Skin and Subcutaneous Tissue
The statement, “melanoma is a relatively uncommon” disease, which appeared in the first edition, would now be deemed inaccurate. Furthermore, it is now accepted that melanoma occurs more frequently in areas of highest total sunlight. The depth of the lesion according to the Breslau scale is now used to define the appropriate extent of surgical excision. The margin of normal skin surrounding the lesion to be removed has been reduced to 1 cm, and patients with peripheral melanoma and involved nodes are not currently treated with limb amputation. Radiation does have a place in the treatment of an involved lymphatic bed. With the exception of B-Raf inhibitors, chemotherapy is rarely used, but immunotherapy has been shown to prolong life. As a consequence of the AIDS epidemic, Kaposi’s sarcoma has been noted more frequently.
As the most common site-specific malignancy, and the leading cause of death in women aged 20-59, cancer of the breast has been a constant focus of attention. The past 50 years have been characterized by an extraordinary and multifactorial expansion of scientific information about the tumor. The application of sophisticated diagnostic radiologic techniques and biologic assessments has influenced treatment. Critical outcomes research coupled with adjuvant radiation therapy and chemotherapeutic manipulations has resulted in the prevalence of less radical surgical procedures. In 1969, “no standard method of staging had been accepted.” Currently, the American Joint Committee on Cancer (AJCC) CancerStaging Manual, in its 7th edition, is the accepted standard.
If Haagensen’s 1943 criteria of operability were applied, only 75% of breast cancers would be deemed operable. In the first edition of Principles of Surgery it was stated, “Mammography represents a relatively recent addition to the diagnostic armamentarium of breast diseases.” Thirteen years later, routine screening mammography was recommended and, subsequently, an inoperable lesion has rarely been encountered. Breast MRI was introduced in 1985. Fine-needle aspiration and core-needle biopsy have become the preoperative diagnostic procedures of choice. Biomarkers, including estrogen and progesterone receptors, and human epidermal growth factor receptor 2 provide information regarding prognosis and response to therapy. More recently, gene expression profiling has been applied to predict response to therapy. The concept of “biological determinism,” which had been introduced in 1966, has become central to current treatment.
The first edition states, “Today, radical mastectomy is the standard treatment for operable cancer of the breast in the United States.” Several surgeons, at the time, advocated more extensive operations, including the internal mammary lymph nodes. Over the ensuing years, there has been a sequential reduction in the extent of the surgical procedure necessary to remove the malignancy. In 1980, a national trial revealed that modified radical mastectomy achieved results equivalent to radical mastectomy. Five years later, partial mastectomy with axillary node dissection and adjuvant radiation therapy was determined to be equivalent to modified radical mastectomy. In 2010, axillary radiation was shown to provide the same results as axillary dissection, and was associated with less lymphedema in some patients with a positive sentinel node. In 2011, completion axillary dissection was shown to be unnecessary for sentinel node-positive patients undergoing breast conservation surgery and whole breast radiation.
Radiation therapy, which had been applied in lieu of radical mastectomy as early as 1936, and, more recently, hormonal manipulations and chemotherapy have all been increasingly incorporated in the therapeutic regimens. The anti-estrogen tamoxifen was incorporated in the therapy in 1978; multi-agent chemotherapy in the 1980s; the use of aromatase inhibitors and trastuzumab (Herceptin) in the 1990s; and pertuzumab (Perjeta) most recently. There has been a concomitant increase in reconstructive procedures after mastectomy, including skin-sparing excisions and prosthetic implants, and pedicled myocutaneous flaps or free flaps using microvascular techniques.
In 1994-1996, BRCA 1 and BRCA 2 genes were identified, and the implications regarding the risk of bilateral involvement prompted prophylactic bilateral mastectomy. Significant improvement in the outcomes of treatment of inflammatory breast carcinoma has been achieved. The use of a multi-modal approach, which includes surgery, radiation therapy, and neoadjuvant chemotherapy, has converted a consistently and rapidly fatal lesion to one associated with a 30% 5-year survival.
Tumors of the Head and Neck
A reconsideration of the chapter in the first edition of Principles of Surgery uncovers changes in nomenclature, advances in technology related to diagnosis, major modifications of surgical operations, and liberal incorporation of adjuvant therapy, all of which have combined to create new protocols for treating disorders addressed by otolaryngologists.
The physical examination of the head and neck region, with its potential pathology, has been changed by the technologic advancements of endoscopy, including rigid and flexible fiberoptic or distal chip camera scopes, which provide both superior visualization and improved patient tolerance. Plain radiographs and laminography have been replaced by CT scanning with contrast, MRI, and ultrasound. The use of vital dyes, to distinguish dysplasia and superficial malignancy, and brush cytology has become obsolete.
The treatment of infantile hemangioma, which often presents in the head and neck region, has been revolutionized by the administration of intravenous propranolol. For carcinoma of the lip, the standard treatment of N0 lesions, currently, incorporates either prophylactic radiotherapy or selective dissection of draining nodes, rather than the previously employed radical neck dissection. In the management of advanced tumors of the oral cavity, chemotherapy has become integral. Segmental mandibulectomy for tumor in contact with the periosteum has become antiquated, and has been replaced by marginal mandibulectomy.
Epiglottic tumors are currently categorized as “supraglottic” tumors, rather than “oropharyngeal” tumors. The treatment of benign lesions affecting the voice has become a distinct multi-faceted subspecialty in which specifically designed instruments are employed for surgical intervention. The consideration of oropharyngeal tumors brings into focus a change in nomenclature. “Lymphosarcoma” is considered an obsolete term for the currently acceptable “lymphoma.” The mainstay for treatment of all lymphomas is chemotherapy, rather than radiotherapy.
The increase in the incidence of oropharyngeal cancers (tongue and tonsil) has been significant. The primary cause in the United States is human papillomavirus (HPV). Endoscopic robotic resection has been applied for smaller lesions. For most patients, the treatment is combined radiation and chemotherapy. In the first edition, radiation or total laryngectomy constituted the alternatives for treatment of laryngeal cancer. Currently, T1 and T2 disease are treated effectively with endolaryngeal surgery or radiation, and there are organ preservation protocols incorporating chemoradiation for T3 lesions.
Contrary to the statement in the first edition that cancer of the hypopharynx is “three to four times as common” as cancer of the larynx, laryngeal cancer is now recognized to be four to five times more common than cancer of the hypopharynx. Aggressive resection of hypopharyngeal malignancies has been advanced as a consequence of the development of reconstructive techniques (flaps and free tissue transfers), which have allowed for swallowing and speech. Chemotherapy has been a significant addition to radiation therapy as treatment for nasopharyngeal malignancies. The prognosis has also improved for tumors of the paranasal sinuses, the resection of which has incorporated the expertise of skull base and reconstructive surgeons.
As a consequence of an increased incidence of HPV-associated oropharyngeal cancer, cervical nodal disease without an apparent primary source has become more common. In regard to the technical aspect of head and neck surgery, radical neck dissection, essentially, has been replaced by modified radical resection, sparing the jugular vein, sternocleidomastoid muscle, and spinal accessory nerve, except in cases of particularly aggressive neck disease. Removal of the mandible is rarely performed to facilitate wound closure.
Chest Wall, Pleura, Lung, and Mediastinum
A comparison between the material that appeared in the first edition related to this field and the current concepts, standards, treatment algorithms, and surgical techniques reflects a significant change. The change is multifaceted, including the disorders to which thoracic surgeons direct their attention, advances in detection and diagnosis, refinements in assessment of pulmonary function and reserve, advances in minimally invasive surgery, and expansion of chemotherapy, immunotherapy, and radiotherapy options.
Pulmonary function tests are now routinely performed prior to pulmonary resection. The forced expiratory volume in 1 second (FEV1) has replaced the vital capacity as the standard. Air exchange is assessed by the diffusing capacity of the lungs for carbon monoxide (DLCO) to determine pulmonary reserve. Bronchoscopy is generally performed with a flexible instrument. A double-lumen endotracheal tube is routinely employed during lung resection. Many lung resections, including sleeve resections, lobectomies, and select pneumonectomies, are performed using video assisted thoracoscopic surgery (VATS).
The treatment of unstable rib fractures by traction has become antiquated and replaced by plating. Compounded wounds of the chest, and those with the possibility of associated abdominal involvement, are investigated by VATS or laparoscopy, rather than open exploration. Most cases of recurrent spontaneous pneumothorax are handled using VATS. There has been a significant shift in the management of empyema, now relying on drainage through small pigtail catheters with or without the intrapleural instillation of fibrinolytic agents, thereby reducing the need for surgical decortication.
The incidence of advanced tuberculosis in other than undeveloped countries has been markedly reduced by effective medical therapy, and the extensive thorocoplastic procedures which dominated the practices of the first generation of thoracic surgeons have essentially disappeared. Pulmonary arteriovenous fistulas are now generally managed by angiographic embolization. The section on “Mucoviscidosis of childhood” would currently be labeled “Cystic Fibrosis,” and the disorder constitutes a common indication for lung transplantation.
The major changes related to the surgical management of pulmonary disease have been focused on cancer. The incidence of lung cancer is second only to prostate cancer in men, and breast cancer in women. It is now appreciated that non-small cell lung cancer (NSCLC), which constitutes about 80-85% of lung cancers, is comprised of a variety of subsets, each of which receives specific therapy. About 40% of lung cancers are adenocarcinoma (the previously applied term, bronchoalveolar carcinoma, has been eliminated). About 25-30% of lung cancer cases are squamous cell (strongly linked to a history of smoking). Large cell undifferentiated carcinoma make up the remainder.
Screening CT scans, to identify lung cancer at an earlier stage, have become the standard for high risk individuals. CT, MRI, and PET scans have become invaluable staging modalities. Stereotactic body radiation therapy (SBRT) with curative intent has been added to the armamentarium. Radiofrequency ablation, cryotherapy, microwave ablation, and proton therapy have also been employed. The role of chemotherapy in early stage NSCLC is currently evolving, and encouraging results are being reported for immunotherapy in advanced disease.
Most mediastinal tumors are also removed by VATS, rather than through a sternal splitting incision. There has been a change regarding thymic tumors, in that they are all considered to be malignant, and are categorized by stage and type.
The combinations of diagnostic procedures, which provide for precise definition of congenital anatomic abnormalities and pathophysiology, coupled with refined supportive care, have resulted in a high success rate for neonates and children undergoing definitive surgical correction. The progress in pediatric cardiac surgery would have been unimaginable 50 years ago. Echocardiography, MRI, and other diagnostic procedures have provided diagnoses early in infancy and, frequently, in utero. Earlier diagnosis and correction has resulted in a marked reduction in the number of patients presenting with profound cyanosis, clubbing, and polycythemia.
Improved diagnosis has led to an appreciation that the frequency of moderate to severe congenital heart disease is actually 6 cases in 1000 live births (double that reported in the first edition). There is also a 3-4% risk of subsequent siblings with congenital heart disease, and 20% concordance of disease. It has become appreciated that drugs, alcohol, and medications may be responsible for genetic mutations that result in congenital heart defects. It is now known that a patent foramen ovale is not completely innocuous, and may be associated with a critical paradoxical embolus. Currently, it is appreciated that there are significantly more than the first edition’s reported “seven common” congenital cardiac malformations, and most are commonly repaired or palliated in infancy or as early as is feasible. The classification of the congenital heart disorders has been modernized to “cyanotic or acyanotic,” “single ventricle or bi-ventricular.”
Sophisticated pediatric anesthesia and postoperative nursing care have allowed for transition to the current prevalence of earlier complete anatomic and physiologic correction as a replacement for the palliation of the past. Postoperative care has been improved with the development of smaller catheters and endotracheal tubes, and better mechanical ventilators.
The treatment for all varieties of congenital heart disease has changed markedly over the past half century. Pulmonic valve stenosis is typically treated during the neonatal period or early infancy by catheter-based balloon valvuloplasty. Extremely high right ventricular pressures (i.e. in Tetralogy of Fallot), such as were recorded in the first edition, are no longer allowed to persist for a significant period. If surgical correction is effected, it is now generally performed antegrade through the right atrium, or retrograde through the pulmonary artery, thereby avoiding a ventriculotomy. Cardiopulmonary bypass is more frequently used, making the instruments illustrated in the first edition obsolete.
Aortic stenosis is readily assessed by echocardiogram, which provides an accurate definition of the severity of valvular pathology. Percutaneous valvuloplasty may be temporizing. At variance with the previously published approach, most surgeons now prefer valve replacement using a pulmonary autograft or aortic homograft for definitive correction. Supravalvular aortic stenosis is now preferably treated by patch angioplasty.
The optimal time for correction of coarctation of the aorta has changed from the previously indicated “5 to 7 years,” to the neonatal or early infancy period. Beta blockers and angiotensin II inhibitors have replaced reserpine as treatment of postoperative paradoxical hypertension. Atrial septal defects are easily defined by echocardiograms and bubble studies. Those defects are often closed percutaneously in the catheterization facility. When operation is required, cardioplegic arrest, rather than ventricular fibrillation, has become preferred. The prognosis associated with surgical correction of total anomalous pulmonary drainage has been improved, and the mortality rate has been reduced to less than 5%.
The results for repair of ostium primum have significantly improved, and, in most cases, the mitral valves will not require replacement during adulthood to correct mitral insufficiency. The operative mortality associated with correction of a persistent atrioventricular canal, which is generally performed at about 6 months of age, has decreased from the “exceeding 75%” (reported in the first edition), to a current 2%. In the first edition, it was indicated that, in infancy, pulmonary hypertension associated with a ventral septal defect was preferably treated by pulmonary banding. This no longer applies, and has been replaced by direct repair of the defect during infancy. The repair is usually performed through a right atriotomy, in order to avoid the previously advocated ventriculotomy. The treatment of patent ductus arteriosus has been modernized to include indomethacin to effect closure during infancy, or coiling under radiologic guidance.
Just as had been the case with the introduction of the Blalock-Taussig shunt, the most dramatic advances have been apparent in the cyanotic children. Early diagnosis and identification of the abnormal anatomy of the Tetralogy of Fallot by echocardiography has allowed for early palliation or repair during the first two years of life. The mortality following repair performed during infancy is about 2% and, after a palliative procedure, about 5%. Dextro-Transposition of the great arteries (d-TGA) had been corrected with the Senning or Mustard procedures prior to the first edition, but has been replaced by the Jatene arterial switch, which has been credited with a 96% or better success rate.
Most of the complex abnormalities, including truncus arteriosus and single ventricle, have been successfully repaired or palliated. The representative statement, “Effective treatment is not possible,” which appeared on page 616 of the first edition and related to single ventricle, is no longer applicable to almost any congenital cardiac abnormality.
Only 16 years had elapsed between the first report of the direct closure of an intracardiac defect in a patient on cardiopulmonary bypass and the publication of the first edition. In the half century since publication, the increased sophistication in assessing cardiac pathology and function, coupled with technological and surgical refinements, has transformed cardiac surgery, extending the indications and applicability to a status that would not have been imaginable 50 years ago. Improved diagnosis and evaluation are the result of advances in imaging, echocardiography, cardiac catheterization, and determinations of myocardial function.
The surgical treatment of every aspect of acquired heart disease has experienced either evolution, marked maturation, or innovation. Cardiopulmonary bypass has undergone refinements, and the addition of cardioplegia has added to the safety of surgical intervention. The use of Extracorporeal membrane oxygenation (ECMO) has been applied more liberally to resuscitate patients with cardiac arrest and ventricular fibrillation.
Prior to the first edition, rheumatic mitral stenosis, because of its prevalence and potential for correction, received dominant attention. Over time, the incidence of mitral stenosis has decreased, and balloon valvuloplasty has replaced mechanical dilators as the initial treatment. The perfection of bioprostheses and mechanical prostheses has resulted in improved mortality and morbidity rates for mitral valve replacement. Mitral insufficiency, secondary to degenerative processes and ischemic heart disease, has become the more commonly surgically corrected mitral lesion. Because of the low risk and high success rate, the indications for an operation have been liberalized. Repair, rather than replacement, is more frequently performed for insufficiency. Mini-thoracotomy, robotic techniques, and transcutaneous procedures have been applied, and multiple devices have been devised to facilitate the repair.
The treatment of aortic valve disease has undergone similar dramatic change. At the time of the first edition, it was stated, “Complications from cardiac prostheses to date have been such that operation should not be recommended when symptoms can be controlled by restriction of physical activity,” and operations on the aortic valve were not advised before symptoms of left ventricular failure were apparent.
The criteria for repair or replacement have been standardized by national guidelines, and age is no longer a restriction. Sutureless aortic valve replacements, and improved biologic and mechanical prostheses, have contributed to the current status of low operative risk and long-term survival associated with correction of both aortic stenosis and aortic insufficiency. Better replacement valves have also been associated with better results for patients following an operation for aortic insufficiency. Also, aortic valve sparing techniques have been developed to correct aortic insufficiency. The recent development of transcatheter aortic valve replacement (TAVR) has extended the indications for intervention to both intermediate and high-risk patients.
The dominant etiology of tricuspid valvular disease has changed from rheumatic fever to complications of pacemaker leads, endocarditis associated with intravenous drug abuse, and pulmonary hypertension. Repair is preferable, but improved valves are credited with improving the results following replacement.
The first edition stated, “At present, surgical procedures for coronary artery disease remain largely experimental.” Shortly thereafter, bypass procedures to improve coronary flow were developed. Subsequently, coronary arterial stents inserted under radiologic visualization have achieved a similar effect. Maturation has occurred along diverse lines, including; “off-pump surgery,” small incisions for limited procedures, definition of preferable vessel use, and modified stents. Coronary artery disease, with its surgical and alternative interventional treatments, has become the most intensely evaluated medical subject.
A new generation of defibrillators and pacemakers has evolved. Interruptive operations (maze procedures) have been developed for treatment of intractable atrial arrhythmias, and reparative operations have been developed for the pathologic consequences of myocardial infarction (ventricular septal defect, ventricular aneurysm, papillary muscle rupture). The development of refined equipment for cardiopulmonary bypass, as well as protocols for perioperative management, has improved results for all aspects of cardiac surgery.
Perhaps, the most dramatic and complex advances have been related to providing mechanical circulatory support for patients with cardiac failure. Assist devices and artificial hearts have achieved extraordinary successes, as the availability of cardiac transplant remains unable to satisfy the demand.
New surgical techniques, such as valve sparing root replacement, deep hypothermic circulatory arrest, antegrade cerebral protection, and stented endovascular grafts, along with valved conduits and arch grafts, have markedly improved the surgical results for patients with aneurysms of the ascending and descending aorta, the aortic arch, and aortic dissections.
Peripheral Arterial Disease
Although the seminal publication of Charles Dotter, and his trainee Melvin P. Judkins, describing angioplasty and a catheter-delivered stent appeared in 1964, no mention of that transformational approach to peripheral arterial disease was included in the first edition. In the 1996 7th edition, the last edition edited by Seymour I. Schwartz, G. Tom Shires, and Frank C. Spencer, endovascular procedures were referred to as “under consideration” for aortoiliac disease, and were absent from the surgical armamentarium to treat infrainguinal arterial occlusive disorders.
Currently, an endoluminal approach is employed for over 80% of infrarenal aortic repairs and for 80% of cases requiring lower extremity revascularization. At the same time, modern medical therapy has addressed the treatment of atherosclerotic occlusive disease with dual anti-platelet therapy and statin-class pleiotropic drugs. Therefore, lumbar sympathectomy, one of the procedures used to hone the technical skills of the six editors of the first edition, has almost totally disappeared.
The statement in the first edition that “an oscillometer may aid in defining a peripheral pulse in an edematous extremity” no longer pertains, and offers evidence of the progress that has been made in the diagnosis and assessment of peripheral arterial disorders. Ultrasounds and computer-generated scans have provided precise definitions of disease and allowed focused treatment. Most visceral artery aneurysms and arteriovenous fistulas are now managed endovascularly. The use of the in situ graft for treatment of femoropopliteal occlusive arterial disease also postdated publication of the first edition.
Remote endarterectomy to treat occlusive arterial disease has become a percutaneous, catheter-based procedure. The removal of distal clots associated with acute arterial occlusions has been modernized with the continuous catheter-directed instillation of thrombolytic agents. The performance of sympathectomy as treatment for Raynaud’s disease, which was considered at length in the first edition, is now rarely indicated.
Venous and Lymphatic Disease
The treatment of venous disorders, which had been an oft-neglected aspect of vascular surgery, has gained prominence and financial relevance. Significant changes have occurred in the management of venous disease at all anatomic strata. Superficial thrombophlebitis is now well managed by NSAID medications, and the statement in the first edition, “Expensive and potentially dangerous ‘antiinflammatory’ drugs do not appear any more effective than aspirin,” would now be considered an error. Duplex ultrasound has completely replaced physical examination and functional venous testing, the illustration of which took up two half pages of the first edition, as the diagnostic mainstay. Ligation of the saphenous vein at its junction with the femoral vein, the first independent operation that I performed as an intern, is rarely done. Superficial venous catheter-based ablation has become the mainstay for treatment of varicose veins. The eponymous “Linton procedure,” to interrupt perforators, is yet another surgical dinosaur.
A more complete understanding of hypercoagulable states and the introduction of new oral anticoagulants have changed the strategy for treating deep venous thrombosis. Most affected patients are now managed in an ambulatory setting without activity restriction. The prophylaxis and treatment of pulmonary embolization was managed 50 years ago by suture compartmentalization of the inferior vena cava, and a decade later by external caval clips, which had the same effect. Currently, caval interruption is accomplished by retrievable filters inserted through a peripheral vein.
Surgically Correctible Hypertension
At a time prior to the development of dependently effective medical regimens for the management of hypertension, surgical solutions received greater attention. Thoracolumbar sympathectomy had enjoyed a period of popularity, but unpredictable success, and was abandoned by 1960. The chapter in the first edition briefly considered the endocrine causes of hypertension (pheochromocytoma, primary hyperaldosteronism, and Cushing’s syndrome). But the raison d’être for the chapter of 26 pages was an in-depth consideration of renovascular hypertension caused by correctible renal artery stenosis. A chapter dedicated to the subject persisted through five editions.
Manifestations of Gastrointestinal Diseases
In 1969, the algorithms for diagnosis of gastrointestinal disorders lacked the sophistications of computer tomography and endoscopy. Computer tomography has replaced abdominal roentgenography to determine the site and cause of intestinal obstruction. Currently, upper and lower gastrointestinal tract endoscopy and endoscopic evaluation of the biliary tract are the mainstays for establishing many diagnoses. Because of the accuracy of these diagnostic modalities, paracentesis is now rarely employed to diagnose abdominal pain.
The spectrum of disease has changed. Peptic ulceration, which occupied a significant portion of the general surgeon’s attention, currently requires surgical intervention infrequently. The first edition’s statement that “peptic ulceration accounts for two-thirds of the cases of upper gastrointestinal bleeding” is no longer applicable.
Colonoscopy has become integral for the diagnosis of constipation, lower gastrointestinal bleeding, and obstruction. The use of long intestinal tubes to manage obstruction has essentially disappeared, and a newly defined bacterium, C. difficile, has been identified as a potentially fatal pathogen.
Esophagus and Diaphragmatic Hernias
During the past 50 years, surgery of the esophagus has been the focus of significant change due to a greater understanding of the pathophysiology of benign disorders and an extraordinary shift in the cellular basis of esophageal cancer. Furthermore, the application of minimally invasive and endoscopic techniques transformed surgical management of esophageal disease.
The original section on anatomy stated that “The distal 1 or 2 cm of the esophageal lumen is lined by columnar epithelium.” It is now accepted that the normal esophagus contains no columnar epithelium, and, if present, it is ascribed to gastroesophageal reflux disease (GERD). High resolution esophageal motility studies have led to the restratification of achalasia into three major subtypes. The term “vigorous achalasia” refers to Chicago type III. The treatment of achalasia has expanded to include endoscopic injection of botulinum toxin, pneumatic dilation, and laparoscopic myotomy coupled with partial fundoplication. Peroral endoscopic myotomy (POEM) represents one of the first widely used natural orifice transluminal endoscopic surgery (NOTES) procedures.
Extramucosal cricopharyngeal myotomy had been recently introduced at the time of the first edition, and has become a standard option for treatment of a pharyngoesophageal diverticulum. The myotomy may be performed transendoscopically.
GERD is currently the most common gastrointestinal disorder, and medical therapy, dominated by proton pump inhibitors, represents a multibillion-dollar industry. Laparoscopic fundoplication is the most commonly performed surgical procedure to address the erosive effect of the reflux. Vagotomy and pyloroplasty or hemigastrectomy are now rarely performed. Several eponymous operations for sliding hernia (Allison, Belsey, Hill) have faded into obscurity. Recently, a magnetic sphincter augmentation device (LINX) has been introduced as an alternative to a fundoplication.
There has been a dramatic change in the cellularity, epidemiology, and anatomic distribution of esophageal cancer in the western world. At the time of publication of the first edition, the vast majority of esophageal carcinomas arose from the squamous epithelium of the esophagus. Currently, most esophageal malignancies are adenocarcinomas of the distal esophagus. GERD and intestinal metaplasia (Barrett’s esophagus) are considered to be the major risk factors. A variety of endoscopic techniques have been applied for ablation of the columnar epithelium and reduction of the risk for progression to cancer.
Extensive staging of esophageal cancers is routine. Endoscopic resection and/or ablation techniques are used for early intraluminal lesions. Neoadjuvant chemoradiation, followed by esophagectomy, is standard for locally advanced tumors. Resection of the esophagus can be performed as a minimally invasive procedure. Many modalities, including stents, laser, and cryotherapy are available for palliation of dysphagia.
A comparison between the first edition’s chapter on the stomach with a current consideration reveals an extraordinary change. The dominant pathology of the past, peptic ulcer, no longer commands the main attention. New areas of interest have appeared as replacements, and an expansive unanticipated area of focus dominates the anatomic region.
In the first edition, the description of the pertinent surgical anatomy of the stomach emphasized that “Knowledge of the autonomic nervous supply to the stomach by the vagus is particularly important today because interruption of the parasympathetic supply to the stomach has become an essential part of the surgical treatment of duodenal ulcer.” By contrast, today’s surgical residents might spend five years of training without performing a single vagotomy. Also, a detailed dissertation on the gastric secretory function was included in the original chapter because the surgical management of peptic ulcer was integral to the practice of many general surgeons. In the first edition, it is stated; “During the first half of this [20th] century peptic ulceration became an increasingly frequent cause of morbidity.”
In the absence of endoscopy, the diagnosis of peptic ulcer was dependent on radiologic examination. Surgeons were integral to the care of patients with peptic ulcer, and its complications of intractability, bleeding, pyloric obstruction, or perforation. Partial gastrectomy and vagotomy with gastric drainage frequently occupied operating rooms. After proton pump inhibitors were introduced, and helicobacter pylori was identified as a prevalent cause of peptic ulcer, surgical procedures for peptic ulcer became rarities.
Other changes in the profile of practice in the past five decades relate to a significant reduction in the incidence of gastric cancer, and the introduction of a new category of uncommon malignancies; gastrointestinal stromal tumors (GISTs), which has replaced the terms leiomyoma and leiomyosarcoma. During the most recent decade, response to targeted therapy for a genetic abnormality in a solid tumor was demonstrated in a GIST.
But the most profound change in the realm of gastric surgery has been the introduction, proliferation, and acceptance of the efficacy of bariatric surgery. The surgical treatment of obesity, a disease of modern times, was initiated in 1969 with the performance of the first gastric bypass. By the 1990s, Roux-en-Y Gastric Bypass (RYGP) became the procedure of choice in the United States, while adjustable banding of the stomach increased in popularity abroad. After the millennium, the laparoscopic approach for bariatric procedures became more routine. Initially, it was used to create a RYGP and, more recently, for performing sleeve gastrectomy.
Throughout the entire gastrointestinal tract, stapling techniques, which were non-existent at the time of the first edition, have become dominant for anastomoses and luminal closures.
A statement that concluded the introductory paragraph of the chapter in the first edition, “Disease is as frequent in the first 3 cm [of the small intestine] as in all of the remaining 300 cm combined,” no longer pertains, due to the decrease in incidence of peptic ulcer disease. Perhaps the most significant change related to small intestinal disease of surgical interest was a consequence of refinements of diagnostic procedures, particularly, magnetic resonance enterography, capsule endoscopy (a swallowed capsule that contains a camera), and fiber optic endoscopy with a long tube.
The first edition’s statements, “The correct diagnosis of acute regional enteritis is usually made only at operation,” and “Barium enema with ileocecal reflux usually suffices to demonstrate involvement of the terminal ileum,” would currently be labeled as incorrect. Improvement in diagnosis has resulted in an appreciation that the incidence of 1.5 per 100,000, as reported in the first edition, understated the case, and the accepted incidence of regional enteritis is, currently, 3.1-14.6 per 100,000.
Subsequent to the first edition, a malignant potential for Crohn’s disease, more marked for colonic than small intestinal involvement, has been defined. Resection of involved segments of small intestine remains the standard, but stricturoplasty is occasionally applicable. Simple bypass of an obstruction is no longer recommended.
Due to the lack of a significant data base in the middle of the 20th century, a survival rate of 20% was listed for adenocarcinoma in the small intestine, whereas, in 2010, the 7th edition of the AJCC Cancer Staging Manual records a 55% observed 5-year survival for Stage I disease, 49% for Stage IIA disease, 35% for Stage IIB disease, 31% for Stage IIIA disease, and 18% for Stage IIIB disease.
The treatment of high volume enterocutaneous fistulas has changed significantly with the institution of total parenteral nutrition (TPN). Immediate surgical repair is to be avoided, and operation to completely exclude the fistula-bearing segment of the bowel has been abandoned.
In the first edition, there was no reference to the role of the CT scan in the diagnosis of acute appendicitis. The definitive assertion, “The use of antibiotic therapy in an attempt to avoid or postpone therapy is dangerous and ill-advised. There is but one treatment for acute appendicitis,” would now be considered wrong. There is growing evidence for an antibiotics-first strategy to treat acute non-perforated appendicitis. An antibiotics-first approach proved effective in the majority of cases and there was no evidence of “non-inferiority.”
The suggestions that ulcerative colitis was an uncommon condition, and that it was due to infection, were wrong. The concept of autoimmune disease had not been defined, and effective immunosuppressive therapy had not been introduced. The differential diagnosis between ulcerative colitis and Crohn’s (granulomatous) colitis remains difficult in some instances. Pseudomembranous enterocolitis, which developed in consequence to antibiotic therapy, was erroneously considered to be caused by Pseudomonas, prior to the appreciation of the existence and role of C. difficile.
In the 50 years since the publication of the first edition of Principles of Surgery, the number of patients in whom the diagnosis of carcinoma of the colon or rectum is made annually has doubled because of improved surveillance. It is now accepted that most colon cancer results from a polyp-to-cancer evolution, and the 1969 printed statement, “the adenomatous polyp is a lesion of negligible malignant potential,” was wrong.
The management of malignancies of the colon and rectum has changed significantly. Randomized trials have demonstrated equivalent survivals for patients who have undergone laparoscopic or open colectomy. Chemotherapy and radiotherapy are more frequently integrated with surgical excision. Sphincter-saving operations and more wide-spread excision of mesorectal tissue characterize the current surgical treatment. There has also been a significant improvement in stoma therapy.
Since the first publication of the text, a combined chemotherapy/radiation therapeutic protocol has transformed the generally fatal squamous cancer of the anus to a more commonly curable lesion. Manometry has been developed as a guide to management of functional disorders of the rectum and anus. Perhaps, the biggest impacts in the field of colorectal and anal surgery have been the result of the liberalization of use of flexible colonoscopy, and the evolution of an understanding of the molecular basis of the diseases.
Over the past half century, surgical procedures associated with the largest and most complex visceral organ, the liver, have undergone extensive change. The segmental anatomy, based on vascular distribution, which had been defined a decade before the publication of the first edition, became more routinely applied, and resulted in more precise resections accompanied by reduced bleeding. Similarly, there has been an increased appreciation of the anatomy and anomalies of the biliary tract. The assessment of hepatic function has changed markedly. Flocculation tests, turbidity tests, dye excretion measurements, and scintillation scanning are no longer generally used. The international normalized ratio (INR) is relied upon as a marker of the liver’s ability to synthesize proteins.
The treatment of significant trauma to the liver has been modified, and the importance of temporary packing, which was mentioned only to be considered as contraindicated in the first edition, is now often employed. Splenoportography and hepatic scintillography have been replaced by CT scanning in the diagnosis of pyogenic abscesses of the liver, for which minimally invasive transabdominal drainage is preferable, and transthoracic drainage is generally avoided.
Solitary nonparasitic cysts are readily unroofed laparoscopically. Echinococcus cysts undergoing surgical therapy are now initially sterilized with hypertonic saline rather than formalin. Hemangiomas, the most common benign tumors of the liver, are excised for pain or rapidly increasing size, rather than for fear of spontaneous rupture. Observation is recommended for asymptomatic patients. Simple enucleation is almost always successful, regardless of the size of the lesion. It has become appreciated that a benign hepatic adenoma, which has the potential for spontaneous rupture and hemorrhage, also has the potential to transform into a malignant tumor and, in general, should be excised. Fifty years ago, there was no consideration of adenomatosis of the liver and the potential for malignant transformation necessitating transplantation. The first edition also failed to mention focal nodular hyperplasia, which has no malignant potential, but may necessitate resection to eradicate severe pain.
Primary malignant tumors of the liver, hepatocellular carcinoma and cholangiocarcinoma, are now frequently detected, incidentally, on CT. With the liberal use of imaging, the statement made in the first edition that spontaneous rupture and hemorrhage is often the first manifestation of a primary liver tumor, no longer pertains. At the time of the first edition, there was no appreciation of hepatitis B and C, and their role in the development of hepatic malignancies. Hepatocellular and intrahepatic cholangiocarcinoma were inappropriately grouped together. Fifty years ago, the only definitive treatment was resection, whereas currently, transcatheter arterial chemoembolization (TACE), Yttrium-90 (Y-90) radioembolization, microwave and radiofrequency, and stereotactic body radiation therapy (SBRT) offer viable options. The nihilism related to the resection of metastatic tumors to the liver, particularly from colorectal primaries, has been erased.
In the first edition, almost half of the chapter on the liver considered the issue of cirrhosis and portal hypertension. At the time, the now antiquated diagnostic procedure of splenic pulp manometry was used to define the hypertension. Balloon tamponade, transesophageal ligation of varices, and portal systemic shunts were procedures to which most surgical residents were exposed, and their relative values were the subject of frequent publications. Currently, bleeding is controlled by transesophageal banding and medical reduction of portal hypertension, utilizing transjugular intrahepatic portosystemic shunts (TIPS). Not a single surgical shunt was performed at the University of Rochester Medical Center in the last 20 years.
The most important advances relevant to hepatic surgery have been improved imaging, the emergence of biliary tract endoscopy and manipulation, induced low central venous pressure during resection, portal vein embolization to stimulate growth of the remnant, energy devices for parenchymal transection, staplers for major vascular ligation and transection, minimally invasive approaches for resection, and refinements in transplantation.
Among the gastrointestinal special organ systems considered individually in the first edition, none has been affected to a greater extent by advances in diagnostic radiology than the pancreas. The liberal incorporation of CT scans (at times enhanced by intravascular contrast) and MRIs in diagnostic algorithms has resulted in more precise preoperative assessments. The absence of those diagnostic tools, which were nonexistent prior to the first edition, accounted for deficiencies in knowledge related to pancreatitis. Also, improved diagnosis significantly increased the frequency of resectable lesions and the recognition of new pathological categories.
In regard to acute pancreatitis, which has become the most common gastrointestinal discharge diagnosis in the United States, two encompassing statements made in the first edition, namely, “Acute pancreatitis is largely diagnosed by clinical history and findings…,” and “Radiological examinations have only occasional value in acute pancreatitis,” would no longer be considered correct.
In the first edition, the only pancreatic neoplasms considered were carcinomas of the pancreas and periampullary region, islet cell tumors, and ulcerogenic tumors of the pancreas. A direct consequence of the addition of CT scans and MRIs to the diagnostic armamentarium has been an appreciation of other varieties of pancreatic neoplasms, often discovered as incidental findings. These include nonfunctioning pancreatic neuroendocrine tumors (PNETs), mucinous cystadenomas, cystadenocarcinomas, and intraductal papillary mucinous neoplasms (IPMNs).
Fifty years ago, minimally invasive techniques for pancreatectomy were not considered to be a future possibility. Regional lymph node metastasis was present in 90% of patients with carcinoma of the pancreas, and about 80% had liver metastasis at the time of diagnosis. Only 10-15% of patients had resectable lesions. No radiotherapy or chemotherapy had been demonstrated to improve cure rates or extend life.
Radioisotopic scanning of the spleen has been replaced by modern CT scanning and angiography. Idiopathic thrombocytopenic purpura is now generally managed with immune gamma globulin, and there has been a consequent reduction in the use of splenectomy to control thrombocytopenia. Thrombotic thrombocytopenic purpura is treated with plasmaphoresis rather than splenectomy, and refractory cases are rare. One of the most common indications for elective splenectomy, namely, for staging of Hodgkin’s disease, is no longer applicable.
Peritonitis and Intra-Abdominal Abscess
The presence of a chapter dedicated to peritonitis and intra-abdominal abscess in the first edition is evidence of the concern that the subjects evoked at the time. The removal of a subject from the textbook’s table of contents is evidence that, although its significance may not have been reduced, it is more appropriately considered as a segment of a more encompassing issue.
The peritoneal cavity is no longer used as a site for transfusion. Primary peritonitis, also referred to as spontaneous bacterial peritonitis (SBP), is now most frequently associated with peritoneal dialysis, and is usually monomicrobial. The most common cause of secondary peritonitis a half century ago was perforation of a peptic ulcer, which is now rarely seen in this country. The time-honored plain films for free air are still diagnostic but have generally been replaced by CT scans. Needle aspiration is a rarity, and lavage is a procedure of the past. Definitive therapy is frequently provided by interventional radiology, avoiding surgical intervention.
“Tertiary peritonitis” was not included in the first edition. It arose in an era of increased survival after prolonged intensive care, and refers to persistence or recurrence of intra-abdominal infection following adequate therapy. The use of antibiotics in peritoneal irrigation remains controversial. The “damage-control” approach for severe sepsis associated with peritonitis (leaving the abdomen open and applying a temporary vacuum dressing) was not a consideration at the time of the initial publication. The detailed anatomic descriptions for surgical drainage of intraperitoneal abscesses that were featured in the first edition are no longer as pertinent. Currently, CT or ultrasonographically guided percutaneously placed drains or laparoscopic drainage is standard.
The chapter on abdominal wall hernias considered inguinal and ventral wall hernias. In reference to inguinal hernias, it was stated, “in most…circumstances an expectant attitude is not warranted.” It is now appreciated that asymptomatic or minimally symptomatic inguinal hernias can be treated expectantly with only rare adverse consequences, which should be balanced against the risks of a surgical procedure.
Most repairs were performed using native tissue based on anatomic principles. The procedures were assigned the names of surgeons who popularized them, such as Bassini, Halsted, McVay, and Shouldice. The names have faded into obscurity, and the use of native tissue is now reserved for contaminated fields. The majority of inguinal hernia repairs are now performed using tension-free prosthetic patches inserted through an inguinal incision or laparoscopically.
Ventral hernias were repaired with sutures primarily, at times accompanied by relaxing incisions. In the original chapter, it was indicated that “most surgeons have not been happy with the use of any foreign material for these repairs.” Primary repair is now an uncommon approach; the use of mesh, applied directly or laparoscopically, has become the preferred method to close the defect.
The pituitary gland, which has been referred to as the conductor of the body’s endocrine symphony, has been the subject, and object, of dramatic change during the half century following the initial publication of Principles of Surgery. The changes transcend anatomy, molecular biology, physiology, clinical syndromes, and surgical approach and applicability.
The application of new immunohistochemical techniques has made the historic designations “basophilic” and “eosinophilic” obsolete, and unroofed precise correlations between cell types, molecular biology, and hormonal function. An improved understanding of endocrine interrelationships has led to safer surgery for pituitary tumors. Radioimmunoassays provide more information and have replaced the metyrapone test to define hypopituitarism.
An error was promulgated in the first edition related to Cushing’s disease when it was stated that a pituitary tumor is a rare cause of Cushing’s disease. It is now known that more than two-thirds of cases are due to pituitary adenoma (most are microadenomas, which were not identifiable at the time because of the lack of refined imaging). The biochemical establishment of the diagnosis has changed. Transsphenoidal surgery has become the first line of treatment, and radiotherapy is reserved for rare surgical failures. Radiotherapy is no longer provided by implants, having been replaced by conformal external beam or stereotactic radiosurgery. Cryosurgery is no longer used to ablate pituitary lesions.
The diagnosis of acromegaly has been modernized by chemical testing for insulin-like growth factor-1 (IGF-1), and if present, an MRI almost always demonstrates the tumor. Treatment is multifaceted, including transsphenoidal or transcranial adenomectomy, radiotherapy ablation, and medical control, using somatostatin analogues or GH-receptor dimerization blockers. Nonfunctioning chromophobe adenomas are the most common adenomas. The statement in the original text that they may produce ACTH is wrong. The other indications for hypophysectomy (diabetic retinopathy, metastatic carcinoma of the breast and prostate) have been relegated to the past.
Transsphenoidal hypophysectomy, which was introduced in the 1970s and gained broad acceptance in the 1990s, is a prime example of a transformational surgical procedure. Continued evolution, with the introduction of endoscopic techniques, has birthed the field of endoscopic skull base surgery.
Dopamine agonists now constitute the initial treatment for prolactinomas. The medications normalize prolactin levels and reduce tumor size in the vast majority of cases.
Bilateral adrenalectomy for metastatic carcinoma of the breast or prostate is no longer performed. A correction is called for regarding a statement in the first edition; two-thirds, rather than the stated “at least 90%,” of patients with primary aldosteronism have a solitary tumor. More importantly, the reported 100% frequency of hypokalemia represents a significant misrepresentation, in that most patients with primary hyperaldosteronism are not hypokalemic, which accounts for the delayed or under-diagnosis.
“Localization of an adrenal pheochromocytoma to either the left or right side is no longer a matter of great importance, now that the concept of an abdominal approach with complete exploration has become generally accepted,” has become an anachronism. Preoperative localization is routine and bilateral “exploration” is no longer done. Metaiodobenzylguanidine (MIBG) scanning can identify a pheochromocytoma or an extra-adrenal paraganglionoma. A variety of genetic syndromes which incorporate pheochromocytoma have been described. Measurements of adrenal hormone levels or their metabolites are now routine. Beta blockers are rarely used to prepare patients with pheochromocytoma for resection because the drugs increase the risk for stroke if the patient is not fully alpha blocked. The procedure of adrenalectomy has benefited from the advent of laparoscopic and retroperitoneoscopic techniques.
In assessing disease of the thyroid, protein-bound iodine and butanol-extractable iodine measurements are no longer performed. Similarly, thyroid biopsy for establishing the diagnosis of thyroiditis is no longer performed. Thyroiditis is considered to be a clinical diagnosis, and should be added as a cause of thyrotoxicosis. Total thyroidectomy has become the accepted treatment of Graves’ disease. Thyroxine suppression is no longer recommended as treatment of goiter, because it is generally ineffective and predisposes to osteoporosis. The statement that “Solitary nodules of the thyroid in patients under the age of forty should be removed” merits correction to “should be biopsied.”
Thyroid fine needle aspiration is now the standard for assessing nodules. Undifferentiated carcinomas of the thyroid make up about 1% of malignant tumors of the gland, rather than the previously stated “10%.” Currently, the technique of thyroidectomy calls for ligation of the inferior thyroid artery close to the thyroid capsule to avoid damage to the recurrent laryngeal nerve, which is now often identified intraoperatively by electrical stimulation, and also minimizes the risk of trauma to the parathyroid glands.
Significant expansions in knowledge concerning parathyroid disorders have been accompanied by modifications in diagnosis and management. Whereas in a 1966 report fewer than 1% of individuals with primary hyperparathyroidism were asymptomatic, this group now constitutes a majority. Less than 33% of patients with hyperparathyroidism have renal stones, and the incidence of peptic ulcer disease is less than 10%, rather than the previously reported 28%, in men. Although the association between hyperparathyroidism and multiple endocrinopathies was referred to in the first edition, it related only to what is now termed MEN 1. MEN 2a and 2b were not defined at the time. The statement in the first edition indicating that complete remission of primary hyperparathyroidism can occur is now considered to be an error.
Primary hyperparathyroidism is now often diagnosed in patients whose calcium is less than 10.5 and, not infrequently, in patients whose calcium is reported as normal. Ionized calcium measurements provide more precise determinations. The phosphate deprivation test, the EDTA test, the Dent test, and the calcium perfusion test are no longer used. Current assays readily differentiate between parathyroid hormone and parathyroid hormone-related peptide. High resolution ultrasound, CT, and technetium sestamibi scans have been added to the armamentarium for diagnosis.
The indications for performing parathyroidectomy in patients with renal involvement have been markedly liberalized. Methods to identify involved glands preoperatively have advanced to the state that an involved gland may be removed through a small incision, followed by demonstrating a drop in PTH level while the patient is anesthetized. Some surgeons still routinely identify four glands.
Pediatric surgery has undergone significant change. The surgical management of infants and children has its own distinctions, as evidenced by the establishment of children’s hospitals and specialized intensive care units. Child life specialists orient children and their parents to the unique aspects of pediatric medical care. Intraoperative maintenance of the patient’s temperature has been modernized with the use of a “bear hugger,” which replaced the water mattress.
A major advance has been made by the application of extracorporeal membrane oxygenation (ECMO). The first neonatal survivor occurred in 1975, and by 1980, the University of California Irvine recorded a 55% survival rate for 40 neonates, and a 20% survival rate for 12 older children in whom it was applied.
Small cystic hygromas are treated by excision, and most mediastinal extensions can be removed thoracoscopically. Large cystic hygromas can be sclerosed. The diagnoses of tracheoesophageal fistula and esophageal atresia are usually made in utero by ultrasonography. A preemptive gastrostomy to prevent aspiration prior to a definitive operation is rarely performed. Similarly, pharyngotomy for control of secretions from the proximal blind pouch has become a procedure of the past. Open or thoracoscopic primary repair is the standard approach, and is tolerated well by premature infants. Immediate colon interposition is rarely employed.
The diagnosis of congenital hypertrophic pyloric stenosis is established by ultrasonography. The lesion is now often corrected laparoscopically. H2 blockers and metoclopromide are administered in the early postoperative period to expedite gastric emptying. Because an increased incidence of malignancy in asymptomatic Meckel’s diverticula has been defined, when the abnormality is encountered during exploration of the peritoneal cavity, it should be routinely removed. Omphalocele and gastroschisis are also often diagnosed in utero. Difficult closures are initially managed by wound vacuum dressings, tissue expanders, and skin flaps, rather than relaxing, incisions, and skin grafts. Exteriorizing and decompressing procedures for intestinal atresia are rarely used. Meconium ileus, which accounts for 9-33% of intestinal obstruction in the newborn, can be detected by routine prenatal ultrasonography. An inherited expression of the cystic fibrosis transmembrane conductance regulator gene (CTFR) has been defined. Early postoperative survival now approaches 100%.
Reduction of intussusception is, generally, initially attempted by pressure reduction using air- or water-soluble contrast material. The diagnosis of Hirschsprung’s disease is now made by suction biopsy of the rectal mucosa, and the surgical correction has been modified to the extent that the incidence of fecal incontinence is low and the prognosis is excellent. The management of imperforate anus has undergone a major change. Ultrasound is used to determine the distance between the blind pouch and the perineum. Posterior sagittal anorectoplasty (The Pena procedure or PSARP) has become the standard.
As will be shown, the combination of a landmark diagnostic breakthrough, which was published about a decade after the first edition of Principles of Surgery appeared, and two major mechanical innovations that were introduced later, dramatically transformed the practice of urology. The first expanded the patient base, while the latter created new paradigms for technical training. A review of the initial chapter on Urology uncovered the need for corrections and modifications that are a result of experience gained in the past half century.
To the list of symptoms related to disorders of the genitourinary system, erectile dysfunction/impotence and subfertility/infertility have been added as integral considerations. A correction is to be made regarding prostatic secretions in that the “tiny refractile bodies” are lecithin rather than, as stated, “cephalin.” Semen analysis can be performed on a specimen after 2-3 days of sexual abstinence, rather than the stated 5 days. The illustration of commonly used urologic instruments portrays the past, and most filiforms and followers have been replaced by hollow followers passed over a wire.
The advent of CT scans, with and without intravenous contrast and delayed images to view the collecting system, magnetic resonance imaging with and without gadolinium, and retroperitoneal and pelvic ultrasound has replaced excretory pyelography, radioisotopic renography, cineradiography, and nephrotomography as diagnostic standards.
The standard treatment for neurogenic bladder dysfunction of varying causes, including post-traumatic paraplegia, is, currently, intermittent self-catheterization. The spectrum of antibiotics used for urinary tract infections has changed significantly and greatly expanded over the years. The diagnosis of ureteral obstruction by a calculus is now usually diagnosed more expeditiously with a CT scan, and, if immediate decompression is required, it is effected by percutaneous catheter drainage. Patients with acute bacterial prostatitis and urinary retention are preferably treated with suprapubic drainage.
The management of urinary calculi has been modernized, both diagnostically and therapeutically. CT scans and ultrasounds provide a high degree of accuracy for the identification and localization of calculi. Technical advances, beginning in 1980 with the introduction of extracorporeal shock wave lithotripsy, and followed by ureteroscopic disruption by laser, have transformed treatment.
In the realm of urologic neoplasms, Wilms’ tumor has been associated with tumor suppressive genes. The combination of resection and multimodal adjuvant therapy has become associated with improved survival rates, even subsequent to resection of liver and lung metastases. With the liberal use of new radiologic techniques, most renal tumors are diagnosed incidentally and treated expeditiously.
The treatment of bladder cancer has added to endoscopic resection and electrodessication the intravesical instillation of bacillus Calmette-Guerin (BCG) for high-grade non-muscle invading urothelial malignancies. The statement, “…no systemic chemotherapeutic agent warrants enthusiastic recommendation,” merits modification. Cisplatin combination treatment, while not curative, has significant efficacy. Although the 5-year survival for patients without muscle invasion remains 77-80%, with deep muscle invasion, survival is now 60%, rather than the previously recorded 10%.
The prostate has been the focus of the most marked changes in urology. In the first edition, BPH was erroneously said to refer to “Benign Prostatic Hypertrophy,” rather than the correct “Benign Prostatic Hyperplasia.” Medical management of BPH is now achieved with alpha blockers (e.g. tamsulosin) and 5 alpha reductase inhibitors (e.g. finasteride). Estrogens and progestins are no longer used, and androgens are not given to increase muscle tone. Transurethral prostatectomy is the more frequently employed surgical procedure, but the first edition incorrectly indicated that the mortality rate for open prostatectomy was four times greater than that of the transurethral procedure. The rate is essentially the same.
The exponential increase in surgical attention to the prostate can be traced to a 1979 publication from Buffalo’s Roswell Park immunology laboratory that identified a “Prostate Specific Antigen” linked to cancer in the gland. In 1986, the FDA gave approval for the use of the PSA as a monitor for response to therapy. In 1994, the use of the PSA for surveillance was initiated. The American Association for Cancer Research has designated PSA as one of the “landmark scientific discoveries of the 20th century.”
Following a marked increase in the number of open prostatectomies, laparoscopic prostatectomy was introduced in 1997. The ultimate modification of robotic resection, which expedited operating within the pelvis, was introduced in 2001, and has become the standard. The new case rate has increased from that initially recorded in the first edition of 32,000, to over 200,000 per year. Rather than the 10% stated for the incidence of localized tumors given in the first edition, that figure is now greater than 80%. Consequently, the 5- and 10-year cure rates have increased from 70% and 40%, to 90% and 60%, respectively.
The cure rates for external radiotherapy and interstitial irradiation have also increased. It has been concluded that about 50% of men with a small focus of tumor with a ≤6 Gleason score lesion need no treatment other than surveillance. The use of androgen deprivation therapy (ADT) and luteinizing hormone-releasing hormone (LHRH) agonists has increased the 5- and 10-year survival rates from the 20% and 10% listed in the first edition, to the current 70% and 25-30%.
The diagnosis and monitoring of testicular tumors now includes measurement of serum alpha-fetoprotein, beta-human choriogonadotropin, and lactate dehydrogenase, rather than urinary gonadotropins. Retroperitoneal lymph node resection continues to be standard, while chemotherapy has been modified to consist of bleomycin, etoposide, and cisplatin. This combination of chemotherapy and surgery has been highly successful in curing patients, even those with widespread metastases.
The most significant categories in which progress has been made in gynecology during the past half century parallel those which pertained to urology. Advances in biochemistry have improved the diagnosis of hormonal change, the assessment of ovarian cancer, and formed the basis for the creation of new drugs used successfully as adjuvant therapy in cancer patients. “Technical Considerations of Gynecologic Operations” is now dominated by operative procedures and approaches which would have been unanticipated at the time the first edition was being collated.
Follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-mullerian hormone (AMH), estradiol, and progesterone can all be assayed quantitatively. Beta-human chorionic gonadotropin (β-hCG) can be detected within 48 hours of fertilization. The “Gynecologic Evaluation of Acute Abdominal Pain,” as it appeared in the first edition, is now outdated. Culdoscopy and culdocentesis are no longer performed, having been replaced by laparoscopy, which is the current cornerstone for evaluating patients with endometriosis, and other imaging techniques. Regarding “Disorders of Reproductive Capacity,” the first in vitro fertilization postdated the publication of the first edition by almost a decade.
The modernization of the 1969 narrative pertaining to gynecologic oncology is multifaceted and of broad scope. Carcinoma of the cervix, which was the most common malignant tumor of the female reproductive tract at the time of publication of the first edition (accounting for 50-60% of cases), now occurs less frequently than ovarian and endometrial cancer in developed countries. The establishment of the causative effect of sexually transmitted HPV, and the development of a vaccine, have been significant achievements that have postdated the first edition by 15 years and 40 years, respectively. Screening for dysplasia and cervical cancer is now performed routinely with cytology and HPV typing.
Loop electrosurgical excision procedure (LEEP) is currently used to treat moderately severe dysplasia, or define the extent of invasion of a malignancy. If there is no evidence of extension into the deep layers, the cone biopsy is considered to be therapeutic, and observation, rather than hysterectomy, is appropriate, especially when maintenance of fertility is desired. Invasive carcinomas of the cervix are evaluated with diagnostic techniques which were not available when the first edition was published (CT, PET scan, MRI). A new staging system has evolved, and appropriate therapy has been defined: Stage IA1-cone or hysterectomy, StageIA2-hysterectomy, Stage IB1or2-radical hysterectomy or chemoradiation. Pelvic exenteration has become a rarity, having been replaced by chemoradiation. The prognosis for patients with all stages of treated cervical cancers has improved over the past half century.
A new International Federation of Gynecology and Obstetrics (FIGO) staging for endometrial carcinoma has replaced the one that appeared in the first edition. The current treatment consists of hysterectomy and bilateral salpingo-oophorectomy, with pelvic and periaortic node dissection, or the biopsy of a sentinel node to determine the extent of lymphatic spread. The terminology currently applied to the types of uterine sarcoma differs from that used in the first edition. It is now appreciated that most vulvar malignancies are HPV related. The treatment has changed from “radical vulvectomy combined with bilateral superficial and deep groin node dissection,” to wide local excision with sentinel node biopsy (if positive, chemoradiation). Most malignant tumors of the vagina are treated with chemoradiation.
Among the gynecologic malignancies, the most extensive advances have been made in the detection, evaluation, and treatment of ovarian carcinoma. The prognosis for ovarian carcinoma has benefited from earlier detection. CA 125 (mucin 16) was introduced in 1981 as a tumor marker for ovarian cancer. More recently, HE4, a new biomarker, has been shown to provide improved detection and specificity over CA 125. The Risk of Ovarian Malignancy Algorithm (ROMATM) assesses the risk of malignancy for an adnexal mass.
A new histologic classification has replaced the one that appeared in the first edition. A FIGO staging system has been adopted for all surgically staged ovarian cancers. Treatment consists of surgical debulking and subsequent chemotherapy. Recently, neo-adjuvant chemotherapy followed by interval debulking has become standard. Radiation therapy, which was popular at the time of the first edition, is now rarely used.
In the first edition it was stated, “Primary malignant tumors of the [Fallopian] tubes are the least frequently seen cancers of the female genital tract.” This is now regarded as false, since it has been shown that about 40% of what were thought to be ovarian cancers arise from cells lining the tubes.
During the recent decades, which were marked by technical advances applied to all aspects of operative surgery, no specialty has been affected to a greater extent than gynecology. Most gynecologic operations are now performed using a minimally invasive approach (laparoscopy or robotic-assisted laparoscopy). The first edition of Principles made no mention of “hysteroscopy,” which actually evolved over two centuries, but didn’t achieve popularity until the 1980s. It has replaced “Dilatation and Curettage” for resection of uterine polyps, excision of submucosal or intracavitary myomas, and removal of retained products of conception.
Medical therapy with methotrexate, or laparoscopy, is generally employed for patients with an ectopic pregnancy. For elective hysterectomy, a minimally invasive technique, with its safety enhanced by electrocautery devices such as LigaSureTM, harmonic scalpel, and ENSEAL, was first successfully performed in 1988, and has become the standard. Vaginal hysterectomy, which was employed before the Common Era, was omitted from the original chapter.
The transformational changes which have taken place in neurologic surgery over the past half century, are, to a great extent, the result of technologic advances. Refinements in imaging have improved diagnosis and have added to precision intraoperatively. The microscope developed for intraoperative use has increased the accessibility of intracranial lesions and markedly improved the safety of their removal. The microscope has also allowed for minimally invasive surgery on the spine. Computerized stereotaxy has become integral to many neurosurgical procedures. Although the technique had been introduced prior to publication of Principles, it is conspicuous by its absence from the narrative and the list of references. A third technologic advance, the endovascular management of intracranial vascular lesions, has been revolutionary.
The introduction of new techniques of nerve transfer has improved the prospect for functional improvement following an operation on a traumatized peripheral nerve. In regard to the treatment of intracranial lesions, in addition to the technologic advances incorporated in surgical excision, the therapeutic armamentarium has been expanded by noninvasive stereotactic radiosurgery. Recent advances in the genetic characterization of malignancies have led to targeted therapy and improved survival.
Arguably, the most apparent advances in neurologic surgery relate to the management of intracranial vascular disease. Microscope guidance has increased the possibility of excision, and improved safety. Radiographically guided endovascular obliteration of aneurysms, and thrombectomy, in the setting of recent ischemic stroke, were not considered 50 years ago.
The management of chronic pain and the amelioration of movement disorders represent two aspects of neurosurgical care that have evolved subsequent to the reviewed publication, and have become a focus of interest for neurosurgeons. Ablative procedures to eliminate epileptic seizures, the use of deep brain stimulation to ameliorate the symptoms of movement disorders, and the application of transcutaneous electric stimulation of the spinal cord to treat chronic pain received no mention in the original chapter.
The revolutionary applicability of skull base surgery to the field of neurosurgery has been addressed in the section on the pituitary gland.
In retrospect, the editors of the first edition of Principles allocated an inappropriate proportion of the textbook to orthopedic surgery. Seven chapters, consisting of 218 pages (12% of the narrative), failed to reflect the extent of specialization that had already occurred and the reduction of exposure of general surgeons to orthopedic disorders. Subsequent to the publication, specialization has intensified and characterizes current medical practice.
In a reconsideration of “Manifestations of Musculoskeletal Disorders,” it is apparent that the advances in diagnostic radiology (CT, MRI, and ultrasonography) have not only resulted in more precise evaluation, but have also altered treatment. CT and MRI have replaced lateral, oblique, and special X-ray views, and markedly reduced the use of lumbar puncture and myelography for diagnosis. The chapter’s consideration of intervertebral disc protrusion antedated the currently popular microdiscectomy. The assessment of gait, which was crude at the time of the first edition, has become very sophisticated, and has radically changed the treatment of cerebral palsy. The surgical treatment of scoliosis has been revolutionized by the use of pedicle screws. The complication of Volkmann’s contracture has been reduced by the adoption of percutaneous fixation of pediatric elbow fractures. The treatment of Osgood-Schlatter disease now rarely requires casting or immobilization.
Significant changes have occurred over the past half century in the management of “congenital orthopedic deformities.” What was termed “Congenital Dysplasia of the Hip” in the first edition is now called “Developmental Dysplasia of the Hip.” Diagnosis of the disorder has been augmented by the development of ultrasonography, which provides assessment prior to the development of the proximal ossification center. The Pavlik harness, which had been introduced in the Czech Republic in the 1950s, has become accepted as the initial strategy to reduce a dislocated hip in an infant. Similarly, the Ponseti technique, which had been introduced at the University of Iowa in the 1950s, has become globally accepted as the treatment of choice for club foot. Both techniques failed to gain inclusion in the first edition. Regarding the treatment of aplasia or dysplasia of long bones, limb lengthening based on the principles of distraction osteogenesis, which had been developed by Ilizarov in Siberia in the 1950s, was not introduced to the Western medical world until 1971 and therefore failed to gain consideration in the first edition.
Among the “Generalized Bone Disorders,” osteoporosis was not officially acknowledged and defined as a disease by the World Health Organization (WHO) until 1994, because dual-energy X-ray absorptiometry (DXA scan), which provides assessment of bone density, had not been perfected. Treatment regimens, which incorporate estrogen agonists, selective estrogen reception modulators (SERMs), and RANK ligand (RANKL) inhibitors, all evolved subsequently. The management of “Tumors of the Musculoskeletal System” has been significantly altered by imaging (CT, MRI, PET) and neoadjuvant and adjuvant chemotherapy to which the sarcomas have proven to be sensitive. The result has been more frequent limb-saving and function-preserving operations rather than amputation, which, at the time of publication of the first edition, was the sole therapy.
The chapter, “Fractures and Joint Injuries,” is notable for providing additional evidence for the assertion that extraordinary advances have been made in all aspects of orthopedic surgery during the past half century. At the time of the first edition, the absence of a grading system for open fractures hindered the acquisition of meaningful data required to predict outcome and allow for the practice of “evidence-based medicine.” The most commonly used system for classifying open fractures (the Gustilo classification) was introduced in 1976, and modified into its current form in 1984. This helped define the contemporary management of open fractures.
The use of plaster (now more frequently fiberglass) casts for immobilization and traction, commonly employed and the subject of illustration in the first edition, has generally been replaced by early internal fixation followed by early mobilization.
In the narratives concerning specific fractures, most of the defined standards of treatment no longer pertain. Femoral neck fractures are now usually treated by internal fixation, hemiarthroplasty, or total hip replacement followed by full weight bearing and early mobilization in the immediate postoperative period. Fractures of the femoral shaft are now treated, almost exclusively, by intramedullary nailing or plate fixation. The first edition’s printed statements, “Femoral shaft fractures in children are treated exclusively by closed methods,” and “Treatment of shaft fractures in adults is best accomplished by skeletal traction,” would now be labeled as incorrect.
Similarly, the current management of traumatic epiphyseal separation of the femur consists of internal fixation and early mobilization. The management of ligamentous injuries of the knee is representative of the modernization of orthopedics. Improved diagnosis, attributable to MRI and arthroscopy, followed by arthroscopic management, minimized hospitalization, and immediate mobilization and rehabilitation, provides a microcosm of the current management of all fracture and joint injuries.
The surgical principles and techniques applicable to amputations, as presented in the first edition, have undergone little change in the ensuing decades. By contrast, prostheses, which are major determinants of the functional capabilities and lifestyles of amputees, have improved significantly. The have become lighter and stronger, less noticeable cosmetically, and are engineered for improved functionality. Myoelectric sensors and microprocessors allow movement to be controlled by the amputee. The achievements of amputees and the improvement in their quality of life are, perhaps, the most visible evidence of the impact of technology on surgical care.
Plastic and Reconstructive Surgery
A poignant disparity between the maiden edition of Principles and the current narrative related to plastic and reconstructive surgery is captured by viewing two sequential subjects on pages 1766 and 1767 in the 1969 publication. Equal space was allotted to microsurgery, dermabrasion, and tattooing. Included among the references in the first edition is a 1966 report by H. J. Bunke, Jr. and W. P. Schulz; the first report of microminiature vascular anastomosis to effect reconstruction of a portion of the body. Microsurgery is now considered to be one of the identifying elements of the discipline.
Revolutionary microsurgical techniques have allowed for the transfer of tissue and body parts to areas in need of reconstruction. More recently, microsurgery has been used to effect composite tissue transplantation from another human source to recreate faces, extremities, and other injured areas otherwise not amenable to repair. Success is a result of the combination of the advances in surgical technique, and capability for achieving immunosuppression to avoid rejection.
Currently, “dermabrasion” is included in the more inclusive “skin resurfacing,” in which laser treatment has replaced the dermabrader as the principle method to remove the epidermis and parts of the dermis to allow for regrowth and apparent rejuvenation. Technologic advances in radiology have resulted in plain films being replaced by computed tomograms to define facial fractures and to create three-dimensional models to plan treatment. Titanium plates and screws have allowed for early repair and stable fixation, leading to earlier mobilization and improved function.
Lip reconstruction was improved by the introduction of the Karapandzic flap in 1974. Microvascular tissue transfer has been used in more complex cases. Free flaps are used to reconstruct sizeable defects of the head and neck. Fibula osseocutaneous flaps are now commonly employed to replace missing bone in the region. The repair of cleft lip and palate has been refined, and the nasal deformity is addressed simultaneously. Nasoalveolar molding techniques to reconstruct separated structures have evolved, and the importance of concomitant sleep apnea is appreciated. Distraction osteogenesis represents the state of the art for treatment of mandibular hypoplasia and other disorders of bony underdevelopment. Most rhinoplasties are now performed as open procedures with inconspicuous incisions, and may incorporate cartilage grafting.
Cosmetic surgery has undergone exponential growth. Botulinum toxin has been added to the armamentarium to treat facial rhytids. Injection of autologous fat harvested by liposuction has been used to restore volume and provide contour. Breast reconstruction has become an integral consideration for patients to be treated for breast cancer. Tissue expanders (permanent implants placed under the pectoralis major at the time of mastectomy), abdominal based muscle flaps, and fat grafting are included among the therapeutic options.
A brief chapter on the hand was included in recognition of the fact that, at the time of preparation of the manuscript, the American Society for Surgery of the Hand, which was established in 1946 by 35 surgeons, had grown to 3500 members worldwide. By the time of the fourth edition, the length of the chapter increased four times.
The initial edition’s chapter included pollicization of the index finger to substitute for a congenitally absent thumb, but antedated by several months the report of the first successful replantation. Hand transplantation was performed for the first time in the late 1990s. Microsurgical toe transfer has become the gold standard for amputated thumb, with a 95% rate of success.
The most notable additions to the surgical armamentarium of hand surgeons have been minimally invasive endoscopic procedures, particularly for correction of carpal tunnel and cubital tunnel syndromes. Also, two refinements have been added to the treatment of Dupuytren’s contracture. Needle fasciotomy to release contractures has proved to be effective, but less durable than excision. Surgery remains the mainstay, but injectable clostridial collagenase is considered an acceptable alternative.