LETTERS TO THE EDITORS The Editors invite readers to submit letters commenting on the contents of articles that appear in the Journal. Also welcome are brief communications in letter form reporting investigative or clinical observations without extensive documentation and with brief bibliography (five titles or less), not requiring peer review but open to critique by readers, Letters to the Editors should be no more than 500 words in length and they may have to be edited for publication.
Restructuring general surgical residencies To the Editors:
During the past few years discussions have taken place at both the American Board of Surgery and the Residency Review Committee for Surgery on the desirability of restructuring general surgical residencies. Currently general surgical residencies provide I to 3 years of preliminary surgical training for individuals going on into the specialties of neurosurgery, orthopedic surgery, otolaryngology, and urology. The programs also provide 5 years of complete general surgical training for individuals going into cardiothoracic, plastic, colon and rectal, vascular, and pediatric surgery. All require General Surgical Board certification before candidates can sit for their certifying examination except plastic surgery. When restructuring is considered, the most common theme is that the general surgery residency would provide a core 4-year program of basic surgical training. After this basic education in surgery, the surgical residents could then complete their specialty training by spending 1 to 3 years in either general surgery, plastic surgery, cardiothoracic surgery, vascular surgery, or pediatric surgery. One of the reasons given for restructuring the program in this fashion is that currently there are not enough of the more major general surgical operations, such as radical neck dissections, esophagogastrectomies, pancreatic resections, liver resections, Whipple operations, and major colon surgery to train the number of general surgical residents in their senior year of training. In other words, residents going into other specialties are being assigned the cases instead of future general surgeons. Others point out that the overall period of training of a young surgeon is too long. They feel that 4 years is an adequate number of years of basic surgical training before specialty training. As a member of the American Board of Surgery and as the representative from the joint vascular societies, I felt it important that the individuals who are responsible for the training of our future vascular surgeons should have some input into these discussions. I therefore polled the 59 directors of the Vascular Surgical Residency Program in the United States. Forty-six of the 59 directors responded. The questions and responses are listed on the following table. Although five directors indicated that they would welcome applicants after a 4-year program, three of the five indicated that if this did occur they would immediately require the residents to have a 2-year clinical program in vascular surgery before considering them to have had adequate training.
Questions
Would you (1) Welcomethe opportunity to accept applicants after a 4-year program? (2) Never accept a resident who has not had the fifth year of general surgery? (3) Prefer5-yearresidents but would accept strong applicants after a 4-year program?
No. positive responses
5 16 25
Sixteen strongly indicated that they would never accept a resident who did not have a 5-year program including a senior year of general surgery. Some of the directors' remarks included, " . . . would further splinter general surgery," " . . . would drive the wedge between general surgery and vascular surgery," and " . . . would take vascular surgery out of the mainstream of general surgery, and vascular surgeons would less likely become directors of general surgical programs and less likely to participate in major national policy making." Other directors were concerned that the core residents would not have experience with complicated abdominal operations, which are so important for the vascular surgeon doing aortic and visceral operations. Others were concerned that they would not do enough vascular surgery in their core program to make them suitable candidates for the vascular residency. Others pointed out that if the core program did not offer a Certificate in general surgery that many vascular surgeons, who still choose to perform both vascular surgery and general surgery, would be left out. Twenty-five directors indicated they would prefer 5-year residencies but would accept strong applicants after a 4-year program. Ten of these directors, however, added comments suggesting that not only must the applicants be strong but the 4-year core program from which they came would have to be strong. Some responders indicated that they would take 4-year applicants only " . . . if all training programs provide significant operative experience during earlier clinical years," " . . . if the core program could train young surgeons to operate independently,.... . . . if the 4-year program made them complete general surgeons." One optimistic director stated that "a properly arranged 4 years of a surgical residency could establish a base from which further specialty training begins." In conclusion, it would appear that despite the strong feelings of 16 of the 46 directors that things should continue as they are, most directors were willing to 435
436
Journal of VASCULAR SURGERY
Letters to the Editors
consider accepting 4-year residents, particularly if both the applicants and the programs from which they came were "strong." It is important that vascular surgeons continue t o be aware of these discussions and participate in them in the future. James A. De Weese,MD
Professor of Surgery University of Rochester Medical School 601 Elmwood Ave. Rochester, NY 14642-8410 Treatment o f abdominal aortic aneurysm by occlusion and bypass: an analysis o f outcome To the Editors:
Shah et al. 1 are to be commended for their continual efforts to introduce new and more artful techniques to the field of vascular surgery. It is likely that all great innovators have had ideas that were not particularly fruitful or useful, and it is suggested that treatment of abdominal aortic aneurysms by exclusion and bypass is one such idea. 1 Although Drs. Ernst and Mannick also questioned the utility of this procedure in their discussion, several other points are worth raising. It is interesting that in only 21% of Shah's patients was placement of a tube graft possible. In many series this is possible in up to 80% of patients. One advantage to opening the aneurysm sac is that this is often the only way to identify the sewing ring for the distal anastomosis. It simply is not apparent from outside as the aneurysm extends right up to the aortic bifurcation. Shah et al. are, therefore, subjecting many patients to an additional, more difficult anastomosis with its attendant additional dissection and blood loss, and at times an additional incision that is mandated by their approach. Shah cites increased distance from peritoneal contents as another advantage of their technique. With multiple layers of tissue, including aneurysm sac, periaortic tissue, and peritoneum, between prosthesis and peritoneal contents when using the midline approach, this assertion is foolish. The position of their prosthesis, by contrast, appears awkward. What could be more "comfortable," to use Dr. Leather's term, than placing the graft exactly where the artery it replaces used to reside. Dr. Leather states " . . . it is not how quick the operative trip is in an aneurysm treatment, it is how smooth physiologically it is." However, the two may be directly related. In most cases performed via a midline approach at our institution, operative time is less than 2 hours, banked blood is rarely necessary thanks to the cell saver, and patients are frequently discharged from the hospital within 5 to 7 days. Published physiologic data relating to the retroperitoneal approach to the aorta d o not seem, however, to translate into faster surgery or earlier discharge. Most telling, perhaps, is Dr. Leather's notion that his technique takes the "blood and thunder" out of the midline approach. The beauty of the endoaneurysmorrhapy technique is the absence of blood and thunder. It is quick,
relatively bloodless with minimal dissection, and most patients return home within a week. Ultimately any new technique must improve on these simple facts. Steven G. Friedman, M D
560 Northern Blvd. Suite 209 Great Neck, NY 11021 REFERENCES
1. Shah DM, Chang BB, Paty PSK, Kaufman JL, Koslow AR, Leather RP. Treatment of abdominal aortic aneurysm by occlusion and bypass: an analysis of outcome. J VASCSURG 1991;13:15-22. Reply To the Editors:
We appreciate the fact that our article, "Treatment of abdominal aortic aneurysm by exclusion and bypass: an analysis of outcome," has drawn Dr. Friedman's careful attention. However, most points he has raised were discussed by the discussants of the paper and responded to by Dr. Leather. We will readdress these points for further clarification. Placement of a tube graft instead of a bifurcation graft is primarily of historical interest and should not be a consideration in modern aortic surgery. There is no advantage of a tube graft over a bifurcation graft as long as the surgical disease at hand is treated. An iliac anastomosis is not a difficult anastomosis, especially when the vascular surgeons are used to performing it and have a 98% 5-year patency rate. The aortoenteric interaction is a known complication of transperitoneal aortic replacement, which led to the devdopment of various techniques for graft and sutureline coverage as discussed. Despite these developments, the incidence of aortoenteric interactions has not decreased. This complication is yet to be reported for retroperitoneal repair Of abdominal aortic aneurysm (AAA). The purpose of this paper was not to compare the two approaches for AAA repair, but to illustrate the follow-up of an excluded aneurysm sac. For Dr. Friedman's interest, other articles address this comparison. 1-3 The contention that quick surgery is more physiologic is naive. Unless one has used both techniques and compared them, an occasional anecdotal report of the value of one technique in one's own hands has very little lasting value. Many "simple facts"~of surgery have been improved on, although initially such improvements have been overlooked. For example, AAA surgery has evolved over the years from a progression of changes including simple ligation, excision, endoaneurysmorraphy, and now exclusion. The impact of these changes is obvious. Dhiraj M. Shah, M D Benjamin B. Chang, M D Robert P. Leather, M D
Department of Surgery, A61 Albany Medical College Albany, NY 12208
Restructuring general surgical residencies To the Editors:
During the past few years discussions have taken place at both the American Board of Surgery and the Residency Review Committee for Surgery on the desirability of restructuring general surgical residencies. Currently general surgical residencies provide I to 3 years of preliminary surgical training for individuals going on into the specialties of neurosurgery, orthopedic surgery, otolaryngology, and urology. The programs also provide 5 years of complete general surgical training for individuals going into cardiothoracic, plastic, colon and rectal, vascular, and pediatric surgery. All require General Surgical Board certification before candidates can sit for their certifying examination except plastic surgery. When restructuring is considered, the most common theme is that the general surgery residency would provide a core 4-year program of basic surgical training. After this basic education in surgery, the surgical residents could then complete their specialty training by spending 1 to 3 years in either general surgery, plastic surgery, cardiothoracic surgery, vascular surgery, or pediatric surgery. One of the reasons given for restructuring the program in this fashion is that currently there are not enough of the more major general surgical operations, such as radical neck dissections, esophagogastrectomies, pancreatic resections, liver resections, Whipple operations, and major colon surgery to train the number of general surgical residents in their senior year of training. In other words, residents going into other specialties are being assigned the cases instead of future general surgeons. Others point out that the overall period of training of a young surgeon is too long. They feel that 4 years is an adequate number of years of basic surgical training before specialty training. As a member of the American Board of Surgery and as the representative from the joint vascular societies, I felt it important that the individuals who are responsible for the training of our future vascular surgeons should have some input into these discussions. I therefore polled the 59 directors of the Vascular Surgical Residency Program in the United States. Forty-six of the 59 directors responded. The questions and responses are listed on the following table. Although five directors indicated that they would welcome applicants after a 4-year program, three of the five indicated that if this did occur they would immediately require the residents to have a 2-year clinical program in vascular surgery before considering them to have had adequate training.
Questions
Would you (1) Welcomethe opportunity to accept applicants after a 4-year program? (2) Never accept a resident who has not had the fifth year of general surgery? (3) Prefer5-yearresidents but would accept strong applicants after a 4-year program?
No. positive responses
5 16 25
Sixteen strongly indicated that they would never accept a resident who did not have a 5-year program including a senior year of general surgery. Some of the directors' remarks included, " . . . would further splinter general surgery," " . . . would drive the wedge between general surgery and vascular surgery," and " . . . would take vascular surgery out of the mainstream of general surgery, and vascular surgeons would less likely become directors of general surgical programs and less likely to participate in major national policy making." Other directors were concerned that the core residents would not have experience with complicated abdominal operations, which are so important for the vascular surgeon doing aortic and visceral operations. Others were concerned that they would not do enough vascular surgery in their core program to make them suitable candidates for the vascular residency. Others pointed out that if the core program did not offer a Certificate in general surgery that many vascular surgeons, who still choose to perform both vascular surgery and general surgery, would be left out. Twenty-five directors indicated they would prefer 5-year residencies but would accept strong applicants after a 4-year program. Ten of these directors, however, added comments suggesting that not only must the applicants be strong but the 4-year core program from which they came would have to be strong. Some responders indicated that they would take 4-year applicants only " . . . if all training programs provide significant operative experience during earlier clinical years," " . . . if the core program could train young surgeons to operate independently,.... . . . if the 4-year program made them complete general surgeons." One optimistic director stated that "a properly arranged 4 years of a surgical residency could establish a base from which further specialty training begins." In conclusion, it would appear that despite the strong feelings of 16 of the 46 directors that things should continue as they are, most directors were willing to 435
436
Journal of VASCULAR SURGERY
Letters to the Editors
consider accepting 4-year residents, particularly if both the applicants and the programs from which they came were "strong." It is important that vascular surgeons continue t o be aware of these discussions and participate in them in the future. James A. De Weese,MD
Professor of Surgery University of Rochester Medical School 601 Elmwood Ave. Rochester, NY 14642-8410 Treatment o f abdominal aortic aneurysm by occlusion and bypass: an analysis o f outcome To the Editors:
Shah et al. 1 are to be commended for their continual efforts to introduce new and more artful techniques to the field of vascular surgery. It is likely that all great innovators have had ideas that were not particularly fruitful or useful, and it is suggested that treatment of abdominal aortic aneurysms by exclusion and bypass is one such idea. 1 Although Drs. Ernst and Mannick also questioned the utility of this procedure in their discussion, several other points are worth raising. It is interesting that in only 21% of Shah's patients was placement of a tube graft possible. In many series this is possible in up to 80% of patients. One advantage to opening the aneurysm sac is that this is often the only way to identify the sewing ring for the distal anastomosis. It simply is not apparent from outside as the aneurysm extends right up to the aortic bifurcation. Shah et al. are, therefore, subjecting many patients to an additional, more difficult anastomosis with its attendant additional dissection and blood loss, and at times an additional incision that is mandated by their approach. Shah cites increased distance from peritoneal contents as another advantage of their technique. With multiple layers of tissue, including aneurysm sac, periaortic tissue, and peritoneum, between prosthesis and peritoneal contents when using the midline approach, this assertion is foolish. The position of their prosthesis, by contrast, appears awkward. What could be more "comfortable," to use Dr. Leather's term, than placing the graft exactly where the artery it replaces used to reside. Dr. Leather states " . . . it is not how quick the operative trip is in an aneurysm treatment, it is how smooth physiologically it is." However, the two may be directly related. In most cases performed via a midline approach at our institution, operative time is less than 2 hours, banked blood is rarely necessary thanks to the cell saver, and patients are frequently discharged from the hospital within 5 to 7 days. Published physiologic data relating to the retroperitoneal approach to the aorta d o not seem, however, to translate into faster surgery or earlier discharge. Most telling, perhaps, is Dr. Leather's notion that his technique takes the "blood and thunder" out of the midline approach. The beauty of the endoaneurysmorrhapy technique is the absence of blood and thunder. It is quick,
relatively bloodless with minimal dissection, and most patients return home within a week. Ultimately any new technique must improve on these simple facts. Steven G. Friedman, M D
560 Northern Blvd. Suite 209 Great Neck, NY 11021 REFERENCES
1. Shah DM, Chang BB, Paty PSK, Kaufman JL, Koslow AR, Leather RP. Treatment of abdominal aortic aneurysm by occlusion and bypass: an analysis of outcome. J VASCSURG 1991;13:15-22. Reply To the Editors:
We appreciate the fact that our article, "Treatment of abdominal aortic aneurysm by exclusion and bypass: an analysis of outcome," has drawn Dr. Friedman's careful attention. However, most points he has raised were discussed by the discussants of the paper and responded to by Dr. Leather. We will readdress these points for further clarification. Placement of a tube graft instead of a bifurcation graft is primarily of historical interest and should not be a consideration in modern aortic surgery. There is no advantage of a tube graft over a bifurcation graft as long as the surgical disease at hand is treated. An iliac anastomosis is not a difficult anastomosis, especially when the vascular surgeons are used to performing it and have a 98% 5-year patency rate. The aortoenteric interaction is a known complication of transperitoneal aortic replacement, which led to the devdopment of various techniques for graft and sutureline coverage as discussed. Despite these developments, the incidence of aortoenteric interactions has not decreased. This complication is yet to be reported for retroperitoneal repair Of abdominal aortic aneurysm (AAA). The purpose of this paper was not to compare the two approaches for AAA repair, but to illustrate the follow-up of an excluded aneurysm sac. For Dr. Friedman's interest, other articles address this comparison. 1-3 The contention that quick surgery is more physiologic is naive. Unless one has used both techniques and compared them, an occasional anecdotal report of the value of one technique in one's own hands has very little lasting value. Many "simple facts"~of surgery have been improved on, although initially such improvements have been overlooked. For example, AAA surgery has evolved over the years from a progression of changes including simple ligation, excision, endoaneurysmorraphy, and now exclusion. The impact of these changes is obvious. Dhiraj M. Shah, M D Benjamin B. Chang, M D Robert P. Leather, M D
Department of Surgery, A61 Albany Medical College Albany, NY 12208
