Loretta Erhunmwunsee

Effectiveness of Laparoscopic Computer Simulator Versus Usage of Box Trainer for Endoscopic Surgery Training of Novices

OBJECTIVE Teaching of laparoscopic skills is a challenge in surgical training programs. Because of the highly technical nature and the steep learning curve, students and residents must learn laparoscopic skills before performing them in the operating room. To improve efficiency of learning and patient safety, research in simulation is essential. Two types of simulators currently in use include virtual reality and box trainers. Our study examined which simulator technique was most effective in teaching novice trainees laparoscopic techniques. DESIGN This is a prospective, randomized, blinded, controlled trial that enrolled fourth-year medical students and surgical interns to participate in a supervised 6-month laparoscopic training program with either computer simulators or box trainers. Subjects were randomized and trained on appropriate laparoscopic camera skills, instrument handling, object positioning, dissection, ligation, suturing, and knot tying. Students within one group were not allowed to practice, learn or train on the opposing trainers. At time points 0, 2, and 6 months all subjects completed a series of laparoscopic exercises in a live porcine model, which were captured on DVD and scored by blinded expert investigators. RESULTS Scores improved overall from the pretest to subsequent tests after training with no difference between the virtual reality and box simulator groups. In the medical students specifically, there was overall improvement, and improvement in the needle-transfer and knot-tying skills specifically, with no difference between the box simulator and virtual reality groups. For the interns, both groups showed significant overall improvement with no difference between the virtual reality and box simulator groups or on individual skills. CONCLUSIONS We conclude that laparoscopic simulator training improves surgical skills in novice trainees. We found both the box trainers and the virtual reality simulators are equally effective means of teaching laparoscopic skills to novice learners.

Surgical management of pulmonary metastases.

Metastasectomy is the only curative option for some patients with secondary pulmonary malignancy. Many studies suggest a survival benefit in selected patients if complete resection of pulmonary metastases is accomplished. There are several operative approaches that may be used, with the goal of complete resection and with minimal parenchymal loss. Evaluation for resection must include ascertainment of control of the primary tumor and assessment of the ability to achieve complete resection. Minimally invasive approaches may offer advantages in quality of life outcomes, with equivalent oncologic outcomes.

Neighborhood-level socioeconomic determinants impact outcomes in nonsmall cell lung cancer patients in the Southeastern United States

Studies examining the impact of lower socioeconomic status (SES) on the outcomes of patients with nonsmall cell lung cancer (NSCLC) are inconsistent. The objective of this study was to clearly elucidate the association between SES, education, and clinical outcomes among patients with NSCLC.

Perceptions and Utilization of Lung Cancer Screening Among Primary Care Physicians

Introduction Lung cancer screening (LCS) with low‐dose computed tomography (LDCT) is effective at reducing lung cancer mortality in high‐risk current and former smokers. Despite the fact that screening is recommended by the U.S. Preventative Services Task Force (USPSTF), few eligible patients are screened. We set out to study the barriers to LCS by surveying primary care physicians (PCPs). Methods We surveyed a randomly selected sample of 1384 eligible PCPs between January and October 2015, using the American Medical Association Physician Masterfile, though surveys sent by mail, fax, and e‐mail. The survey included questions regarding knowledge of LCS guidelines, utilization of LCS over the prior 12 months, and perceptions of barriers to LCS. Training background, years in practice, practice type, and demographics were also collected. Results The survey response rate was 18%. Responders and nonresponders did not differ by practice or demographic characteristics. Of the respondents, 47% indicated that LCS was recommended by the USPSTF, 52% had referred at least one patient for LDCT, and 12% had referred at least one patient to a LCS program over the prior 12 months. Perceived barriers to LCS included uncertainty regarding ther benefit of LCS, concern regarding insurance coverage, and the harm of LCS. Conclusions Although LCS is recommended by the USPSTF, LDCT is utilized in a minority of eligible patients, as reported by surveyed PCPs. Approximately half of PCPs are familiar with USPSTF recommendations for LCS and a number of physician barriers to adherence to guidelines exist. Additional study of physician‐ and system‐based interventions to improve adherence to LCS recommendations is needed.

The Prognostic Importance of the Number of Dissected Lymph Nodes After Induction Chemoradiotherapy for Esophageal Cancer

BACKGROUND Analyses of adequacy of lymph node dissection during resection of esophageal cancer are based on patients who have not undergone induction chemoradiotherapy. We sought to determine the minimum number of dissected lymph nodes necessary to ensure adequate staging after induction chemoradiotherapy. METHODS A prospectively maintained thoracic surgery database was queried to identify consecutive patients undergoing postinduction esophagectomy from 1996 to 2010. Cox proportional hazard and recursive partitioning survival analyses were performed. RESULTS Complete lymph node data were available for 395 patients. Mean age was 59.5 years, and 64 patients (16%) were female. The median number of dissected lymph nodes was 8 (range, 0 to 63). When pathologic (p)T stage, pN stage, and the number of dissected lymph nodes were used as predictors, only pN stage (odds ratio, 1.3; 95% confidence interval, 1.2 to 1.7) and age (odds ratio, 1.03; 95% confidence interval, 1.01 to 1.04) independently predicted survival. Recursive partitioning was performed on 262 pN0 patients using T stage and the number of dissected lymph nodes as predictors. No pN0 patient with 28 lymph nodes dissected died during follow-up. For patients with fewer than 28 lymph nodes dissected, the next prognostic factor was T stage. For pT1-2 N0 patients, the number of lymph nodes dissected did not affect survival. For pT3-4 N0 patients, a significant survival decrement was noted for patients with fewer than 7 lymph nodes dissected compared with those with more than 7 lymph nodes dissected. CONCLUSIONS T stage determines prognosis in postinduction pN0 patients with fewer than 28 lymph nodes evaluated. Postinduction pT3N0 patients with fewer than 7 lymph nodes evaluated are understaged.

Detection of occult N2 disease with molecular techniques.

Lymph node involvement is the most important factor affecting the prognosis and treatment of patients with potentially resectable NSCLC. Radiographic imaging is inadequate to ascertain lymph node involvement accurately. Currently, lymph nodes are histologically examined with standard histopathologic techniques, such as H&E staining; however, lymph node micrometastases (occult N2 disease) may be missed, leading to inaccurate staging and suboptimal treatment. More accurate strategies, using molecular biologic techniques, are currently being studied. IHC using antibodies to cytokeratins improves the sensitivity of lymph node assessment. Other techniques, such as RT-PCR, may be superior to IHC, and the detection of various cancer-specific gene transcripts by RT-PCR is being evaluated. Many transcripts with high sensitivity also demonstrate low specificity, either because of their presence in non-neoplastic tissue or (as is the case of CK-19) because of the existence of associated pseudogenes. At the present time, the most promising molecular detector may be KS1/4, which is infrequently present in noncancerous cells but has a high sensitivity in metastatic nodes. Genomic analysis of lymph nodes, which may be used to improve the detection of micrometastases and to improve risk stratification, is currently being studied. Genomic signatures have the potential to guide therapeutic decision making as well.

Preparing Cancer Patients and Family Caregivers for Lung Surgery: Development of a Multimedia Self-Management Intervention.

The surgical treatment of lung malignancies often results in persistent symptoms, psychosocial distress, and decrements in quality of life (QOL) for cancer patients and their family caregivers (FCGs). The potential benefits of providing patients and FCGs with preparatory education that begins in the preoperative setting have been explored in multiple medical conditions, with positive impact observed on postoperative recovery, psychological distress, and QOL. However, few studies have explored the benefits of preparatory educational interventions to promote self-management in cancer surgery, including lung surgery. This paper describes the systematic approach used in the development of a multimedia self-management intervention to prepare cancer patients and their FCGs for lung surgery. Intervention development was informed by (1) contemporary published evidence on the impact of lung surgery on patients and FCG, (2) our previous research that explored QOL, symptoms, and caregiver burden after lung surgery, (3) the use of the chronic care self-management model (CCM) to guide intervention design, and (4) written comments and feedback from patients and FCGs that informed intervention development and refinement. Pilot-testing of the intervention is in process, and a future randomized trial will determine the efficacy of the intervention to improve patient, FCG, and system outcomes.

Surgical Management of the Radiated Chest Wall and Its Complications

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

Bleeding risk associated with eptifibatide (Integrilin) bridging in thoracic surgery patients

Antiplatelet use for treatment of coronary artery disease (CAD) is common amongst thoracic surgery patients. Perioperative management of antiplatelet agents requires balancing the opposing risks of myocardial ischemia and excessive bleeding. Perioperative bridging with short-acting intravenous antiplatelet agents has shown promise in preventing myocardial ischemia, but may increase bleeding. We sought to determine whether perioperative bridging with eptifibatide increased bleeding associated with thoracic surgery. After Institutional Review Board approval, we identified thoracic surgery patients receiving eptifibatide at our institution (n = 30). These patients were matched 1:2 with control patients with CAD who did not receive eptifibatide from an institutional database of general thoracic surgery patients. The primary endpoint for our study was the number of units of blood transfused perioperatively. There were no differences in our primary endpoint, number of units of blood products transfused. There were also no differences noted between groups in intraoperative blood loss, chest tube duration, or postoperative length of stay (LOS). While there were no difference noted in overall complications, including our outcome of perioperative MI or death, composite cardiovascular events were more common in the eptifibatide group. In our retrospective exploratory analysis, eptifibatide bridging in patients with high-risk or recent PCI was not associated with an increased need for perioperative transfusion, bleeding, or increased LOS. In addition, we found a similar rate of perioperative mortality or myocardial infarction in both groups, though the ability of eptifibatide to protect against perioperative myocardial ischemia is unclear given different baseline CAD characteristics.

Thoracic Emergencies: Tracheobronchial, Pulmonary, and Pleural Diseases

Emergencies that affect the airway, including obstruction and hemoptysis, are potentially life threatening and can have etiologies unique to cancer patients. Several additional urgent problems, including pneumothorax and pleural effusions, are commonly encountered in the cancer patient. In this chapter, we examine the causes, evaluation, and treatment of tracheobronchial, pulmonary, and pleural disease, focusing specifically on conditions commonly seen in cancer patients.