Faculty Bibliography

PURPOSE: To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). METHODS AND MATERIALS: Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. RESULTS: Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade >/=3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. CONCLUSIONS: Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.

Over the past decade, the capabilities and use of endoscopic simulators have steadily expanded. Nevertheless, simulator use has yet to become fully integrated into standard endoscopic training programs. There are two obstacles. First, we lack adequate knowledge about how competency should be defined and how people become proficient in various specific techniques. Second, there has not been an affordable and convenient model to effectively assist in training and assessment. This paper explores the barriers to incorporation of simulators in training programs, and discusses currently available mechanical, computer, and ex vivo tissue models for assessment.

The growing importance of colonoscopy in the prevention of colorectal cancer has stimulated an effort to identify and track quality indicators for this procedure. Several factors have been identified so far which are readily measurable and in many cases have been associated with improved patient outcomes. There is also ample evidence of variations in performance of this procedure. As a result, gathering data about quality indicators may play a vital role in the process of continuous quality improvement. Quality indicators for colonoscopy in colorectal cancer prevention are described along with the evidence that supports their use in benchmarking, quality reporting, and continuous quality improvement.

Leaks after laparoscopic sleeve gastrectomy can be challenging to manage. Nonoperative management is preferred after the immediate postoperative period. No single treatment is effective in all cases. The best approach is to be persistent, to utilize a multidisciplinary team and to apply one or more endoscopic therapies, often in combination. We present a case of persistent leak after laparoscopic sleeve gastrectomy that highlights these issues

One consequence of recent health care reform efforts has been an increasing focus on defining and delivering high-quality care. Esophagogastroduodenoscopy (EGD) is a fundamental procedure for endoscopists and quality indicators for measurement have been proposed. These indicators are classified temporally as preprocedural, intraprocedural, and postprocedural. Although some indicators are evidence based, many are derived from expert consensus and may require further validation. An ideal quality indicator is easy to measure at the time of service, correlates well with patient outcome and experience, and has enough variation in practice to allow differentiation between good and poor performers. Among the many proposed quality measurements, it remains uncertain which best meet such criteria. Beyond compliance with reporting quality indicators for EGD, successful endoscopy practices will embrace quality improvement initiatives that collect, organize, and analyze their performance data to improve patient outcomes and the patient endoscopic experience. In recognition of these forthcoming changes, organizations have developed national repositories to assist endoscopy groups in this effort. These initiatives to first gauge and then improve the quality of EGD must lead in parallel to the development of standardized criteria for competency that can be adopted by all programs in which endoscopy is taught, regardless of specialty. 2012 Elsevier Inc