Faculty Bibliography

OBJECTIVES/OBJECTIVE:To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance. MATERIALS AND METHODS/METHODS:The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors' institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles. RESULTS:Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%. CONCLUSION/CONCLUSIONS:PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.

INTRODUCTION/BACKGROUND:The video game industry has become increasingly popular over recent years, offering photorealistic simulations of various scenarios while requiring motor, visual, and cognitive coordination. Video game players outperform nonplayers on different visual tasks and are faster and more accurate on laparoscopic simulators. The same qualities found in video game players are highly desired in surgeons. Our investigation aims to evaluate the effect of video game play on the development of fine motor and visual skills. Specifically, we plan to examine if handheld video devices offer the same improvement in laparoscopic skill as traditional simulators, with less cost and more accessibility. METHODS:We performed an Institutional Review Board-approved study, including categorical surgical residents and preliminary interns at our institution. The residents were randomly assigned to 1 of 3 study arms, including a traditional laparoscopic simulator, XBOX 360 gaming console, or Nintendo DS handheld gaming system. After an introduction survey and baseline timed test using a laparoscopic surgery box trainer, residents were given 6 weeks to practice on their respective consoles. At the conclusion of the study, the residents were tested again on the simulator and completed a final survey. RESULTS:A total of 31 residents were included in the study, representing equal distribution of each class level. The XBOX 360 group spent more time on their console weekly (6 hours per week) compared with the simulator (2 hours per week), and Nintendo groups (3 hours per week). There was a significant difference in the improvement of the tested time among the 3 groups, with the XBOX 360 group showing the greatest improvement (p = 0.052). The residents in the laparoscopic simulator arm (n = 11) improved 4.6 seconds, the XBOX group (n = 10) improved 17.7 seconds, and the Nintendo DS group (n = 10) improved 11.8 seconds. Residents who played more than 10 hours of video games weekly had the fastest times on the simulator both before and after testing (p = 0.05). Most residents stated that playing the video games helped to ease stress over the 6 weeks and cooperative play promoted better relationships among colleagues. CONCLUSIONS:Studies have shown that residents who engage in video games have better visual, spatial, and motor coordination. We showed that over 6 weeks, residents who played video games improved in their laparoscopic skills more than those who practiced on laparoscopic simulators. The accessibility of gaming systems is 1 of the most essential factors making these tools a good resource for residents. Handheld games are especially easy to use and offer a readily available means to improve visuospatial and motor abilities.

PURPOSE/OBJECTIVE:In recent years, the use of numeric paging in many medical centers has been largely replaced by 1-way alphanumeric paging. There is currently no research studying the potential for alphanumeric paging to lead to problems in communication. The purpose of this article is to determine whether the use of alphanumeric pagers may lead to potential problems in patient care and/or communication. METHODS:Alphanumeric pages sent to residents on 3 surgical services at the Medical College of Virginia Hospital were collected over a 3-month period. The pages were classified according to reason for the page, amount of information provided, and follow-up required. RESULTS:A total of 52,384 alphanumeric pages were sent to residents on the surgical services over a 3-month period. There were 1037 pages (2.0% of total) that contained patient laboratory results. 11,844 pages (22.6% of total) contained a callback number with no sender information and 6198 (11.8% of total) contained a callback number and sender information. Trauma pages totaled 10,312 (19.7% of total). There were 2636 pages (5.0% of total) that contained identifying information, potentially violating HIPAA regulations. CONCLUSIONS:The authors have observed a significant number of occurrences in which alphanumeric pages lack sufficient information, do not indicate the urgency of the page, and still require immediate callback by residents. This potentially interrupts patient care and educational activities.

Complications after transhiatal esophagectomy include pneumonia, recurrent laryngeal nerve injury, and anastomotic leak. Although damage to the trachea is a potential complication, there are minimal reports of tracheal compression after esophagectomy with gastric pull-through. We report a case of severe tracheal compression and obstruction requiring mechanical ventilation presenting 2 days postoperatively. Placement of a silicone tracheal stent relieved the obstruction in the distal trachea and facilitated extubation.

Primary breast lymphoma is a rare disease. Estimated incidence is 72 to 910 cases per year. We report a patient who developed anaplastic large cell lymphoma in her breast adjacent to a silicone breast implant 14 years after elective breast augmentation. Metastatic work up revealed no other focus of disease. She was treated with systemic chemotherapy. Review of the literature revealed five cases of primary breast lymphoma associated with a breast implant. Patients presented with either a mass or a periprosthetic fluid collection an average of eight years after either silicone gel-filled or saline-filled breast implant placement. Diagnosis was obtained with either biopsy or aspiration. All patients had the same histological subtype, anaplastic large cell lymphoma. It is unlikely that any cause-effect relationship exists between breast implants and primary breast lymphoma since chance alone could easily account for the low incidence of primary breast lymphoma in patients with breast implants. However, a fluid collection around a breast implant may be a unique presentation for this population of patients. Clinicians should include malignancy in the differential diagnosis of periprosthetic fluid collections and periprosthetic masses. Useful diagnostic tests may include MRI, aspiration with cytology, and percutaneous or open biopsy.

OBJECTIVE:The goals of this study are to define the demographics of program directors (PDs), characterize professional responsibilities and scholarly activities, assess career goals and perceptions, and determine what resources PDs have and how they use them. METHODS:A cross-sectional, confidential, Institutional Review Board (IRB)-approved, Internet-based survey was sent to general surgery PDs. PDs were identified from lists of known residencies from the Association of Program Directors in Surgery (APDS) and the Accreditation Council for Graduate Medical Education (ACGME). E-mail follow-up was used to contact nonresponders and partial responders. Demographic data were analyzed with descriptive statistics. RESULTS:The response rate was 58%. The mean age was 51.3 +/- 8.2 years. Most respondents were male (89.7%), Caucasian (86.9%), and fellowship trained (63.7%). Few PDs have teaching credentials (11%), but most PDs have sought additional training in teaching (63%). PDs work a total of 73 hours per week. They spend about 41 hours per week on clinical duties and about 22 hours per week on program director duties. PDs have an average of 4-5 support staff members; 81.5% of PDs have an assistant program director (APD). A few PDs have formal protected time (38.7%). Most PDs feel they have support for professional development and feel supported by their chairperson (90.8% and 94.1%, respectively). Lower job satisfaction scores were observed in measures of feeling valued by colleagues and in the availability of institutional resources. CONCLUSION/CONCLUSIONS:Most surgery PDs are fellowship trained, are currently conducting research, have an APD in their program, and feel supported by their chairperson. Most PDs do not have protected time, and some feel insufficient institutional resources are available for their responsibilities.

BACKGROUND:We evaluated the necessity of a tumor bed boost after whole-breast radiotherapy for early-stage breast cancer after breast-conserving surgery and negative re-excision. METHODS:Of patients treated at the Virginia Commonwealth and Tufts Universities with breast-conservation therapy for early-stage breast cancer between 1983 and 1999, 205 required re-excision of the tumor cavity to obtain clear margins and were found to be without residual disease. Adjuvant conventionally fractionated whole-breast radiotherapy was given to a total dose of 50 Gy in 25 fractions. The tumor bed boost was omitted. RESULTS:The median follow-up was 98 months (range, 6-229 months). The tumor histological diagnosis was primarily infiltrating ductal carcinoma (183 cases; 89%). Nodal involvement was documented in 49 cases (24%). There were four documented recurrences at the tumor bed site. Five in-breast recurrences were documented to be in a location removed from the tumor bed. The overall Kaplan-Meier 15-year in-breast control rate was 92.4%, and the freedom from true recurrence rate was 97.6%. CONCLUSIONS:The findings support the concept that postlumpectomy radiotherapy can be tailored according to the degree of surgical resection. There is an easily identifiable subgroup of patients who can avoid a tumor bed boost, thus resulting in a reduced treatment time and improved cosmesis, while maintaining local control rates that approach 100%. The data suggest that in patients who undergo a negative re-excision, treatment with whole-breast radiotherapy to 50 Gy is a sufficient dose to maximally reduce the risk of local recurrence.

Investigators have looked at the effect of night call on surgical residents but not at learning of laparoscopic skills. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) tests 6 tasks similar to a laparoscopic cholecystectomy. We hypothesized that night call would impair laparoscopic performance and that skills would not improve but rather deteriorate after night call. Seventeen volunteers were tested before and after night call. Data collected included economy of movement, time, and number of errors for each hand/foot. A paired Student t test was used for statistical analysis. On the first 2 tasks, there was an improvement in all parameters post-call, with significance reached in 5 of 18 parameters (P<or=.05). In the "running of the bowel,'' 8 of 9 parameters were significantly improved (P<or=.05). In the final task, 9 of 11 parameters showed a deterioration post-call, but only economy of movement of the foot was significant (P<or=.05). Most parameters (16) showed improvement rather than deterioration post-call, which is consistent with learning of laparoscopic skills despite lack of sleep from night call.