John J. Ferrara

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

BACKGROUND Surgery is a skill-driven discipline. While other high-stake professions with comparable cognitive and psychomotor skill requirements often use warm-up exercises for achieving better proficiency, the effects of such practice have not been investigated sufficiently in surgical tasks. DESIGN Subjects performed standardized exercises as a preoperative warm-up, after which the standardized exercises were repeated in a randomized order. In a variation to investigate the generalizability of preoperative warm-up, the experimental group was allowed to warm-up with the standardized exercises, after which a different task (electrocautery simulation) was performed. To investigate the effect of warm-up on fatigue, participants were involved in eight sessions (four before night call, four after night call), after which the tasks were repeated. Results were analyzed using ANOVA to plot differences between warm-up and followup condition. RESULTS All outcomes measures demonstrated statistically significant improvements after all of the post-warm-up exercises (p < 0.01), and were seen in all groups with differing experience levels. In addition, the simple warm-up exercises led to a significant increase in proficiency in followup electrocautery task for the experimental group when compared with the control group (p < 0.0001). There was also significant improvement in performance of the fatigued group to approximately baseline performance (p < 0.05), although they were not able to reach their optimal potential performance. CONCLUSION Preoperative warm-up for 15 to 20 minutes with simple surgical exercises leads to a substantial increase in surgical skills proficiency during followup tasks.

Comparison of mammographically guided breast biopsy techniques.

OBJECTIVE To determine which mammographically guided breast biopsy technique is the most efficient in making a diagnosis in women with suspicious mammograms. SUMMARY BACKGROUND DATA Mammographically guided biopsy techniques include stereotactic 14-gauge core-needle biopsy (SC bx), stereotactic 11-gauge suction-assisted core biopsy (Mammotome [Mbx]), stereotactic coring excisional biopsy (Advanced Breast Biopsy Instrument [ABBI]), and wire-localized biopsy (WL bx). Controversy exists over which technique is best. METHODS All patients undergoing any one of these biopsy methods over a 15-month period were reviewed, totaling 245 SC bx, 107 Mbx, 104 ABBI, and 520 WL bx. Information obtained included technical success, pathology, discordant pathology, and need for open biopsy. RESULTS Technical success was achieved in 94.3% of SC bx, 96.4% of Mbx, 92.5% of ABBI, and 98.7% of WL bx. The sensitivity and specificity were 87.5% and 98.6% for SC bx, 87.5% and 100% for Mbx, and 100% and 100% for ABBI. Discordant results or need for a repeat biopsy occurred in 25.7% of SC bx, 23.2% of Mbx, and 7.5% of ABBI biopsies. In 63.6% of ABBI and 50.9% of WL bx, positive margins required reexcision; of the cases with positive margins, 71.4% of ABBI and 70.4% of WL bx had residual tumor in the definitive treatment specimen. CONCLUSION Although sensitivities and specificities of SC bx and Mbx are good, 20% to 25% of patients will require an open biopsy because a definitive diagnosis could not be reached. This does not occur with the ABBI excisional biopsy specimen. The positive margin rates and residual tumor rates are comparable between the ABBI and WL bx. The ABBI avoids operating room and reexcision costs; therefore, in appropriately selected patients, this appears to be the most efficient method of biopsy.

Initial experience with laparoscopic repair of incisional hernias

BACKGROUND Development of a safe, unobtrusive means to repair the large incisional hernia continues to represent a challenge to surgeons. METHODS A retrospective analysis of the first 12 patients who underwent an attempt at laparoscopic repair of an incisional hernia at a single institution was carried out. RESULTS Of the 12 attempts at laparoscopic repair, 11 were completed. No serious perioperative morbidity was encountered. During a mean follow-up of 12.5 months, one recurrence (due to a technical shortcoming that has since been overcome) was identified. CONCLUSIONS The laparoscopic approach to incisional hernia repair is a safe alternative to open repair of abdominal wall defects.

Causes for the undertreatment of elderly breast cancer patients: tailoring treatments to individual patients

BACKGROUND Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS The average age was 59.9+/-13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSION Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.

Pathways of Lymphatic Drainage From the Breast

Background: The current standard for obtaining accurate sentinel lymph node SLN mapping is intraparenchymal lymphophilic dye/radiocolloid injection close to the breast tumor. We hypothesized that common lymphatic trunks drain both a large volume of breast parenchyma and skin and that intradermal or intraparenchymal routes flow to the same axillary node.Methods:99mTc-labeled filtered sulfur colloid was injected intradermally directly over the breast tumor in 119 patients. Blue dye was injected intraparenchymally in the same quadrant as the primary tumor concordant quadrant in 66 and in a discordant quadrant in 53 patients. During axillary exploration, both blue and gamma-emitting hot nodes were found. End points were SLNs that were hot and blue, either the same node or different nodes.Results: In 62 93.9% of 66 of concordant quadrant and in 49 92.5% of 53 of discordant quadrant patients, the same SLN was both hot and blue P = .99; Fisher’s exact test. In eight cases in which two distinct nodes were blue and not hot and hot but not blue, the lymph nodes were very close to each other.Conclusions: The dermal and parenchymal lymphatics of the breast seemed to drain to the same axillary lymph nodes. Lymph from the entire breast seemed to drain through a small number of lymphatic trunks to one or two lymph nodes.

Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients.

BACKGROUND We hypothesized that implementing a quality care initiative, including peri-incisional antibiotic administration, tight blood glucose control, and hair removal with clippers would reduce surgical site infection (SSI) rates in patients undergoing coronary artery bypass grafting (CABG), with or without valve replacement. METHODS Patients undergoing CABG were studied retrospectively, before (n = 808) and after (n = 674) instituting a patient care protocol. The pathway included peri-incisional antibiotics, tight glucose control (80 mg/dL-110 mg/dL) throughout intensive care unit (ICU) stays, and hair removal with clippers. RESULTS SSIs were significantly decreased in the experimental group (1.5%), compared with the control group (3.5%), (P = .001, odds ratio [OR] = .21). Significant independent predictors of infection included diabetes mellitus (P = .001, OR = 4.71), Nosocomial Infection Surveillance System (NNIS) wound class II (P = .044, OR = 2.07), and female gender (P = .001, OR = 2.83). CONCLUSIONS Protocols implementing timely perioperative antibiotics, tight blood glucose control, and avoidance of shaving decrease SSI rates in CABG patients.

Trauma: the impact of repeat imaging

BACKGROUND Patients referred to trauma centers often undergo an extensive diagnostic work-up before transfer. The purpose of our study was to quantify and examine the effects of repeat imaging in this population. METHODS A prospective cohort study of 410 patient transfers was performed. Repeat imaging was conducted at the discretion of the accepting surgeon for multiple reasons. Two groups were compared, those who did and those who did not require repeat imaging. RESULTS Overall, 53% of referrals received repeat imaging, at an average cost of

Surgical management of pancreas divisum

2,985 per patient. This group was older (42 vs 37 y; P < .05), more severely injured (injury severity score, 12 vs 9; P < .05), and experienced longer delays before transfer (244 vs 192 min; P < .05). By using logistic regression analysis, injury severity score was found to be an independent predictor of the need for repeat imaging (P = .003). CONCLUSIONS Severely injured trauma patients often receive films that ultimately require duplication, resulting in transfer delay, unnecessary morbidity, and increased resource use. Targeted education and development of centralized radiology systems could alleviate some of the burden of unnecessary imaging.

Measuring movement expertise in surgical tasks

Pancreas divisum is a congenital anatomic variant characterized by nonunion of dorsal and ventral pancreatic ducts in an otherwise fused pancreas. Of 21 patients with divisum documented by endoscopic retrograde cholangiopancreatography, 6 (28 percent) were found to have no reason other than divisum to account for multiple attacks of pancreatitis. Cholelithiasis was present in one patient, who remains free of recurrent pancreatitis after cholecystectomy only. The remaining five patients underwent surgical treatment directed at pancreas divisum in the belief that stenosis of the duct of Santorini at the entrance into the duodenum is responsible for recurrent attacks of pancreatitis. Four of five have done well with follow-up of 12, 13, 18 and 28 months. Successful sphincteroplasty of the duct of Santorini appears to prevent recurrent attacks of pancreatitis due to pancreas divisum. Pancreaticojejunostomy is reserved for those with markedly dilated ducts secondary to chronic pancreatitis.

A method for intraoperative identification of the recurrent laryngeal nerve

Surgical movement is composed of discrete gestures that are combined to perform complex surgical procedures. A promising approach to objective surgical skill evaluation systems is kinematics and kinetic analysis of hand movement that yields a gesture level analysis of proficiency of a performed movement. In this paper, we propose a novel system that combines surgical gesture segmentation, surgical gesture recognition, and expertise analysis of surgical profiles in minimally invasive surgery (MIS). Kinematic analysis was used to segment gestures from a continuous motion stream. Human anatomy driven Hidden Markov Models (HMMs) are adopted for gesture recognition and expertise identification. When the proposed system was tested on a library of 200 samples for every basic surgical gesture, the gesture recognition module reported a perfect accuracy rate for the basic gestures, while the expertise identification module showed 94.7% accuracy.