Red
Major medical advances came from
blood to maintain blood pressure was
Cross base hospitals—that came from
World War I. Oswald Hope Robertson
one of the most significant treatments
some of the finest medical schools and
championed the first use of blood
of shock during World War II.
hospitals in the U.S. Academic medical
transfusion. The contributions of
During World War II, more than
centers to this day have supported our
Walter B. Cannon are probably the
231,000 seriously wounded and sick
armed forces when put in harm’s way.
most exhaustive and well-written
patients who would not serve again
Amazingly, the total bed capacity
concepts of shock to come out of this
were evacuated to the United States
increased from 30,890 in July 1918
war. His book, published in 1923, is
by hospital ship and airplane from the
to 163,368 in December 1918. It is
just as appropriate now as it was then.
United Kingdom and the Continent.
noteworthy that the Meuse-Argonne
Reconstructive and plastic surgery
Another change in the evacuation of the
171
Helicopters were used to evacuate injured soldiers during the Vietnam War.
injured was in the South Pacific, where
in Japan and then on to Tripler Army
be effective whereas others were
helicopters were used—albeit rarely—
Medical Center and Brooke Army
dismissed because of too many prob-
to evacuate casualties from the remote
Medical Center for care of burn
lems. The most remarkable improve-
jungles to the hospitals in the rear. Of
wounds. Blood was readily available
ment in the care of the wounded was
393,987 South Pacific battle casualties
at forward hospitals. For example,
the time from wounding to the first
treated, 12,523 died for a rate of 3.2
in 1965, 100 units were brought into
surgery, which recently was shown to
percent, the lowest yet attained.
Vietnam; this increased to 38,000
be about 26 minutes. Furthermore, as
units in February 1969. Complex
the patient progressed back through
operat ion s
Later Conflicts
PHOTOS BY BEN EISEMAN
Surgery on a soldier in a field operating room during the Vietnam War.
va sc u la r
the chain of command, it was not atyp-
surgery and neurosurgery routinely
i nclud i ng
ical to return a wounded soldier to the
Five years after the end of World
were performed far forward. The Air
continental United States within 48–72
War II, the war in Korea broke out
Force also acquired its first specially
hours. This was particularly true for
and helicopters revolutionized the
designed air medical jet, the C9A
burn injuries.
chain of evacuation of the wounded.
Nightingale, in August 1968.
The problem of moving the surgeon
The next conflict of note was in
forward was solved by bringing
1990–1991 with the first Gulf War.
wounded back to the Mobile Army
Medical readiness proved to be infe-
Surgical Hospitals (MASHes) and
rior to previous conflicts, which has
From the very onset of the COT, the
even the evacuation hospitals. The
been documented in Government
members worked in a selfless and altru-
time from wounding to surgical care
Accountability Office studies and more
istic approach to trauma care. John W.
was 65–70 minutes. Also for the first
recently in the Excelsior Lecture of
Batdorf, MD, in his reflections for the
time, vascular surgery salvaged many
2011. This was also true for the conflict
75th anniversary, highlighted some of
limbs by repair of blood vessels. The
in Somalia in 1993. Fortunately, the
the early concerns of the Committee.
U.S. Navy hospital ships also served
military, particularly the Air Force,
They were interested in critical care
as floating hospitals off Korea rather
was ready for Iraq and Afghanistan.
area development and head injury
than as medical transports.
Once again, research was carried
priorities. Wound care and hand care
Thoughts on the Committee on Trauma Since 1980
Many advances were made in
out in theater and led to significant
were high on the list. Deke Farrington,
Vietnam, particularly the use of
innovations. Use of tourniquets was
MD, focused in on pre-hospital care in
aircraft to take the patient from the
life-saving and, in some instances,
a paper called “Death in a Ditch.” They
combat area to the MASH hospitals.
limb-saving. Blood was shown to be
also pursued reducing the number of
For the first time, larger aircraft
life-saving, particularly if it was fresh,
funeral homes that owned the ambu-
such as the C-130 and the C-141 were
warm blood. The ratio of plasma,
lance systems. Hand care and burn
used to transport the wounded from
packed red blood cells, and platelets
care posters for emergency rooms
Vietnam to Clark Air Force Base in
was worked out. Local hemostatic
describing various injuries were devel-
the Philippines to Kishini Barracks
agents in injuries also proved to
oped. Dr. Batdorf, Cuth Owens, MD, and
173
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Dedicated to increasing awareness, improving education, training, innovation, research and patient care in the field of HPB Surgery. For more information, please visit ahpba.org and ahpbaconference.org
Henry Cleveland, MD, started an annual trauma course in Las Vegas that was very successful from the beginning. It included nurses, particularly critical care nurses and emergency room nurses. Similar courses were developed in Kansas City and Atlantic City. Dr. Stephenson’s history ended in 1980. Four years before, the Committee came out with the first Optimal Care booklet, which was a It is not uncommon for soldiers who sustain traumatic injuries to receive surgical care of their wounds within 30 minutes.
guideline for development of Level I, II, and III trauma centers. The first document was contentious since it pitted the academic centers against
presented. I met with the Executive
Board of Regents. This included the
very good non-academic centers.
Director of the ACS in September
VIP program, verification of trauma
These issues were addressed in the
1983 and articulated that we wanted
centers was approved, and ATLS
second Optimal Care document.
to translate Advanced Trauma Life
was eventually translated and is now
®
(ATLS ) into Spanish for
offered in multiple countries. One of the
of the COT, and I believe, as I stated
our Latin-American colleagues and
remarkable things accomplished was
in my reflections, this was character-
into French for the Quebec province
the National Trauma Database, which
ized as “stormy.” I did not believe it
in Canada. We also wanted to develop
now has more than 3 million patients
was a contentious tenure, just stormy.
a parallel track for our nursing
in the registry. It is an opportunity for
There were several issues facing the
colleagues so they could take ATLS.
research and a document that can be
Committee. It was very difficult to
Additionally, we had an embryonic
used to improve the COT’s programs.
get programs through the Board of
trauma registry run by Howard
Looking back on the Committee on
Regents. This was not the fault of the
Champion in Washington, DC, but this
Trauma in 1980, I have never worked
Regents because in fact, they were
was turning into a tremendous work-
with a more committed and dedicated
only given certain bits of information
load and we wanted to transfer it to
group of surgeons. The commitment
and what we put forward as poten-
the College. A proposal was sent to the
of the Committee to a public health
tial agenda items were not always
Robert Wood Johnson Foundation and
problem is truly remarkable. The COT
had been approved. Another conten-
works extremely hard and at times, even
tious issue was establishing rosters of
plays hard. One of the reasons that the
trauma centers within the U.S. that
Committee on Trauma is so successful is
might be used by the President’s office
the support staff, which is outstanding. Q
In 1982, I assumed the chairmanship
PHOTO COURTESY OF DR. DONALD D. TRUNKEY / PHOTO COURTESY OF WWW.Z-MEDICA.COM
®
Support
or other VIPs when they traveled. I sent a follow-up letter to C. Rollins Hanlon, MD, which set off a firestorm of letters. Eventually in February of the following
Hemostatic agents, such as QuikClot Combat Gauze®, have proven effective in traumatic injury treatment on the battlefield.
year,
the
Donald D. Trunkey, MD, FACS, a trauma surgeon, served as Chair of the
Executive
Oregon Health & Science University
Committee of the COT met with the
Department of Surgery from 1986 to
Board of Regents, Dr. Hanlon, and the
2001 and continues to be active on
President of the American College of
the trauma call schedule. He headed
Surgeons. The COT was not deterred by
the ACS Committee on Trauma from
the nature of this meeting. Eventually
1982 to 1986 and remains an advocate
we got almost every program that was
for improved trauma care throughout
perceived as contentious through the
Oregon and the United States.
175
A Look Inside Advancements in Urologic Surgery by JACK W. MCANINCH, MD, FACS, FRCSENG (HON)
Urology as we know it today describes the medical and surgical specialty that focuses on the urinary tracts of males and females, and on the reproductive system of males. Urological disorders affect organs including the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs. The origin of the word “urology,”
(from Greek, “lithos,” or stone, and
treat the organs and anatomy addressed
however, derives from uroscopy: the
“tomos,” or cut). Lithotomists, consid-
by the field. That’s where the modern
ancient practice of the inspection of
ered surgeons not physicians, cut
specialty known as urology begins.
urine—its taste, smell, and gradations
bladder stones, employing different
of color—to draw conclusions about
types of incisions into the perineum.
The Cystoscope and the Endoscopic Revolution
the general state of health of the entire
Imperfect as uroscopy and lithotomy
body. From the time of Hippocrates
were, both are at the roots of urology.
(approximately 460 BC–370 BC), and
The two “blind” techniques evolved over
From the inception of medicine,
likely before, uroscopy was viewed as
centuries to deal with a range of geni-
physicians, and more particularly
a legitimate method for determining
tourinary disorders. What was missing
surgeons, desired a way to look inside
the progress or course of diseases
was a method to visualize and visually
the human anatomy to see and study
in general. Diagnosis of individual diseases was secondary. But in an era before rudimentary diagnostic tools, uroscopy was a simple, non-invasive technique whereby physicians might gain insight into urine-forming organs, the urinary tract, and, more generally, the human body’s internal organs. Flawed though violate the tenants of the famed physicians’ Hippocratic Oath—“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art”—may have also promoted its acceptance. The cutting of stones, or calculi, also dates back at least as far as ancient Greece; however, it was left to “specialists,” those who practiced lithotomy
176
The Lichtleiter developed by Phillip Bozzini.
PHOTO COURTESY OF THE AMERICAN COLLEGE OF SURGEONS
it was, the fact that the practice did not
the inner workings of the body. That “look inside” is known as endoscopy. Endoscopy was thousands of years in the making. Over centuries, lithotomists developed various methods (lateral, perineal, and suprapubic lithotomy) and special instruments for crushing or removing calculi, and though they were initially shunned,
A Nitze female cystoscope. The platinum wire filament that provided illumination can be seen in the tip of the instrument. Also visible are the two water irrigation horns for cooling the wire.
ALL PHOTOS COURTESY OF THE WILLIAM P. DIDUSCH CENTER FOR UROLOGIC HISTORY UNLESS OTHERWISE NOTED
they eventurally gained greater public acceptance. Prior to the nineteenth
German physician. Maximilian Nitze’s
The ability for the first time to
century, however, even the most
“cystoscope” is perhaps the most
examine and diagnose intraure-
sophisticated of these techniques
significant contribution to modern
thral and intravesical diseases was
were blind.
urology and the wider landscape of
groundbreaking. But Dr. Nitze also
Surgeons could only insert tubular
medical technology. Designed to look
recognized that the cystoscope could
instruments into the bladder through
inside the bladder, the cystoscope was
be used operatively. Fitted with
which they passed blades, burrs, or
initially comprised of a thin metal tube
cautery cutting loops and knives, the
pincers to feel for, grasp, and crush or
with a water-cooled electric platinum
instrument could remove tumors and
remove stones. The few body cavities
filament lamp at the tip of the instru-
cauterize the tumor bed for the treat-
that could be examined could only be
ment and a lens system to allow a clear
ment of bladder cancer. The device
inspected with the use of specula.
view inside the urinary tract, allowing
gave rise to a large array of special-
It wasn’t until a German army surgeon
the inspection of the urethra. The first
ized instruments or scopes that allow
named Philipp Bozzini conceived and
design was somewhat compromised
us to operate inside the human body.
demonstrated his “Lichtleiter,” or light
by the need for a cumbersome cooling
Among them was the resectoscope,
conductor” in 1806 for the inspection
system for the platinum wire at the tip.
introduced in 1926 by urologist
of the pharynx and the nasal cavities
The device was markedly improved
Maximilian Stern, MD, of New York.
that the first endoscopic instrument
in 1888 when fitted with a miniatur-
The resectoscope incorporated a
debuted. Bozzini’s primitive endo-
ized electric light bulb (the mignon
wide-angle telescope and an electri-
scope consisted of a tube with various
bulb), which eliminated the need for
cally activated wire loop for trans-
attachments that could be inserted
the cooling system and had the added
urethral removal or biopsy of lesions
into a body cavity. A candle and angled
benefit of making the instrument
of the bladder, prostate, or urethra.
mirrors inside the device enabled the
affordable. Thereafter, the cystoscope
Improved and refined, many types of
physician to see inside the cavity.
was widely used and paved the way
resectoscope are in use today.
Though the usefu lness of the
for endoscopy and, later, laparoscopy.
More refined cystoscopes, both rigid
Lichtleiter was initially dismissed it
and flexible, were developed in the
inspired an array of European and
following decades, including examples
American nineteenth century physi-
with fiber-optic lens systems. These
cians and scientists to experiment
and other advances in technology
with the development of endoscopic
paved the way for the endoscopic revo-
dev ices. Pa ra l lel development s
lution in urology and other specialties.
in artificial lighting (from gas to
Laparoscopy was pioneered in 1901
electricity) and the development of
by German physician Georg Kelling.
optics (mirrors and lenses) were
But laparoscopic tools and techniques
incorporated by these pioneers for
advanced most significantly from the
the improvement of early endoscopes.
1950s forward, leading to the modern
The first breakthrough in endoscopy was pioneered in 1877 by another
video and digital/fiber-optic laparoMaximilian Stern
scopes used widely today in urology.
177
human kidney stones. Their successful Stern resectoscope
animal testing program led to a new prototype lithotripter, the HM1 (Human
So effective and popular with
During experiments with shock
Machine). The first human patient was
patients were the minimally invasive
waves created by high-speed water
treated with the HM1 in February 1980.
laparoscopic procedures that they
droplets shot at a target, a Dornier
The first commercially available
quickly overtook American urology
engineer noted the effect on biological
lithotripter debuted in 1984, trans-
in the 1990s. Laparoscopic surgery
tissue (pain as from an electrical
forming urologists’ approach to renal
displaced open surgery in operations
shock) when in contact with the shock
calculi. Further developments led to a
including nephrectomy, cystectomy,
wave setup. The phenomenon led to a
wide range of ESWL devices, including
urinary diversion, radical prostatec-
project funded by the German Ministry
lithotripters utilizing electrohydraulic
tomy, and in transplantation.
of Defense to research the effect of
energy. These common lithotripters
Today, robot-assisted laparoscopy
shock waves on biological structures.
generate a shock wave in an ellipsoidal
allows urologists to perform very precise
Subsequent experiments with high-
reflector located below the patient.
minimally invasive procedures including
speed water droplets proved that it
The sedated or anesthetized patient
prostatectomy. Robots are also making
was possible to destroy kidney stones
lies down in the apparatus' bed, with
it possible for urologic surgeons to
within closed waveguides. Physicists at
the back supported by a water-filled
perform surgery remotely, operating
Dornier were able to fragment stones
coupling device placed at the level of
machines via robots at distant locations.
in an open water bath using shock
kidneys. A fluoroscopic X-ray imaging
waves generated by a light-gas gun.
system or an ultrasound imaging
The shock wave source, located in an
system is used to locate the stone and
ellipsoid reflector, allowed shock wave
aim the treatment. Acoustic pulses of
concentration on a kidney stone.
varying power fragment the stones into
Extracorporeal Shock Wave Lithotripsy Extracorporeal shock wave litho-
The process was known as shock
smaller pieces that then can easily pass
tripsy (ESWL) is another endoscopic
wave lithotripsy, and by the early
through the ureters or the cystic duct.
procedure that revolutionized urologic
1970s, Dornier sought a clinical partner
Millions of ESWL treatments have
surgery. Created as a minimally inva-
to develop the application of ESWL
been successfully performed since the
sive means of treating kidney stones
in humans. Urologists Eisenberger,
1980s and the minimally invasive tech-
(renal calculi) and stones in the gall-
Chaussy, and Forssmann began devel-
nique remains popular. Open surgical
bladder and liver (biliary calculi), the
opment work on a “lithotripter,” experi-
removal of stones has largely disap-
ESWL technique attempts to break up
menting with dogs implanted with
peared from urology and has been
calculi with minimal collateral damage by using an externally applied, focused, high-intensity acoustic pulse. Research into the approach began in the 1970s at the University of Munich by doctors Ferdinand Eisenberger, Christian
Chaussy,
and
Bernd
Forssmann. The effort built on prior investigations done by German aerospace firm Dornier in the late 1960s to study the effects of shock waves produced in supersonic flight on metal fuselage structures. Shock waves such as those produced by raindrops or micrometeorites impacting a fuselage can cause significant metal fatigue.
Christian Chaussey, Ferdinand Eisenberger, and Bernd Forssmann conduct extracorporeal shock wave lithotripsy research.
179
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replaced by ESWL and endoscopic as
combined w ith chemotherapy in
well as percutaneous procedures, all
selected cases are used to treat many
of which represent great advacements.
urologic pelvic cancers. The advent of the prostate-specific antigen, or PSA, screening for prostate cancer in the
Urologic Cancer Treatment
1980s was also a significant if someThe impact of urologic oncology
what controversial advancement. Hugh Young
on most forms of cancer has been
NIH NATIONAL LIBRARY OF MEDICINE
tremendous. Progress in treating
Erectile Dysfunction
testicular cancer in particular, the
MD
most common cancer in males aged
Hospital), who worked to improve the
Impotency has always been a chal-
20 to 39 years, has been near mirac-
technique of transurethral bladder
lenge for urology. Largely untreatable
ulous. Combating testicular tumors
tumor resection using early resecto-
for millennia, erectile dysfunction
with a combined surgical and medical
scopes for basic surgery.
(ED) is also one of the prime complica-
(Sloan-Kettering
Memorial
tions of radical pelvic surgery.
(chemotherapy) approach has dramat-
In 1904, Hugh Young, MD, at Johns
ically improved chances for survival.
Hopkins Hospital, assisted by William
Early efforts for treatment included
As recently as 50 years ago, survival
Stewart Halsted, MD, performed a
home remedies and a considerable
rates were no more than 15 to 20
radical prostatectomy. A perineal
amount of quackery. By the begin-
percent among men. Today, in excess
incision was made, and the seminal
ning of the twentieth century, contem-
of 90 percent of patients treated via
vesicles were also removed. It was
porary therapy addressed lack of
urological surgery and chemotherapy
one of a number of early operations
testosterone primarily. Around 1900,
survive, giving testicular cancer one
to treat prostate cancer that met with
intramuscular injection of dog testic-
of the highest cure rates of all cancers.
limited success. Surgeons at Johns
ular extract was suggested and by the
Orchiectomy, the removal of a
Hopkins, led by Dr. Patrick Walsh,
end of World War I, testicular implan-
testicle aff licted with a cancerous
have continued the advancement of
tation was widely practiced in Europe.
tumor, often performed as robot-
treatment of prostate cancer, utilizing
Ligation of the dorsal vein of the penis
assisted laparoscopy, and retroperi-
the retropubic surgical approach with
was also tried in the 1920s and 1930s
toneal lymph node dissection (surgery
erectile nerve sparing. This has become
but results weren’t impressive.
executed on the retroperitoneal /
a standard accepted worldwide.
Penile implants were first tried in
paraaortic lymph nodes to accurately
Dr. Jewett was one of the early inves-
the mid-1930s using rib cartilage, and
determine whether the cancer is in
tigators of intravesical chemotherapy
by the 1950s experiments with single
stage I or stage II and to reduce the
(treatment via injection of an antineo-
acrylic rod implants were under way.
risk that malignant testicular cancer
plastic drug or with a combination of
Wounds and infections were common.
cells may metastasize to lymph nodes
such drugs directly into the bladder
Silastic (a silicone and plastic combi-
in the lower abdomen) are the most
through a catheter rather than being
nation material) rods were proposed
common surgical procedures.
given by mouth or injected into a vein) in
in the 1960s, but again, perforations and infections were common.
Modern treatments for testicular
the treatment of bladder cancer during
cancer and other genitourinary tumors
the mid-twentieth century. In the late
The first real advance took place
stem from work done early in the twen-
1960s, he reported on his experience of
in 1972 with the introduction of the
tieth century in the treatment of bladder
preoperative radiation therapy followed
inflatable prosthesis by Texas-based
and prostate cancer by several noted
by radical cystectomy. He concluded
urologist Brantley Scott, MD. Dr. Scott’s
urologists. Austrian physician Joseph
that external beam radiation rarely
initial implant was cumbersome and
Grünfeld was a pioneer in transurethral
eradicated all bladder cancer.
plagued by technical drawbacks, but
therapy of bladder cancer, preceding
Today, laparoscopic and robotic
it began modern penile prosthesis, a
urologists including Lawrence Green,
procedures including robotic pros-
technique that advanced through the
MD (Mayo Clinic), Hugh J. Jewett, MD
t at ec t omy, c y s t opro s t at ec t omy,
1980s and 1990s but which became
(Johns Hopkins), and Willet Whitmore,
and anterior pelvic exenteration
secondary by the current century.
181
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ClinicalKey invites you to booth #2722 at the Annual ACS Clinical Conference to experience its breakthrough search capabilities.
Erectile dysfunction treatments
researchers developed the drug, finally
epididymal sperm aspiration, percuta-
introducing it as Viagra in 1998.
neous biopsy of the testis, and micro-
All ED therapies have made a great
surgical epididymal sperm aspiration.
difference to the lives of men, none
Advances in sperm preservation,
more so than modern drugs. Procedures
including cryopreservation or sperm
such as nerve-sparing prostatectomy,
freezing, have helped make possible ex
Development of pharmacological
first introduced in 1982, and minimally
vivo fertilization, or the fertilization of
treatments for ED began in the late
invasive laparoscopic surgery have also
human eggs outside the living organism.
1980s. In 1992, the use of intracaver-
contributed to a decrease in impotency
nosal vassal active agents was demon-
associated with urologic treatments.
strated. The intracavernous injection therapy technique involved the injec-
ART and other developments in reproductive urology are rapidly transforming treatments for infertility,
Reproductive Urology
tion of vasodilator medicine into the
positively impacting the lives of childless couples. In fact, this is one of the
part of the penis having the least
Understanding of the human repro-
sensation. Three principal medica-
ductive process and reproductive
tions—prostaglandin E1, papaverine,
disorders such as infertility has been
and phentolamine—or a mixture of
and continues to be one of the great
two or three of these agents can be
challenges for urology. Advancements
Space permitting, other advance-
self-injected by ED patients.
fastest-advancing fields of urology.
Conclusion
have been many over time, however,
ments including those in treating
The revolutionary development
beginning with the first recorded
urinary incontinence, percutaneous
that overtook other ED treatments
artificial insemination with donor
lithotripsy and nephrostomy for kidney
came in the late 1990s with the first
sperm by Philadelphia physician
stone removal, and the development
pharmacological approach using an
William Pancoast in 1884.
of ureteral stents could be mentioned.
oral agent. The result was the blue ®
Through the 1930s, research into
But I’ll close with this thought:
pill now famously known as Viagra .
reproductive endocrinology and human
Urologic surgery has made its most
The genesis of the drug began with
sexuality laid the groundwork for the
impressive progress over the last two
research into the chemical compound
first experiments in in-vitro fertilization,
to three decades. By way of illustra-
sildenafil for the treatment of angina
undertaken in 1934 by Harvard scientist
tion, I started as a urology resident
at pharmaceutical giant Pfizer.
Gregory Pincus in rabbits. By the 1970s,
in 1964. I probably do less than 20
During clinical trials, the drug was
efforts to fertilize human eggs in the
percent now of what I learned in
found to have little effect on angina
laboratory were successful but artificial
my training. I use many of the same
but researchers noticed an unex-
insemination remained highly contro-
principles that I learned at the begin-
pected side effect. Sildenafil could
versial. Nevertheless, in 1978, the first
ning of my career, but the actual
improve and sustain a man’s penile
“test-tube baby” was born in England.
procedures that I do today are vastly
erection by increasing blood flow to
The success and slow acceptance
different. What we can see and what
the region. Pfizer then stopped the
of in vitro fertilization as a means of
we can do now is amazing. Every day
research on sildenafil as heart medi-
dealing with infertility set the stage for
I go to work I learn something new. Q
cation and initiated investigation on it
the development of a range of male and
for penile erection.
female infertility therapies in the 1980s
Sildenafil was found to increase the muscle relaxing effects of nitric
and 1990s, giving rise to assisted reproductive technology, or ART.
Jack W. McAninch, MD, FACS, FRCSEng (Hon), is Professor of Urology
oxide, a chemical that is released
The field, embraced by urolo-
at the University of California, San
when a person is sexually stimulated.
gists, has resulted in modern treat-
Francisco, and Chief of Urology at
The relaxation of smooth muscle in
ments including sperm harvesting
San Francisco General Hospital. He
the penis facilitates higher rate of
via surgical sperm techniques such
has served as a Regent and as a
blood flow and helps in producing an
as electroejaculation, testicular fine
First Vice-President of the American
erection. Through the 1990s, Pfizer
needle aspiration, percutaneous
College of Surgeons.
183
No Roadblocks Advancements in Vascular Surgery by MAHMOUD MALAS, MD, MHS, FACS, AND JULIE FREISCHLAG, MD, FACS
The story of modern vascular surgery is an international tale. Born in the late 19th century, the field was at first an outgrowth of conflict as doctors in Europe attempted to treat battlefield injuries during the Napoleonic Wars via ligation. Reconstruction or restoration-of-circulation were not truly considerations. Still, it was clear that
Recognition of aneurysmal disease
In simple terms, it’s a surgical proce-
invaginated the proximal end into
f irst surfaced a century earlier.
dure to join together two hollow
the distal vessel, and held it in place
Brothers William and John Hunter,
organs such as blood vessels. Most
with sutures.
Scottish physicians, and English
vascular procedures, including all
But it was another French-born
doctor Astley Cooper brought the
arterial bypass operations, aneurys-
surgeon, Alexis Carrel, who would
treatment of vascular diseases other
mectomies, and solid organ trans-
revolutionize surgery of the vascular
than bleeding associated with trauma
plants, require anastomosis.
system. Dr. Carrel, who emigrated
to the attention of contemporary clini-
Two French physicians, Mathieu
cians. But as in the following century,
Jaboulay and Eugene Briau, made the
ligature was the only method known
initial breakthrough in performing
to deal with such conditions.
what would become anastomosis.
It wasn’t until the late 1800s in
Together, they published a paper in
the wake of the century’s many wars
1896 on an experimental surgery they
that a small group of surgeons began
had performed in dogs in Lyon, France.
to visualize and pioneer the repair
The publication described a technique
and treatment of the circulatory
that consisted of suturing a carotid
system. Since then, the evolution
artery end to end, literally connecting
of vascular surgery—the specialty
two ends of the vessel together using
for the treatment of non-cardiac
an inverted U-shaped suture.
vascular disease—has been a process
The idea took hold in the U.S. at about
of clearing roadblocks, both in the
the same time. Just after Dr. Jaboulay
circulatory system itself and to gain
and Dr. Briau’s work appeared, J. B.
acceptance of the discipline as an
Murphy, MD, an American doctor who
independent specialty.
had experimented with arterial and venous repair in animals, performed
The First Vascular Anastomosis
the first successful circular suture in a human. On October 7, 1896, the Chicago-based physician united
Vascular surgery as we know it in
the ends of a femoral artery injured
the twenty-first century begins with
by a gunshot wound. He excised
the technique known as anastomosis.
the damaged section of the artery,
184
An illustration by J. B. Murphy depicting a suture technique for repairing severed arteries and veins.
NIH NATIONAL LIBRARY OF MEDICINE
amputation, the most frequent outcome of wartime ligation, was less than satisfactory.
hemodialysis. Dr. Carrel’s techniques for anastomosis are considered the foundation of vascular surgery.
The First Aortic Reconstruction and First Bypass to the Lower Extremity The next great step in vascular surgery took place almost a half century after anastomosis was established as the fundamental technique in treating arterial insufficiency. A raft of early advancements from surgical specialists including Rudolph Matas, MD (pioneered endoaneurysmorrhaphy in 1888, the treatment of aneurysms without graft placement), Jay McLean, MD (discovered heparin in 1916, an anticoagulant allowing vascular occlusion without distal thrombosis), Dr. Reynaldo Dos Santos, Alexis Carrel
and Dr. Egas Moniz (developed angi-
NIH NATIONAL LIBRARY OF MEDICINE
ography in 1920, the first diagnostic to America in 1904, worked at both
Interestingly, Dr. Carrel also collab-
roadmap for vascular surgeons), and
the University of Chicago (along
orated with famed pilot and friend,
breakthroughs during World War I
with Charles Guthrie, MD) and the
Charles Lindbergh. Attempting to
and World War II in anesthesia and
Rockefeller Institute for Medical
devise a pump for organ perfusion (the
the transfusion of blood for the treat-
Research in New York City. He built
injection of fluid into a blood vessel
ment of shock set the stage for a huge
upon the early work of Dr. Jaboulay,
in order to reach an organ or tissues,
advancement in the late 1940s.
Dr. Briau, and Dr. Murphy with a
usually to supply nutrients and
The first successful aortic recon-
technique in which he triangulated
oxygen), Carrel enlisted Lindbergh
struction also originated in France.
arteries and sutured them end to end
to aid in engineering such a device.
Three French surgeons, Dr. Jean
with fine needles and suture mate-
Lindbergh came up with a pump
Kunlin, Dr. Charles Dubost, and Dr.
rials. He also devised a side-to-side
that was used for many years at the
Jacques Oudot, undertook the first
anastomosis. From end-to-end and
Rockefeller Institute for preserving
successful reconstructions of the
side-to-side anastomosis, he went on
organs. The device could be consid-
aortoiliac segment for both aneu-
to graft arteries using a vein, then
ered the first pump oxygenator, or
rysmal and occlusive disease.
proceeded to transplant organs from
mechanical heart.
In 1948, Dr. Kunlin, who was a
animal to animal. The work led to Dr.
In 1912, Dr. Carrel received a
trainee and later an assistant to Dr.
Carrel’s development of the “patch-
Nobel Prize for his milestone work in
René Leriche (a student of Dr. Jaboulay
graft” technique of reconstruction. In
anastomosis. It’s the basic technique
who authored more than 1,000 papers
addition, he pioneered the preserva-
vascular surgeons still use today to
on surgery and physiology), performed
tion of blood vessels in cold storage so
bypass blockages in arteries and to
the first successful femoral popliteal
that preserved arteries could be used
create arteriovenous fistulas—doing a
bypass with saphenous vein. He
for days or weeks after harvesting
bypass with a conduit, connecting an
referred to it as “long vein transplan-
from donor animals.
artery to a vein or to a plastic graft for
tation in treatment of ischemia caused
185
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by arteritis [inflammation of the walls
The First Carotid Endarterectomy
of arteries, commonly the result of infection or auto-immune response]” in a 1951 paper on the technique.
The significance of the first carotid
Dr. Kunlin subsequently presented
endarterectomy, the removal of material
eight similar cases the same year,
on the inside of an artery, was its impact
transforming the surgical approach
in lowering the incidence of stroke. The carotid arteries on either side
to profound lower extremity ischemia. Dr. Kunlin’s technique evolved
Rudolph Matas
the beginning of a separation of
for treating AAA. Operating on a
and cholesterol deposits) to form in the
vascular surgery from general and
very famous patient to remove intes-
arteries as humans age. The plaque
cardiac surgery. Today, bypass for limb
tinal cysts at the Jewish Hospital in
can build up on the inner surface of
salvage—relieving arterial blockages
Brooklyn, NY, Dr. Nissen discovered
the artery, narrowing or constricting
that can lead to tissue loss, gangrene,
another problem. Albert Einstein had
it. Small pieces of plaque called emboli
and ultimately the loss of a limb—
a large intact AAA. A brand-new tech-
can break off, traveling up the carotid
accounts for as much as half of the
nique developed over the preceding
artery to the brain where they may
procedures vascular surgeons perform.
decade, which involved wrapping the
block a major cerebral vessel, causing
aorta with polyethene cellophane to
the death of brain tissue and stroke.
The First Open Aortic Aneurysm Repair with Homograft Graft
induce fibrosis (the formation of excess
Dr. DeBakey performed the first
fibrous connective tissue in an organ
carotid endarterectomy in August 1953
or tissue in a reparative or reactive
on a 53-year-old school bus driver.
process) and restricting the growth
Over a two-year period, the patient
Abdominal aortic aneurysms (AAA)
of the aneurysm, was worth a try. Dr.
was having minor strokes in the form
occur when the large blood vessel that
Nissen pulled off the tricky procedure,
of transient ischemic attacks (TIA),
supplies blood to the abdomen, pelvis,
resulting in another seven years of life
losing vision in his eyes temporarily
and legs becomes abnormally large or
for the famed physicist, who died in
or having weakness in his arm or leg.
balloons (dilates) outward. The condi-
1955 when the aneurysm ruptured.
On a hunch, Dr. DeBakey listened to
tion is most often seen in males older
Progress in the development of
than 60 who have one or more risk
homografts and end-to-end anasto-
factors. AAA rupture is a true medical
mosis of the aorta through the 1940s
That sound he heard with his stetho-
emergency and is the 13th leading
paved the way for the first successful
scope indicated that there was an
cause of death in the U.S.
resection of an abdominal aortic
abnormal blood flow through the left
aneurysm with graft replacement.
carotid artery, suggesting a narrowing.
Early attempts to treat A A A via
NIH NATIONAL LIBRARY OF MEDICINE
of the neck supply blood to the brain. Atherosclerosis causes plaque (calcium
dramatically in the U.S. and marked
his neck. He heard a whishing sound referred to as a “bruit.”
ligation were unsuccessful until
On March 29, 1951, Dr. Dubost used
He was able to convince the patient that,
1923, when Dr. Matas successfully
a thoracic aorta, taken three weeks
even though it had not been confirmed
ligated the abdominal aorta (he
earlier from a 20-year-old female, as
medically, the reason for the driver’s
tied the aorta before and after the
a graft. The landmark accomplish-
TIA was a blockage in the carotid artery.
aneurysm) in the treatment of an
ment rapidly changed the perception
Further, Dr. DeBakey persuaded the bus
abdominal aneurysm. The success
of vascular surgery’s potential, and
driver that he could open the artery
was only temporary, however, as the
other successful operations using Dr.
surgically and carve out the plaque to
patient died 18 months later when the
Dubost’s technique were reported by a
fix the problem. Amazingly, the patient
aneurysm eventually ruptured. By
selection of noted surgeons, including
agreed to the untested procedure.
1940, there were only five recorded
the legendary American surgeon
During the surgery, Dr. DeBakey
cases in which ligation had worked.
Michael E. DeBakey, who used his
confirmed his suspicion, discovering
In December 1948, Rudolph Nissen,
wife’s sewing machine to create the
severly stenotic atherosclerotic plaque
first Dacron graft to treat AAA.
with a fresh clot completely occluding
MD, pursued an alternate strategy
187
American College of Surgeons 100th Anniversary
The Society for Vascular Surgery congratulates the American College of Surgeons on its
100th Anniversary. ACS continues to inspire specialty surgical societies to maintain
high standards and improve patient outcomes.
VascularWeb.org
the left artery. He successfully carried out an endarterectomy, restoring circulation. The patient made a full recovery and lived for another 19 years without any further strokes. Doubts lingered about carotid endarterectomy, even decades after Dr. DeBakey’s initial success. Some specialists including neurologists Michael E. DeBakey
disputed its long-term effectiveness. The North American Symptomatic Carotid Endarterectomy Trial (1987–
enabled in three ways—via a cath-
extremity bypass is the creation of
1990) showed clearly that the surgery
eter, an arteriovenous graft, or an
an AV fistula for dialysis.
was more effective than other courses,
arteriovenous (AV) fistula. A fistula
such as taking aspirin. Patients under-
is a surgically created connection of
going endarterectomy experienced
an artery directly to a vein without
less than one-third the rate of recur-
the need for a graft.
ring strokes as those taking aspirin.
AV fistula is the preferred type
The most significant advancement
The techniques introduced in the
of access because when the fistula
in the modern era of vascular surgery
1950s including aortic aneurysm
properly matures, strengthens, and
is the move away from invasive or
repair and carotid endarterectomy
enlarges, it provides vascular access
open vascular surgery to non-invasive
represented breakthroughs for open
with good blood flow that can last for
endovascular surgery.
arterial surgery. The following two
decades. Thereafter, a patient can go
Beginning in the mid-1960s with
decades would see the growth of
two or three times a week for dialysis,
advances such as interventional radi-
operative procedures with advances
puncturing into their own vein to
ology and transluminal angioplasty,
such as the introduction of the cath-
connect to the dialyzer.
the movement toward treatment of vascular disease without the scalpel
eter selective arteriogram, refinement
The first AV fistula for hemodialysis
of prosthetic grafts, revasculariza-
was invented and developed by Kenneth
tion procedures extended to all parts
C. Appell, MD, at Bronx Veterans
The first angioplasty in the leg was
of the body, and the emergence of
Administration Hospital in 1963. Dr.
performed in 1964 by Charles Dotter,
new imaging techniques such as
Appell’s original procedure was a type
MD, and his assistant, Melvin Judkins,
ultrasound, computed tomography
of AV fistula known as a radial-cephalic
MD. Dr. Dotter, who had been instru-
(CT) scan, and magnetic resonance
fistula, between the radial artery and
mental in the development of interven-
imaging (MRI).
the cephalic vein near the wrist.
tional radiology, treated an 82-year-old
The Creation of the First Arteriovenous Fistula for Dialysis
AP PHOTO
The First Endovascular Repair for Aortic Aneurysm
gathered momentum.
Prior to Dr. Appell’s creation of
woman with a blockage of the superficial
the AV or “native fistula” (so called
femoral artery in her left leg with a proce-
because it uses the patient’s own blood
dure he called transluminal angioplasty.
vessels), dialysis was chiefly admin-
The non-invasive technique employed a
istered using tubing and a catheter.
percutaneous dilating catheter.
Dialysis is an artificial replacement
The painful procedure also was prone
A balloon attached to the long tube
for lost kidney function in people with
to problems including bleeding, infec-
catheter was guided by X-ray images
renal failure. The process, performed
tion, erosion, clotting, and the need for
from the femoral artery in the groin to
with the aid of a dialysis machine
the patient to have a bulky dressing in
the blockage and then inflated, thereby
or “dialyzer,” removes wastes and
order to maintain sterility.
opening the artery. The procedure
excess water from the blood normally
Today, the procedure performed
went well and the patient’s blockage
filtered by the kidneys. Hemodialysis,
most often by the average American
was relieved without open surgery.
one of three types of dialysis, can be
vascular surgeon along with lower
However, Dr. Dotter’s philosophy of
189
MERCY HOSPITAL & MEDICAL CENTER SALUTES THE AMERICAN COLLEGE OF SURGEONS AND ITS FELLOWS FOR 100 YEARS OF INSPIRATION, LEADERSHIP AND UNWAVERING COMMITMENT TO EXCELLENCE IN SURGICAL CARE.
L I V I N G
W E L L
I N
T H E
A Member of Trinity Health
www.mercy-chicago.org
C I T Y
non-invasive surgery and his technique
surgery was formally recognized as
were resisted for a number of years by
an independent specialty. Q
many in the medical community. Endovascular surgery didn’t become a reality until almost three decades
Mahmoud Malas, MD, MHS, FACS,
later with the first endovascular repair
is an Associate Professor of Surgery
for aortic aneurysm (EVAR). The non-
at Johns Hopkins University and the
invasive counterpart to invasive open
Director of Endovascular Surgery and of
surgery for AAA, the first EVAR was
The Vascular and Endovascular Clinical
performed in the Soviet Union in 1987
Research Center at Johns Hopkins
by Russian physician Nicholas Volodos.
Illustration of AV fistula for dialysis.
NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES, NATIONAL INSTITUTES OF HEALTH
The procedure, described in a 1988
Bayview Medical Center. Dr. Malas is the Johns Hopkins principal investi-
publication, was relatively rudimen-
and refining existing procedures.
gator for 14 clinical trials, including
tary. The real breakthrough came in
Despite skepticism from specialists in
six trials involving prevention of stroke
1990 when Argentinian surgeon Dr.
other fields, vascular surgeons became
and carotid artery disease treatment
Juan Carlos Parodi implanted the first
global leaders, performing angioplas-
comparing endarterectomy to stenting
stent graft to treat AAA in a friend of
ties and an array of different endovas-
with several cerebral protection
Carlos Menem, Argentina’s president
cular techniques, such as angioplasties
methods, endovascular treatment of
at the time. Instead of making a cut
of vessels in the legs or carotid stenting.
abdominal aortic aneurysm and periph-
in the abdomen to perform open
Frank J. Veith, MD, one of the early
eral arterial disease. He is the national
surgery and sewing a graft to recon-
proponents of endovascular surgery,
principal investigator for the ROBUST
struct the aorta, Dr. Parodi inserted
was among those who argued for the
randomized trial comparing bypass to
an endovascular stent graft through
recognition of vascular surgery as a
stenting of the lower extremities.
the femoral artery in the groin to line
defined specialty based on five pillars:
up the aorta from inside and relieve
an understanding of the natural
Dr. Freischlag is The William
the pressure of the aneurysm sac.
history of vascular disease; mastery
Stewart Halsted Professor, Chair of the
Parodi’s success with EVAR literally
of non-interventional or medical treat-
Department of Surgery and Surgeon-in-
changed vascular surgery. Patients
ment of vascular disease; knowledge
Chief at The Johns Hopkins Hospital in
who might not otherwise be candidates
and understanding of invasive and
Baltimore, MD. Dr. Freischlag has served
for open surgery (most commonly due
non-invasive diagnostics; mastery
as a Governor of the American College
to age and other complications) could
of open surgical techniques; and
of Surgeons (2000–2006) and is pres-
now be treated with a non-invasive,
mastery of endovascular techniques.
ently a Regent of the American College
less surgically risky technique. This
“In the late 1990s, it became obvious
of Surgeons. She is the national prin-
made vascular repair practical for a
to many of us that vascular surgery
cipal investigator of the VA OVER trial
much wider variety of people. Without
could no longer be restricted to a few
(Open Versus Endovascular Repair) of
invasive surgery, patients could walk
operations done as a sideline of either
abdominal aortic aneurysms. The study
the next day, eat the same night, and
cardiac or general surgery,” said Dr.
is a prospective randomized trial, which
leave the hospital within 24 hours
Veith. “I and others felt that we had
has randomized over 800 patients from
versus having to stay at least a week.
to modify our training paradigms so
34 medical centers across the country.
Shortly after this initial EVAR,
that a vascular surgeon could devote
She is presently serving President-elect
American interventional radiologist
the bulk of his postgraduate training
of the Society of Vascular Surgery. She
Michael Dake performed the same
to this specialty.”
is the Editor of the Archives of Surgery,
operation with similar results.
Today, minimally invasive tech-
which is one of the major surgical jour-
Through the 1990s, vascular surgeons
niques are the standard for repairing
nals. She also serves on several other
improved and adapted the technique of
a neu r ysms —popu la r w it h bot h
editorial boards. She has published over
endovascular repair, developing new
vascular surgeons and the public—
200 manuscripts, numerous abstracts,
technology (stents and stented-grafts)
and in the early 2000s, vascular
and book chapters.
191
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