Presidential address, 1995. Surgery 2000: a look back to the future.

The present demoralized state of Canadian surgery is due to a number of short-term influences. They include financial restraints, the desire of government agencies to off-load blame for unpopular decisions onto doctors and altered public expectations. The major long-term challenge will be a shortage of physicians and a severe shortage of general surgeons because of the superimposition of longer-term trends in medical demographics on short-term political reactions to a perceived oversupply of doctors. General surgeons need to identify the significant, long-term threats and challenges. If they can do this and plan their responses knowledgably, with some measure of altruism, the future in general surgery will be a bright one for present and future residents and medical students.

Splenic vein thrombosis as a cause of variceal bleeding.

Splenic vein thrombosis as a cause of variceal bleeding is underdiagnosed. Newer, noninvasive techniques of diagnosis that have been introduced recently appear to be accurate. Isolated gastric varices in the presence of normal liver function and especially in the presence of pancreatic disease should prompt a search for splenic vein thrombosis. Splenectomy is the treatment of choice.

Thoracic outlet compression.

In a review of his experience with thoracic outlet compression, the author attempts to define factors that will help select patients for operation. Fifty-three patients underwent 59 transaxillary resections of the first rib. In almost all cases the diagnosis was clinical, based mainly on the history. Aortography was useful only when intrinsic vascular disease was suspected. Nerve-conduction studies were not helpful and were used only to confirm a diagnosis of peripheral nerve compression. Of 44 patients followed up, 33 had good or excellent results. Of the 11 patients with poor results, 8 complained of persistent neck and shoulder pain. The author concludes that the diagnosis of thoracic outlet compression is clinical and is based mainly on the patient's history. Transaxillary resection is safe and effective, particularly for patients whose symptoms are mainly in the hand and arm. It is not effective for those whose predominant complaint is neck and shoulder pain.

Early gastric cancer.

Early gastric cancer confined to the mucosa or submucosa, similar to that described in the Japanese literature, exists in Newfoundland, on area of North America in which gastric cancer is four times more prevalent that on the rest of the continent. If untreated, this early gastric cancer will progress to advanced disease. The clinical presentation of 10 patients suffering from cancer confined to the mucosa and submucosa of the stomach is described. The disease presents with acute or chronic bleeding or unexplained dyspepsia; no abnormality of the stomach can be seen on roentgenograms. The diagnosis may be suspected at endoscopic examination. Cytologic studies using touch preparations may be suggestive but the diagnosis should be confirmed by biopsy before operation is performed.

Laceration of superior vena cava due to blunt trauma: successful surgical management.

Injuries of the superior vena cava are usually due to penetrating trauma. Injuries due to blunt trauma are rare. The diagnosis of superior vena caval injuries, which may be intrapericardial or extrapericardial, is usually made retrospectively. In the case described in this report the patient, a 21-year-old man, sustained an intrapericardial laceration due to blunt trauma. The patient was managed successfully by median sternotomy and immediate control of the bleeding.

Endoscopic diagnosis of intestinal metaplasia in Canada and Japan.

We carried out comparative studies on chronic atrophic gastritis with accompanying intestinal metaplasia using the methylene blue dye spraying, endoscopic technique on 167 Japanese and 77 Canadian outpatients free of gross stomach disease. In both population samples (Kyoto, Japan and St. John's, Newfoundland) with increasing subject age, the fundic-pyloric (F-P) border shifted cephalad indicating atrophy of the fundic mucosal glands. Japanese subjects, however, showed greater variation in location of the F-P border. The reduction in fundic gland area with aging was followed by intestinal metaplasia, the incidence and severity of which was greater in Japanese than in Canadian outpatients. From these data we conclude that a difference in the gastric mucosa in these two countries may be related to the pathogenesis of gastric cancer.

Pyogenic psoas abscess secondary to infection of the lumbar disc space.

Two cases of staphylococcol psoas abscess are reported. These occurred many years after operations on lumbar discs, complicated by post-operative disc space infection. Clinical and radiological findings are reported. The features of psoas abscess and the management are discussed.

Some aspects of wound healing research: a review.

Mammalian response to injury essentially is that of tissue repair and re-epithelialization. The most important component of repair tissue is collagen, and after injury collagen turnover is greatly increased. Collagen biosynthesis is initiated by nuclear DNA of fibroblasts; the steps in biosynthesis are complex but studies of collagen biosynthesis may eventually have clinical potential. Normally, wound healing lasts for up to 2 years but nutritional and metabolic factors, such as malnutrition, delay healing; hyperalimentation would likely be beneficial under these conditions. Other factors that influence wound healing are the oxygen tension in tissues, the hemodynamic status, and the effects of substances such as cortisone, vitamins A and C, and zinc.