Faculty Bibliography

BACKGROUND:Historically, management of pancreatic cancer has been determined based on whether the tumor was amenable to resection and all patients deemed resectable received curative intent surgery followed by adjuvant therapy with chemotherapy (CT) ± RT. However, patients who undergo resection with microscopic (R1) positive margins have inferior rates of survival. The purpose of this study is to identify patients who have undergone pancreatectomy for pancreatic cancer, determine the surgical margins, types of adjuvant therapies given and patterns of failure. Our hypothesis was that in patients who have surgery without pre-operative therapy, there is a high rate of R1 resections and subsequent local recurrence, despite adjuvant therapy. METHODS:CT alone, stratified by surgical margin status. RESULTS:13 months, P=0.06), but there was no significant difference in time to death compared to patients with CT alone (P=0.68). CONCLUSIONS:After curative resection, the addition of RT to CT improves PFS in both R0 and R1 settings. However, patients with R1 have significantly worse PFS and OS compared to patients with R0 and even aggressive adjuvant therapy does not make up for the difference. The paradigm has shifted and now for patients with resectable pancreatic cancers we recommend neoadjuvant CT + RT to improve RT targeting and treatment response assessment and most importantly, improve chances of obtaining R0.

OBJECTIVE:To describe and evaluate a root cause analysis (RCA)-based educational curriculum for quality improvement (QI) practice-based learning and implementation in general surgery residency. DESIGN/METHODS:A QI curriculum was designed using RCA and spaced-learning approaches to education. The program included a didactic session about the RCA methodology. Resident teams comprising multiple postgraduate years then selected a personal complication, completed an RCA, and presented the findings to the Department of Surgery. Mixed methods consisting of quantitative assessment of performance and qualitative feedback about the program were used to assess the value, strengths, and limitations of the program. SETTING/METHODS:Urban tertiary academic medical center. PARTICIPANTS/METHODS:General surgery residents, faculty, and medical students. RESULTS:An RCA was completed by 4 resident teams for the following 4 adverse outcomes: postoperative neck hematoma, suboptimal massive transfusion for trauma, venous thromboembolism, and decubitus ulcer complications. Quantitative peer assessment of their performance revealed proficiency in selecting an appropriate case, defining the central problem, identifying root causes, and proposing solutions. During the qualitative feedback assessment, residents noted value of the course, with the greatest limitation being time constraints and equal participation. CONCLUSION/CONCLUSIONS:An RCA-based curriculum can provide general surgery residents with QI exposure and training that they value. Barriers to successful implementation include time restrictions and equal participation from all involved members.

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.