Zebras

May 25, 2007
Surgical Rounds®, May 2006, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

I rarely if ever began an editorial with a case history, but for this is?sue, it seems appropriate. About 1 year ago, a 22-year-old woman was referred to me with an adrenal mass found incidentally on ultrasonography performed for abdominal pain. She had consulted an excellent urologist who assured her, largely based on her young age, that the lesion was certainly benign. I was uncomfortable with his assessment. I could feel the lesion on deep palpation. The outline of the tu?mor on a computed tomography (CT) scan seemed slightly irregular. In contrast to the urologist, who was lulled into a false sense of security by the patient's youth, her age had me even more concerned. After a lengthy consultation, she selected me as her surgeon. I elected an open approach and did a wide local excision taking a generous soft tissue margin around the lesion. Pathologically, the tumor was an adrenocortical carcinoma, and, fortunately, the margins of resection were clear. At 1-year follow-up, she was well and her abdominal and chest CT scans were negative for metastatic disease.

Surgical Rounds

My practice is quite unusual in today's urban medical environment. It includes gastrointestinal, endocrine, bariatric, and oncology surgery, and I regularly operate on the neck, chest, and abdomen. Practices like mine are throwbacks to the heyday of general surgery and run contrary to the current focus on ultraspecialization. I particularly love operating on the adrenals, but a career limited to operative therapy of adrenal disorders would not satisfy my surgical instincts. That is likely also true for the authors of the three articles on adrenal lesions included in this month's focused issue of .

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It is well known that common things occur commonly. That implies that uncommon things occur uncommonly. There is an apropos surgical adage, "When you hear hoof beats, think about horses, not ." Giant adrenal cysts and adrenocortical carcinomas found in 22-year-old patients are . It is cases like these that make the practice of surgery fun, but there is a strong push to centralize such cases in institutions that have particular experience in the area.

The impetus for referral centers really began with Whipple procedures for carcinoma of the pancreas. It is obvious from recent reports that very few institutions perform large numbers of these procedures. Since pancreaticoduodenectomy is a high-risk and moderate-yield operation, there is ample justification for centralizing this pro?cedure. According to multiple published re?ports, operative mortality rates are somewhat lower and survival rates are slightly higher in these centers. The medical bureaucrats appreciate that inpatient costs are lower because of fewer complications and shorter hospitalization.

On the other hand, there are distinct disadvantages to this centralization process. Patients and their families have to travel significant distances and live away from home for some time. This makes it increasingly difficult on ex?tended family support systems. Even more disturbing is the fact that not all patients can afford to be cared for at one of these venues, even if their insurance pays the hospital bills. Which is more important: improved surgical care or equal access for all patients? I will leave that decision to you. It is a political and ethical question, not a medical one.

While the data are not as compelling, similar improvements in operative mortality and cancer survival have been reported for colon, thyroid, and other malignancies. Hernia surgeons are convinced that they achieve lower recurrence rates, but with the technologies currently used, it is difficult for me to understand how much better their operations can be. Breast surgeons also claim to offer improved survival, but surgery plays such a limited role in the care of this malignancy that it is more likely the medi?cal and radiation oncologists who carry the ball.

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Where will it end? Will residents being trained today learn one or two operations so well that these procedures will be the only ones they practice? For example, there are already a number of surgeons who perform only lap band procedures and gastric bypasses. Assuming unlimited access, unioperative specialists could improve the care for patients in whose diseases they specialize. It is obvious why that would be advantageous to patients, but it might also be attractive to some practitioners. All cases would be elective and night call would be of historical interest only. Think of how easy coding would be, and there would be much less new information to keep up with. Ultraspecialization would create voids in trauma and intensive care, but these fields would become independent specialties and mandate much broader training.

Surgical Rounds

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Unfortunately, our country seems to be heading in the direction of ultraspecialization, and I don't like the trend. The practice of unidimensional surgery would be dull and more like a trade than a profession. The surgical field certainly would not recruit the best and the brightest, and under those conditions, it should not. Except for research (both basic and clinical), there would be very little challenge, and a lot less to take pride in. The repetition of performing one or two procedures, even in referred patients, would quickly become routine and lead to early burnout. It would also mean no occasional tasty surgical morsels, no interesting case reports, and no .