Unlike medical rounds, where in order to “keep up” you need to “one up” by quoting a current (preferably yesterday’s) journal article, in surgery, you can flourish by knowing the following references-but you need to know them cold.

1. Mangano DT, Goldman L: Pre-operative assessment of patients with known or suspected coronary disease. N Engl J Med 333:1750-1756, 1995.
This is an update of Goldman’s original (NEJM, 1977) article in which he pioneered the concept of “risk adjusted surgical outcome.” You should copy Table 2, Three Commonly Used Indexes of Cardiac Risk, and always carry it with you. Intuitively, a triathlete will weather a surgical stress better than a supreme court judge, but this article provides a point system with which you can calculate objective perioperative risk.
2. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breast conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227-1232, 2002.
Seven hundred women with less than 2 cm breast cancer were randomized to radical mastectomy or quadrantectomy and radiation therapy. After 1976, patients with positive axillary nodes also received adjuvant CMF (cyclophosphamide, methotrexate and 5-fluorouracil). After 20 years, 30 women in the conservative treatment group and 8 women in the radical mastectomy group suffered local recurrence (p , 0.01). Conversely, the incidence of deaths from all causes at 20 years was identical at 41%. The authors conclude that breast conservation therapy is the “treatment of choice” for women with “relatively small breast cancers.”
3. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1223-1241, 2002.
Clinical investigation is hard to do. The National Surgical Adjuvant Breast and Bowel Project (NSABP) Trials, initiated 25 years ago, continue to serve as the benchmark for superb prospective, randomized investigations. In this study, 1851 women were randomized after the breast tumor was excised and the nodal status was documented. The authors conclude that lumpectomy followed by breast irradiation is appropriate therapy. In order to appreciate the huge problems in interpreting clinical trials, you must read this article carefully. Radiation did decrease death from breast cancer, but this reduction was partially offset by an increase in deaths from other causes.
4. Barnett HJ, Taylor DW, Eliasziw M, et al: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 339:1415-1425, 1998.
This is the North American Symptomatic Carotid Endarterectomy Trial (NASCET) initiated in 1987. NASCET randomized patients with severe carotid stenosis (70-99%) and moderate stenosis (< 70%) into standard medical therapy or carotid endarterectomy (CEA). By 1991, the clear advantage of surgery in symptomatic patients with severe stenosis was so clear that the study was stopped for this group. This manuscript reports a 5-year reduction in ipsilateral stroke from 22.2% (medical) to 15.7% (surgical) (p = 0.045) in patients with moderate (50-69%) stenosis. Once a patient with carotid disease becomes symptomatic, that is ominous. As you witness various diseases, you subconsciously compile a list of diseases you don't want. A big burn and a big stroke are on the top of everyone's list.
5. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. J Am Med Assoc 273:1421-1428, 1995.
The Asymptomatic Carotid Atherosclerosis Study (ACAS) randomized 1662 asymptomatic patients with > 60% carotid artery stenosis to medical prescription (one aspirin a day plus risk factor modification) or carotid endarterectomy. After only 2.7 years, the projected 5-year risk of ipsilateral stroke/death was 5.1% in the surgical group and 11% in the medical group. This is an aggregate (including perioperative trouble) risk reduction of 53%. This article concludes that an asymptomatic patient with a 60% or greater carotid artery lesion, who is an acceptable risk (atherosclerosis is a systemic disease) for elective surgery will enjoy a reduction in 5-year risk of ipsilateral stroke if the surgery can be accomplished with less than a 3% aggregate morbidity/mortality.
6. Selzman CH, Miller SA, Zimmerman MA, Harken AH: The case for beta-adrenergic blockade as prophylaxis against perioperative cardiovascular morbidity and mortality. Arch Surg 136:286-290, 2001.
When patients suffer perioperative morbidity and mortality, the cardiovascular system is typically the culprit. Patients with coronary artery disease cannot increase coronary blood flow to meet the enhanced oxygen demand associated with surgical stress. Beta-adrenergic blockade decreases myocardial oxygen consumption, and cardioselective beta-blockers do not exacerbate bronchospasm in patients with COPD. These authors argue that all patients over 40 years old will benefit from beta-adrenergic blockade initiated 2 weeks prior to elective surgery.
7. Van den Berghe G, Wouters P, Weekers F, et al: Intensive insulin therapy in critically ill patients. N Engl J Med 345:1359-1367, 2001.
Both hyperglycemia and insulin resistance are characteristic of critically ill patients. These authors randomized 1548 SICU patients to either aggressive blood glucose control (maintained at 80-110 mg%) or conventional therapy (give insulin only if blood glucose exceeds 215 mg%). Aggressive glucose control decreased ICU mortality from 8% to 4.6% (p , 0.04) with the largest impact in patients with multiple organ failure from a septic focus.
In surgery, attention to detail counts big:
* Keep blood sugar between 80 and 110 mg%.
* Give prophylactic antibiotics 0-2 hours preop so the patient will have a good antibiotic blood level at the time of the incision.
* Keep your patient warm (37°C).
* Hyperoxia reduces infection.
8. Van De Vijver MJ, He YD, van’t Veer LJ, et al: A gene expression signature as a predictor of survival in breast cancer. N Engl J Med 347:1999-2009, 2002.
The authors postulate that 70 of our 35,000 genes dictate the character of breast cancer. So cancer, unlike cystic fibrosis and sickle cell disease, requires a constellation of genetic mutations-not just one. They followed 295 patients for 12 years and report that this “70 gene signature” predicts survival better than the classical indicators of patient age, tumor size, tumor histology, pathologic grade, and hormone receptor status and even lymph node disease. The latter is the shocker. The authors observe that distant metastasis kills you, positive lymph nodes don’t. In patients with either positive or negative lymph nodes, gene profile determines survival. Each cancer does not acquire an ability to metastasize as it grows, that capability is programmed into the very first neoplastic cell that establishes residence in your patient.
9. Sandham JD, Hull RD, Brant RF, et al: A randomized controlled trial of the use of pulmonary artery catheters in high risk surgical patients. N Engl J Med 348:5-14, 2003.
This is a superb study in which 1994 surgical ICU patients were randomized to goal-directed therapy guided by a pulmonary artery catheter or standard care without a PA catheter. The patients were sick and, to be included for randomization, had to be over 60 years old, have estimated ASA class III or IV risk (major disease), and scheduled for elective or urgent surgery. Hospital mortality and survival at 6 and 12 months were essentially identical. Following years of impassioned debate, the utility of a PA catheter, even in sick surgical patients, can no longer be justified. Conversely, if, after you have given fluid and low-dose cardiotonic agents, your patient is not improving or still presents a confusing picture, place a PA catheter and get more information. When your patient improves, pull it out.
10. Harken AH: Enough is enough. Arch Surg 134:1061-1063, 1999.
This article explores the surgeon’s responsibility to assess surgical risk, to relate risk to anticipated physiologic and psychological benefit, and to develop common sense strategies to appreciate individual patient happiness. When benefits exceed anticipated operative risks-this is easy-proceed with surgery. When risks excee