Brian J. Kaplan

Comparing Video Games and Laparoscopic Simulators in the Development of Laparoscopic Skills in Surgical Residents

INTRODUCTION 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.

Who Are Surgery Program Directors and What Do They Need

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 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.

Severe Tracheal Compression Causing Respiratory Failure After Transhiatal Esophagectomy

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.

Predictors of Short-Term Readmission After Pancreaticoduodenectomy

BackgroundReadmissions are a common complication after pancreaticoduodenectomy and are increasingly being used as a performance metric affecting quality assessment, public reporting, and reimbursement. This study aims to identify general and pancreatectomy-specific factors contributing to 30-day readmission after pancreaticoduodenectomy, and determine the additive value of incorporating pancreatectomy-specific factors into a large national dataset.MethodsProspective American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data were retrospectively analyzed for patients who underwent pancreaticoduodenectomy (PD) between 2011 and 2015. Additionally, a subset of patients with pancreatectomy-targeted data between 2014 and 2015 were analyzed.ResultsOutcomes of 18,440 pancreaticoduodenectomies were analyzed, and found to have an 18.7% overall readmission rate. Multivariable modeling with pancreatectomy-specific variables increased the predictive value of the model (area under receiver operator characteristic 0.66 to 0.73). Statistically significant independent contributors to readmission included renal insufficiency, sepsis, septic shock, organ space infection, dehiscence, venous thromboembolism, pancreatic fistula, delayed gastric emptying, need for percutaneous drainage, and reoperation.ConclusionsLarge registry analyses of pancreatectomy outcomes are markedly improved by the incorporation of granular procedure-specific data. These data emphasize the need for prevention and careful management of perioperative infectious complications, fluid management, thromboprophylaxis, and pancreatic fistulae.

Changing paradigm in pancreatic cancer: from adjuvant to neoadjuvant chemoradiation

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 Seventy-one patients with curative resections for pancreatic cancer between 2003 and 2015 were reviewed. Tumor stage, margin status, distance to closest margin, receipt of adjuvant therapy and length of survival were collected. Patients were divided into two groups based on whether they received adjuvant CT + RT (n=37) or CT alone (n=37). Patients were further divided based on whether resection was R1 (n=29) or R0 (n=42). Wilcoxon survival tests and Cox proportional hazards regression models were performed to determine the effects of CT + RT vs. CT alone, stratified by surgical margin status. RESULTS Of the 29 patients (39%) who had R1, 15 received CT + RT and 14 received only CT. Patients who received CT + RT experienced a significantly longer period of PFS (13 vs. 7.5 mos, P=0.03) than patients who received CT alone. However, there was no significant difference found in time to death post cancer resection between CT + RT vs. CT alone (P=0.73). Of the 42 patients with R0, 21 received CT + RT and 21 received CT. There was a trend towards increase in PFS in patients treated with CT + RT (25 vs. 17 months, P=0.05), but there was no significant increase in time to death compared to patients treated with CT alone (P=0.53. Of the 36 patients with CT + RT, 21 had R0 and 15 had R1. Patients with R0 were more likely to have longer PFS (25 vs. 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.

Maintenance of Certification: What Everyone Needs to Know

Glenda G. Callender, MD, Brian J. Kaplan, MD, Richard L. White, MD, David R. Brenin, MD, Anees B. Chagpar, MD, MSc, MA, MPH, MBA, Kimberly M. Dalal, MD, Marissa Howard-McNatt, MD, James Howe, MD, Joseph Kim, MD, Scott H. Kurtzman, MD, John C. Mansour, MD, Elizabeth A. Mittendorf, MD, PhD, John H. Stewart IV, MD, Larissa K. F. Temple, MD, Patti Stella, BA, CCMEP, Charmaine Cummings, PhD, RN, CCMEP, Sandra L. Wong, MD, MS, and V. Suzanne Klimberg, MD

Widening the Therapeutic Window using an Implantable, Unidirectional LDR Brachytherapy Sheet as a Boost in Pancreatic Cancer

• Patients with borderline resectable pancreatic cancer are typically treated with neoadjuvant therapy including chemotherapy followed by chemoradiation with the goal of becoming surgical candidates. • Unfortunately, due to inflammatory changes after treatment the pre-operative imaging is not reliable in determining resectability and many patients still have concern for close or positive retroperitoneal margins given the proximity to major vasculature. • Post-operatively, an external beam RT (EBRT) boost is difficult given bowel constraints and difficulty in identifying the area at highest risk. • The purpose of this study is to demonstrate the ability of the LDR brachytherapy CivaSheet to deliver a focal high-dose boost, targeted to the area at highest risk in patients who received neoadjuvant chemoradiation.

The CivaSheet- the new frontier of intraoperative radiation therapy or a pricier alternative to LDR brachytherapy?: CivaSheet brachytherapy for re-irradiation

When defining the balance between tumor control and toxicities, considerable caution must be exercised near organs with serial functional subunits, such as the spinal cord and named nerves, because of the potential for irreversible damage. In such challenging clinical scenarios, the highly targeted nature of intraoperative radiation therapy (IORT) may offer a viable option to improve patient outcomes. Traditionally, IORT refers to the delivery of focused radiation immediately after surgical resection via intraoperative electron beam, superficial x-ray, or highor low-dose rate (HDR; LDR) mesh techniques. Although these methods provide a theoretical benefit because of their capacity for precise radiation delivery through a single procedure, several disadvantages have limited their use in clinical practice. Both electron and x-ray IORT require the costly installation of an intraoperative linear accelerator. The large size and customization limitations of currently available IORT electron cones make targeting of complex anatomic surfaces difficult. HDR IORT requires the use of an HDR remote after-loader and a shielded operating room. When using LDR mesh, source orientation and spacing can be difficult to maintain during mesh customization, leading to large dose inhomogeneities. The CivaSheet (CivaTech Oncology Inc., Durham, NC), an implantable unidirectional palladium-103 (Pd-103) planar low-dose brachytherapy device, overcomes many of these shortcomings and offers a novel radiation delivery approach in sites with close proximity to organs at risk. The CivaSheet consists of individual Pd-103 sources encapsulated in an organic polymer and embedded within an 8 mm × 8 mm grid that consists of a flexible bio-absorbable substrate. The sources are shielded on one side with gold to attenuate the dose to only one tenth of the total dose. The CivaSheet received approval from the U.S. Food and Drug Administration in 2014 for planar LDR brachytherapy. A recent abstract demonstrated that, in a patient with a pelvic side wall malignancy, the device offered significant reductions in dosage to critical structures, such as the bowel and bladder, compared with conventional LDR. Here we describe the case of a 78-year-old man with persistent squamous cell carcinoma of the left axilla after external beam radiation therapy (EBRT) who underwent surgical resection and CivaSheet implantation.