The subspecialization of surgery: a paradigm shift.

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Proximal radial artery as inflow site for native arteriovenous fistula.

BACKGROUND: Most vascular surgeons favor an initial radial-cephalic anastomosis at the wrist for dialysis access when possible. As populations age and more chronically ill patients are offered dialysis, this native arteriovenous fistula (NAVF) is less frequently available. A brachial-cephalic anastomosis is generally considered to be the second choice for NAVF site. We report our experience in a series of patients where the proximal radial artery (PRA) serves as the primary inflow vessel. STUDY DESIGN: We reviewed 139 consecutive dialysis access operations performed by the senior author. One hundred fourteen had an NAVF constructed. Seventy-three of these procedures in 71 patients involved the PRA as arterial inflow and are the subject of this report. RESULTS: Mean age was 57 years. Thirty-six of the 71 were men. Seventy-one percent of the patients were diabetic and more than half had previous access surgery. Twenty-nine patients underwent preoperative ultrasonographic evaluation for feasibility and planning of the NAVF fistula. The 1-month patency rate for patients undergoing PRA fistula was 98%. Cumulative patency was 80% during the followup period of up to 42 months. No infectious or ischemic complications were noted during the study period. CONCLUSIONS: We find the anterior position and mobility of the PRA offers a simple and tension-free anastomosis to the median antebrachial vein or one of its tributaries. This anastomotic site frequently allows dialysis in both the forearm and upper arm. The PRA allows for adequate arterial inflow while avoiding the risk of steal syndrome found with brachial artery fistulas. More extensive procedures or use of prosthetic grafts can be avoided.

Choledochal Cystic Diseases.

Cystic disease of the intrahepatic and extrahepatic bile ducts results in rare malformations with a variable presentation. The majority of patients present during childhood with symptoms of abdominal pain, cholangitis, and an abdominal mass. A palpable mass is unusual in adults, and adult patients tend to present with recurrent cholangitis, pancreatitis, or rarely portal hypertension. The cause of this disorder also is debated, with both congenital and acquired origins postulated. The gold standard for the treatment of choledochal cysts is complete excision with the establishment of biliary flow into the gastrointestinal tract. The well described malignant potential of the cyst and the high rate of recurrent cholangitis with internal drainage procedures mandate cyst excision when possible. In the event of extensive scarring or malignant changes of the cyst, the posterior wall of the cyst may be left in situ to avoid endangering the portal vessels, which are found posteriorly. Alternatively, various endoscopic or percutaneous interventions may provide symptomatic relief. However, every effort should be directed towards complete resection of the cyst and the re-establishment of biliary-enteric continuity.