From: ((Steven B. Harris))
Subject: Re: How to Select a Surgeon??
Date: 23 Jun 1995

In <3sca5b$hkb@mindcrime.interstate.net> john@interstate.net (John
O'Brien) writes:

>My wife needs a surgically induced hernia on her abdomin repaired. She
>went to a surgeon yesterday and was impressed with his demeanor and felt
>real good about the surgery after leaving his office. BUT, she also had
>occasion to visit our FP that afternoon and when she told him about her
>visit he discretely warned her not to use that particular surgeon and
>then went on to recommend another surgeon. She's now in a quandry about
>what to do. I told her that she shouldn't be basing her decision on bed-
>side manner but I really don't know how to tell her what to do in order
>to make a good decision.
>
>How does one question a surgeon; what questions can be asked; what
>outside resources are available to 'really' determine a surgeons
>competence?  I looked for FAQ's which might deal with this on rtfm.mit.
>but found nothing.  So, can anyone advise us?   Thanks


Perhaps the most foolproof way to find a good surgeon is visit a major
hospital and talk to the OR nurses.  They all know who the best ones
are.  You can also get a lot of good info from surgical ICU nurses, who
take care of the end results of all the surgeons.  You don't have to ask
who the bad ones are, just who the really good ones are.  Find one who
does a lot of the proceedure you're interested in (not so important for
you, since you're gettting a relatively simple thing done), but still
important.

                                                   Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Recommendations for a surgeon?
Date: 30 Sep 1998 07:23:28 GMT

In
<E15FD5F937EC5195.62B581BE49A3DA90.80279EAA6BE30F08@library-proxy.airne
s.net> trx140@xmission.com (theurgy) writes:

>I'm considering having some plastic surgery done. There are *lots*
>of plastic surgeons, but surely there are excellent ones and not so
>good ones. I magine one gets pretty much what one pays for, and for
>this surgery I'm looking for the best surgeon I can find.
>
>However, trying to get an honest and unambiguous recommendation from
>another physician is next to impossible. The physicians I've asked
>either recommend someone they've known since med school and play
>golf with, or they refer me to the phsicians referral service, which
>will present me with a long list of surgeons, all of whom have the
>required certifications to practice plastic surgery.
>
>That doesn't help.
>
>Does anyone here either have sufficiently wide personal experience
>to recommend someone, or are there services that will locate and
>confidentially rate plastic surgeons? If Hugh Hefner or Vanessa
>Redgrave want a facelift, whom do they go to?
>
>Regards.



   Suggest you use the Harris Method:  Go you your nearest large
teaching center which does a lot of plastic surgery.  Find out where
the recovery units are, and the surgical suites (much of this will be
done in offices, but enough will be done in hospital for you to still
do this).  Then start asking around among the OR scrub nurses and
surgical nurses.  They know who the surgeons with the golden hands are,
and they're not shy about saying who they are.

                                   Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Pancreatoduodenectomy (Whipple Operation)
Date: 20 May 1999 10:52:46 GMT

In <clw-1905991648430001@i48-03-35.pdx.du.teleport.com>
clw@teleport.com writes:

>In article <7hvb22$g42@dfw-ixnews4.ix.netcom.com>,
>sbharris@ix.netcom.com(Steven B. Harris) wrote:
>
>> In <7hu4gv$pu8$1@nnrp1.deja.com> wesolowski@freewwweb.com writes:
>>
>> >What are the mortality and morbidity numbers on this procedure?
>> >Internet research revealed nothing.
>> >
>> >Thanks,
>> >Jack
>>
>>
>> Use www.ncbi.nlm.nih.gov/pubmed.   The procedure is often used
>> paliatively in people with cancer.  It's not a cure, just a stopgap to
>> keep the tumor from obstructing the GI tract.  This causes some
>> difficuly in assessing long term outcome, since people who have it are
>> usually rather ill from something else.
>
>Actually no.  In about 40 years of working in the OR, about 5% of
>proceedures listed for Whipple were open and close.  Most of the Whipples
>were done for pancreatic or ductal tumors found incidentally when they
>were very small.  By the time a tumor in that area becomes symptomatic, it
>is just too late.
>
>also, the proceedures used for palliation are not pancreatoduodenectomy.
>They are gastro-jujeneal bypass and cholecysto (or choledochal)-jejunal
>bypass.



Comment:
   It's true they don't do the Whipple for big tumors, but that doesn't
mean the person isn't ill in terms of having a very, very serious
disease (pancreatic cancer, usually).  They just may not be symptomatic
(yet).

   In response to the poster's question, opperative mortality depends
mostly on whether the hospital does a lot of the procedure.  But that's
true of any complex surgery.  Even if you have to travel 3000 miles to
get to a place where they do a lot of what you need done, DO it.
That's Harris' first rule of surgery.  Many a person picks a nice small
homey hospital close to home for that absdominal aneurism resection or
bypass.  A place where the relatives can visit and where they know
everybody.  And where they will die.



Surgery 1999 Mar;125(3):250-6
Effect of hospital volume on in-hospital mortality with
pancreaticoduodenectomy.
Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher
ES

Center for the Evaluative Clinical Sciences, Dartmouth Medical School,
Hanover, NH, USA.

BACKGROUND: Reports of better results at national referral centers than
at low-volume community hospitals have prompted calls for regionalizing
pancreaticoduodenectomy (the Whipple procedure). We examined the
relationship between hospital volume and mortality with this procedure
across all US hospitals. METHODS: Using information from the Medicare
claims database, we performed a national cohort study of 7229 Medicare
patients more than 65 years old undergoing pancreaticoduodenectomy
between 1992 and 1995. We divided the study population into approximate
quartiles according to the hospital's average annual volume of
pancreaticoduodenectomies in Medicare patients: very low (<
1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate
logistic regression to account for potentially confounding patient
characteristics, we examined the association between institutional
volume and in-hospital mortality, our primary outcome measure. RESULTS:
More than 50% of Medicare patients a undergoing pancreaticoduodenectomy
received care at hospitals performing fewer than 2 such procedures per
year. In-hospital mortality rates at these low- and very-low-volume
hospitals were 3- to 4-fold higher than at high-volume hospitals (12%
and 16%, respectively, vs 4%, P < .001). Within the high-volume
quartile, the 10 hospitals with the nation's highest volumes had
lower mortality rates than the remaining high-volume centers (2.1% vs
6.2%, P < .01). The strong association between institutional volume and
mortality could not be attributed to patient case-mix differences or
referral bias. CONCLUSIONS: Although volume-outcome relationships have
been reported for many complex surgical procedures, hospital experience
is particularly important with pancreaticoduodenectomy. Patients
considering this procedure should be given the option of care at a
high-volume referral center.

PMID: 10076608, UI: 99175904

----------

Ugeskr Laeger 1999 Feb 1;161(5):598-601


[Pancreaticoduodenectomy--Whipple's operation--for periampullary cancer
in patients over 70 years of age].
[Article in Danish]


Olsen SD, Trillingsgaard J, Struckmann JR, Burcharth F

Kirurgisk gastroenterologisk afdeling D, Amtssygehuset i Herlev.

Thirty-four consecutive patients with an age over 70 years with
periampullary cancer were operated on with pancreaticoduodenectomy
(Whipple's procedure). The operative procedure included an extensive
dissection of the regional connective tissue and lymph nodes including
the retroperitoneum. Postoperative medical complications occurred in 24%
and surgical complications in 53% of the patients. Four patients (12%)
died in the postoperative period (within 30 days), and three patients
(9%) died later in the postoperative course.  The cumulative and age
corrected five-year survival for the remaining patients was 26%. Fifteen
patients died from recurrence, and seven patients from other causes. In
patients with a non-radical operation the median survival was 1 1/2
years, which is longer than could be expected with other palliative
procedures.  Apart from a moderately increased postoperative mortality
the results were similar to those reported for younger patients. In
conclusion, pancreaticoduodenectomy may be considered in patients with an
age over 70 years with operable periampullary cancer. A five-year
survival rate of 20-35% can be obtained. Palliative resection is
indicated in patients in good general condition, as resection gives the
best palliation and longer survival than other palliative methods.

PMID: 9989195, UI: 99143740

----------

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Pancreatoduodenectomy (Whipple Operation)
Date: 21 May 1999 00:26:50 GMT

In <7i20u1$knh$1@nnrp1.deja.com> wesolowski@freewwweb.com writes:

>The game plan is to effect a local resection, have the polyp analyzed,
>and then proceed with Whipple if there is cancer. However, the surgeon
>says that a Whipple will be performed if local resection is not possible
>(and the lesion turns out to be benign).

  I assume he's not planning in that case to remove enough of your
pancreas to make you diabetic (that would be a high price to pay to get
rid of a benign tumor).  One option with a benign tumor is simply
remove as much as you can, and keep doing that every time it gets big
enough to bother you.  This may be better than a surgury which does a
major chop job on your gut.



> This is the scary part:
>fear of dying or morbidity from an operation on a benign tumor.


   For sure.  In that case, a number of smaller operations over the
rest of your life, each of which has less risk, might be more
preferable.



>On the plus side, he does "dozens" of Whipples a year at nearby Johns
>Hopkins Hospital.
>
>Jack


   That's good, but it's only part of the battle.  You want to have the
surgery done at a hospital where it is done often, and the OR and ICU
nurses have seen every possible complication from it.  The surgeon's
only part of the team.