How can trauma surgeons maintain their operative skills?

BACKGROUND: The operative experience of the dedicated trauma surgeon is declining. Much attention has focused on the operative workload of trauma surgeons as it is critical in both maintaining operative skills and promoting the interest of surgical residents in trauma careers. We examined the operative experience of our surgical service which includes trauma, emergency general surgery, and elective general surgery to analyze changes occurring over the past decade. METHODS: A retrospective study was performed by extracting data from the operative database at our Level I trauma center from January 1995 to December 2005. The cases were classified as trauma, emergency general surgery, or elective general surgery. Data were analyzed using weighted linear regression to analyze statistical significance. RESULTS: Although the total number of cases performed by the trauma service remained constant, the proportion of initial operative trauma cases (<24 hours from arrival to operation) decreased from 14% to 8% (r2 = 0.91, p < 0.001) over the study period. In contrast, emergency general surgery cases increased over this time period (r2 = 0.57, p < 0.01). Elective case volume was unchanged. The majority of the waning of trauma cases was due to decreased surgery on the liver and spleen and fewer neck explorations. CONCLUSIONS: Trauma operative experience decreased but emergency general surgery increased over a decade at our trauma center. It appears possible to maintain a busy operative trauma service by the inclusion of emergency general surgery consultations.

A single institution review of new breast malignancies identified solely by sonography.

BACKGROUND: The role of sonography as a sole identifier of breast malignancy remains undetermined. Currently, the American College of Radiology Imaging Network (ACRIN) trial, protocol 6666, is accruing high risk patients, with dense breast tissue on mammography, to evaluate the performance of screening sonography. STUDY DESIGN: We conducted a retrospective single institution review to identify the detection rate of nonpalpable, mammographically occult breast malignancies identified solely by sonography. RESULTS: A total of 34,694 breast sonograms were performed at our outpatient radiology affiliate between April 1998 and April 2006. This number includes unilateral and bilateral examinations, and, 6-month followup examinations. Computerized databases and individual charts were retrospectively reviewed. Sonographic and mammographic findings were compared to determine concordance of identified lesions. Four thousand ninety-one ultrasound guided biopsies, (fine needle aspiration biopsy [FNA] and core needle biopsy [CNB]) were performed over the 8-year period, and 452 malignancies were identified. Discarded fluid contents of pure cyst aspirations were not included in this number. Seven percent (32) of the biopsy-proved malignancies were mammographically occult, of which 59% (19) were palpable, and 31% (10) were not palpable. Of all cancers diagnosed, 2.2% were identified solely by sonography. The number of cancers identified solely by sonography relative to the total number of sonograms done was 0.03%. CONCLUSIONS: Given these results, we advocate the selective use of sonography in appropriate populations, namely, in those with palpable findings, mammographic abnormalities, and in women with dense tissue who have personal or family history of breast cancer.

The significance of surgical margins for patients with atypical ductal hyperplasia.

BACKGROUND: The significance of surgical margins for patients with atypical ductal hyperplasia is unknown. PATIENTS AND METHODS: We reviewed our experience with atypical ductal hyperplasia and correlated the margin status of the specimens removed with the risk of recurrence as atypical ductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma. Seven hundred forty-seven patients were identified between February 1995 and September 2005 as having biopsy proven atypical ductal hyperplasia (ADH). One hundred fifty-five of these patients were found to have "pure" atypical ductal hyperplasia without associated premalignant or malignant breast disease or a history of ipsilateral disease. Margin status of the initial excisional biopsy was noted and was correlated with the risk of recurrence. RESULTS: Of the 155 patients whose excisional biopsy specimens were "pure" atypical ductal hyperplasia, 44% (68) had negative margins, 5% (7) had positive margins, and 52% (80) were not reported. No patient underwent re-excision for close or positive margins. Follow-up ranged from 0 to 119 months, with a mean of 26 months. Seven patients (5%) presented with new findings at the site of their initial excisional biopsy, 1 of whom was found to have an invasive ductal carcinoma and 6 of whom had benign findings. Of the 87 patients with margins positive or unknown for ADH at surgical excision, none went on to develop malignancy. CONCLUSION: Our results suggest that clear surgical margins at surgical excision for atypical ductal hyperplasia did not affect the risk of subsequently developing a malignancy.