David R. Farley

Sentinel Lymph Node Biopsy With Metastasis: Can Axillary Dissection Be Avoided in Some Patients With Breast Cancer?

PURPOSE Recent studies have suggested that the sentinel lymph node (SLN) biopsy is an accurate alternative staging procedure for women with breast cancer. The goal of this study was to identify a subset of breast cancer patients in whom metastatic disease was confined only to the SLN. MATERIALS AND METHODS From two institutions, we recruited 222 women with breast cancer for SLN biopsy. A SLN biopsy was performed in each patient, followed by an axillary dissection in 182 patients. Histologic and immunohistochemical cytokeratin stains were used on all SLNs. RESULTS The SLN was identified in 220 (97. 8%) of the 225 biopsies. Evidence of metastatic breast cancer in the SLN was found in 60 (27.0%) of the 222 patients. Of these patients, 32 (53.3%) had evidence of tumor in the SLN only. By multivariate analysis, two factors were found to be significantly associated with a higher likelihood of tumor involvement in the non-SLNs: primary tumor size larger than 2.0 cm (P =.0004) and macrometastasis (> 2.0 mm) in the SLN (P =.002). Additional analysis revealed that none (0%; 95% confidence interval, 0% to 18.5%) of the 18 patients with primary tumors < or = 2.0 cm and micrometastasis to the SLN had remaining axillary lymph node involvement. CONCLUSION The primary tumor size and metastasis size in the SLN are independent factors in predicting the incidence of tumor in the non-SLNs. Therefore, the SLN biopsy alone may be adequate for staging and/or therapy decision making in patients with primary breast tumors < or = 2.0 cm and micrometastasis in the SLN.

Spontaneous rupture of the spleen due to infectious mononucleosis.

Spontaneous splenic rupture is an extremely rare but life-threatening complication of infectious mononucleosis in young adults. Although splenectomy remains effective treatment, reports of successful nonoperative management have challenged the time-honored approach of emergent laparotomy. On retrospective analysis of our institutional experience with 8,116 patients who had this disease during a 40-year period, we found 5 substantiated cases of atraumatic splenic rupture due to infectious mononucleosis. Four additional cases of suspected splenic rupture were noted. All nine patients were hospitalized and treated (seven underwent splenectomy and two were treated with supportive measures only), and they remain alive and well. In patients with infectious mononucleosis suspected of having rupture of the spleen, a rapid but thorough assessment and prompt implementation of appropriate management should minimize the associated morbidity and mortality. On the basis of review of the medical literature and careful scrutiny of our own experience, we advocate emergent splenectomy for spontaneous splenic rupture in patients with infectious mononucleosis.

An Optimal Algorithm for Intraoperative Parathyroid Hormone Monitoring

BACKGROUND A minimally invasive approach to primary hyperparathyroidism is equivalent to bilateral exploration when intraoperative parathyroid hormone (IOPTH) monitoring is used. The optimal strategy for the monitoring has been debated. HYPOTHESIS There exists an optimal strategy for IOPTH monitoring. DESIGN Retrospective study. SETTING Tertiary referral hospital. PATIENTS AND METHODS A total of 1882 patients underwent parathyroidectomy for primary hyperparathyroidism with IOPTH monitoring. Successful exploration was defined as a 50% or more decline in IOPTH level from baseline and a normal or near-normal IOPTH level at 10 minutes postexcision. These results were compared with those of alternative strategies for IOPTH monitoring, including a 50% decline at 10 minutes, 50% decline at 5 minutes, and normal IOPTH levels at 10 minutes, using the preoperative parathyroid level as baseline. RESULTS A curative operation was performed in 1830 patients (97.2%). The current strategy had a sensitivity of 96% and an accuracy of 95%. Multiglandular disease was present in 271 patients (14.5%); 134 of 1858 patients (7.2%) whose outcomes failed to reach curative criteria had confirmed multiglandular disease. Using only a 50% decline from baseline as the curative criterion would result in a failed operation in 22.4% of patients with multiglandular disease. A 50% decline at 10 minutes was 96% sensitive and 94% accurate. A 5-minute value was 79% sensitive and 80% accurate. With use of the 5-minute value, unnecessary bilateral exploration would have been performed in 272 of 1460 patients (18.6%) compared with 62 of 1750 patients (3.5%) when using a 10-minute value. A normal 10-minute value is 91% sensitive and 90% accurate. CONCLUSIONS A 10-minute postexcision IOPTH level that decreased 50% from baseline and is normal or near normal is highly successful. Relying on a 50% decrease alone increases the rate of operative failure in patients with multiglandular disease.

The Zollinger-Ellison syndrome - A collective surgical experience

A retrospective study of 90 surgically treated patients with the Zollinger-Ellison syndrome seen from 1958 through 1990 was performed. Fifteen patients had Zollinger-Ellison syndrome as a manifestation of multiple endocrine neoplasia type I. Preoperative tumor localization was positive in 46% of 54 patients studied. Gastrinomas were identified in 66% of patients, 38% of the tumors being malignant. Postoperative eugastrinemia was achieved in 11% of patients after a variety of surgical procedures. Exploratory laparotomy provides the only chance for cure and identifies the significant prognostic factors associated with long-term patient survival: small tumor size, extrapancreatic primary, and absence of tumor metastases.

Are Concomitant Surgical Procedures Acceptable in Patients Undergoing Cervical Exploration for Primary Hyperparathyroidism

Cervical exploration for primary hyperparathyroidism is an extremely safe procedure with essentially no operative mortality or morbidity and with success rates approaching 98%. These results have encouraged experienced surgeons to perform other surgical procedures concomitantly with cervical exploration with use of the same general anesthetic agent. This retrospective study was performed to assess the safety and efficacy of this practice. At our institution, 117 patients underwent cervical exploration for primary hyperparathyroidism in combination with an additional surgical procedure, including breast (25), biliary (21), gynecologic (19), intra-abdominal (18), and cardiothoracic (6) operations. The mean operative time was 155 minutes, and the mean duration of hospitalization was 7.6 days. Postoperatively, 115 patients (98%) were normocalcemic. Nine complications (mostly minor), which occurred in eight patients, related primarily to the concomitant surgical procedure. No operative mortality occurred. If performed by experienced surgeons in carefully selected patients, cervical exploration for primary hyperparathyroidism in combination with another elective operation is safe and cost-effective.

Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection

Background: There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma. Methods: Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first‐time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed. Results: Follow‐up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6). Conclusions: Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.

Factors that Predict an Intern's First ABSITE Score are Known by September

BACKGROUND Previous studies offer conflicting relevance of a variety of factors to predict resident performance on the The American Board of Surgery In-Training Exam (ABSITE). With numerous stellar applicants scoring poorly on their first ABSITE, we sought to identify key factors that might allow us to tailor pre-emptive study efforts in the fall and early winter to enhance scores. METHODS General Surgery residents in our program from 2009 through 2016 were included in our cohort study. Specific trainee data (sex, prelim vs categorical, United States Medical Licensing Examination (USMLE) Step 1 and 2 scores, ABSITE scores, clinical rotations, biannual objective structured clinical examination OSCE-type scores, and in-house prep test [IHPT], etc.) were collected retrospectively. The data were analyzed using JMP pro 10 and MedCalc. RESULTS ABSITE scores of our 110 trainees did not vary by sex or by categorical vs preliminary residents. USMLE step 1 and 2, IHPT and one objective structured clinical examination (OSCE) station (Sim-Based Trauma Exam) scores were positively correlated with ABSITE scores (p < 0.05; correlation coefficient (CC) = 0.6 [strong] for IHPT, 0.5 [moderate] for step 1 and 2 and [weak] 0.3 for Sim-Based Trauma Exam). The mean (standard deviation) ABSITE %tile score for residents scoring above 230 (USMLE 1 or 2) vs <230 were different: 81 (3) vs 56 (4) (p < 000.1). Of residents scoring lower than 230 in USMLE 1 or 2, their ABSITE performance had a strong positive linear correlation with their performance in the IHPT (CC = 0.7) and SBTA (CC = 0.5). Residents rotating twice on the Acute Care Surgery services before the ABSITE scored higher than those with 1 or zero rotations (p < 0.05). CONCLUSIONS USMLE steps 1 and 2 are useful parameters in our program to predict subsequent resident ABSITE performance. An in-house 60-minute preparation test in September, a 6-minute simulation-based trauma assessment in July, and rotation schedule with 2 stints on Acute Care Surgery were surprisingly useful early intern year tools to predict ABSITE scores.

Board #147 - Research Abstract Pancreaticoduodenectomy and Hepaticojejunostomy: Simple, Low-cost, and Effective Modeling of Advanced Surgical Techniques (Submission #9933)

Hypothesis General Surgery (GS) residents salivate at the opportunity to participate in major hepatobiliary (HPB) operations. Pancreaticoduodenectomy (PD) along with its associated pancreaticojejunostomy (PJ) and hepaticojejunostomy (HJ) are technically complex procedures which are highly revered and eagerly sought by surgical trainees. Exposure to the basic concepts underlying these procedures in a simulated environment may lead to better understanding of such advanced techniques. We aimed to construct an effective HPB skills session for GS interns using low-cost, low-fidelity models. Methods An inexpensive model was constructed using cardboard, fabric (liver, jejunum), portion of a Penrose drain (common bile duct) and portion of a hot dog (pancreas). GS interns (n=18) initially participated in a 3-hour didactic/simulation session which taught technique for the components of a PD. Residents were then asked to perform a PD with the associated PJ and HJ using the model. Knowledge evaluation was accomplished using a 10-question pre- and post-task written exam. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment, and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results All residents completed the session. Each model cost roughly

Board 409 - Research Abstract Simulating Azygos Vein Ligation - Deliberate Practice is Invaluable (Submission #1187)

1 and required 2-3 minutes for construction. Mean pre-test scores were 5.1 (range 3-8, SD = 1.57). The post-test mean was 6.5 (range 4-9, SD = 1.29; p=0.002). Mean Likert scores were 4.1. Conclusion A simple, low-cost model with an assessment tool can be educationally effective and improve understanding of complex surgical procedures such as HJ and PJ. Participants enjoyed the session and felt the model was realistic. Future research will assess the influence of this model on technical prowess in the operating theater. Disclosures None

Laparoscopic ventral hernia repair: Are there comparative advantages over traditional methods of repair? Discussion

Introduction/Background General Surgery (GS) residents painstakingly learn to ligate vessels in continuity. Swift and skillful knot tying in the chest is a particular challenge to the burgeoning thoracic surgeon. We sought to assess baseline proficiency in ligating the azygos vein within a simulated chest among GS interns, medical students and thoracic surgery staff. Methods A low-fidelity chest model was constructed in the left lateral decubitus position using cardboard (scapula, ribs and chest wall), fabric (skin, subcutaneous tissue, muscle, fascia, esophagus, vagus and intercostal nerves, lung, mediastinal pleura and superior vena cava) and a 10 mL water filled balloon (azygos vein). GS interns (n = 34), medical students (n = 4) and thoracic surgery staff (n = 2) were asked to ligate the azygos vein in continuity through an eight cm diameter thoracotomy with a depth of 20 cm using 2-0 silk ligatures. Of the 40 participants, only staff surgeons had prior thoracic knot tying training. Scores were based on a 20-point grading scale including task completion, timing and completeness of lumen occlusion. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results Thirty nine of 40 trainees completed the task. The mean score for GS interns was 9.2 (range 3–16, SD = 2.7), medical students 8.5 (range 5-10, SD 2.3, p = 0.54) and thoracic surgeons 18 (SD 0, p = 0.03). Mean task completion times among residents and medical students were slow (133 vs 132 seconds respectively). Staff surgeons were faster (mean = 36 seconds, p = 0.02). Proximal or distal azygos vein stump leaks of any kind occurred in 20% (13/68) of surgical resident veins, 38% (3/8) of medical student veins and none for staff. When azygos stumps were subjected to a force of 22.5N, 33% (4/12) of initial drip leaks worsened to unimpeded flow among surgical residents. Of the veins initially without leak, 2% (1/50) progressed to a detectable drip while 4% (2/50) progressed to unimpeded flow among surgical residents when stump force was applied. Survey response was 80%. Mean Likert scores for usefulness in teaching thoracic knot tying (4.6), utility in learning to tie in other difficult anatomic locations (4.6) and enjoyability (4.2) rated the highest. Trainees and staff felt that the model was acceptable with regards to realism (3.8) and usefulness as a practice tool (4.0). Conclusion This low-fidelity simulator is able to separate novice thoracic knot tiers from experienced surgeons. Participants validate its usefulness as a teaching tool with favorable response. This study further exposes the need for deliberate practice among young trainees. Disclosures None.