Ephraim McDowell's Ovariotomy on General Overton's Wife.

Ephraim McDowell's removal of a massive ovarian tumor from Jane Todd Crawford in Danville, Kentucky, in 1809 revolutionized the practice of surgery. Most academic physicians then believed that operating in the abdomen would inevitably result in peritonitis and death. McDowell proved them wrong and performed numerous ovariotomies with an acceptable complication rate for the era. His expertise brought patients from afar. McDowell also operated on patients in their homes, sometimes far from Danville. This article addresses an operation done in Nashville, Tennessee, on Penelope Holmes Overton, wife of General Thomas Overton, a prominent Tennessean.

Spiral rectal valves: Anatomy, eponyms, and clinical significance.

Rectal wall valves are obscure anatomic parts that rarely are considered in current medical practice. Yet from the seminal analysis of them in the early nineteenth century by the Irish anatomist and surgeon, John Houston, their structure, purpose, and clinical significance were topics of surprising disagreement. Were they true structures? What function might they have? Did disease originate in rectal valves? Were special operations required for any such diseases? Because Houston's anatomic analyses of rectal valves were substantiated, they came to be known in the English literature as the Spiral Rectal Valves of Houston. In the mid-nineteenth century, a single mid-rectal valve was described by the Hanoverian, Otto Kohlrausch., creating confusion with the established eponym "Houston's Valves." Many hypotheses about rectal valves have been discredited; and their physiologic functions are still unknown.

Postoperative morbidity and mortality among Veterans Health Administration patients undergoing surgical resection for large bowel polyps (bowel resection for polyps).

BACKGROUND: Large bowel polyps with malignant characteristics or those that are too large to remove colonoscopically may require bowel resection. METHOD: We performed a retrospective review of 126 Veterans Health Administration patients who underwent elective resections for colonoscopically unresectable colorectal polyps over a 10-year period. We evaluated the association of patient characteristics and operative management on the composite outcome of 30-day postoperative morbidity and mortality. RESULTS: 98% of patients were males. Mean age was 65.1 years. Most patients had comorbidities, including cardiac or vascular disease (47.4%), diabetes mellitus (54%), and tobacco (41%) or alcohol (32.5%) use. The majority (85.7%) of patients were considered to be in American Society of Anesthesiologists (ASA) physical status classifications III and IV. 92% of resections were completed via laparotomy. Thirty-day postoperative morbidity and mortality occurred among 40 (31.7%) patients. Fifty-six patients (44.4%) had operative specimens with malignant features. The only comorbidity statistically associated with 30-day morbidity and mortality was body mass index >30. CONCLUSION: Approximately one third of patients had significant postoperative morbidity or mortality. Clinical pathways chosen to treat colonoscopically unresectable polyps should be tailored to patients' conditions and the characteristics of their colorectal lesions.

Management of senescent gynecomastia in the Veterans Health Administration.

Senescent gynecomastia is common in Veterans Health Administration patients because of clinical characteristics in the population, mainly obesity and the use of numerous etiologic drugs. To assess management of the disease, we studied patients treated between January 1, 2003 and December 31, 2007, in the Veterans Affairs-Tennessee Valley Healthcare System. Four hundred and fifty-four cases of senescent gynecomastia were retrieved from 670 charts addressing breast complaints (positive predictive value = 68%). Average patient age was 68.5 years. Mean body mass index was 29.7. Ninety-two percent of patients were using multiple medications associated with gynecomastia. Medications were considered at least partially etiologic in 79.3% of cases. Medical conditions caused gynecomastia in 13.7%. Over 50% of patients underwent diagnostic imaging studies. One-fifth of patients were tested for etiologic endocrine tumors. Yield on this testing was 1.1% (1/93). Ninety-four percent of patients were managed nonoperatively. Case management in the Tennessee Valley Healthcare System was generally correct, though there was excessive use of imaging, invasive diagnostic procedures, and endocrine assessment. Senescent gynecomastia, a benign disease, can usually be diagnosed by history and physical examination, requires little diagnostic testing, and should be treated nonoperatively.

Methods and complications of anterior exposure of the thoracic and lumbar spine.

OBJECTIVE: To review the methods and complications of exposing the anterior aspects of the thoracic and lumbosacral spine. DATA SOURCES: PubMed (journals database of the National Library of Medicine), text books, the University HealthSystem Consortium Clinical Process Improvement Benchmarking Project, a newspaper, and the US government Healthcare Cost and Utilization Project. STUDY SELECTION: Descriptions of morbidity and mortality specifically related to anterior spine exposure depicted in both case reports and clinical series were used. DATA EXTRACTION: Mortality data from clinical series with more than 30 cases were tabulated. Morbidity incidences were described. DATA SYNTHESIS: The frequency of anterior exposure of the spine for structural operations is steadily increasing. Both thoracic and lumbosacral anterior spine operations are associated with exposure-related complication rates of 10% to 50%. Pulmonary complications are frequent after thoracic exposures. Chylothorax is the most common of several rarer chest-exposure complications. Vascular complications, particularly arterial thrombosis (<1% of cases) and venous bleeding (2%-15% of cases), are the most frequent complications at the lumbar level. Other lumbosacral exposure complications include ureteral and nerve (somatic and sympathetic) injury. The mortality rate in anterior spine exposures is less than 1%. CONCLUSIONS: The exposure portions of anterior spine operations result in numerous complications. There are fewer reported complications with endoscopic exposures of the anterior spine than with open exposures, although endoscopic exposures have been used for less complicated cases. In comparable cases, neither exposure nor results of endoscopic operations have proven better than operations done through minilaparotomy incisions. Perioperative cooperation between exposing and spine surgeons is necessary to enhance results in anterior spine operations.