[Show abstract][Hide abstract] ABSTRACT: In this 2-site randomized trial, we investigated the effect of antiseptic drain care on bacterial colonization of surgical drains and infection after immediate prosthetic breast reconstruction.
Annals of Surgical Oncology 08/2014; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgery interns' training has historically been weighted toward patient care, operative observation, and sleeping when possible. With more protected free time and less clinical time, real educational hours for trainees in 2013 are precious.
[Show abstract][Hide abstract] ABSTRACT: While the immune microenvironment has been investigated in breast cancers, little is known about its role in non-malignant breast tissues. Here we quantify and localize cellular immune components in normal breast tissue lobules, with and without visible immune infiltrates (lobulitis). Up to ten representative lobules each in eleven normal breast tissue samples were assessed for B cells (CD20), cytotoxic T cells (CD8), helper T cells (CD4), dendritic cells (CD11c), leukocytes (CD45), and monocytes/macrophages (CD68). Using digital image analysis, immune cell densities were measured and compared between lobules with/without lobulitis. 109 lobules in 11 normal breast tissue samples were evaluated; 31 with lobulitis and 78 without. Immune cells showed consistent patterns in all normal samples, predominantly localized to lobules rather than stroma. Regardless of lobulitis status, most lobules demonstrated CD8+, CD11c+, CD45+, and CD68+ cells, with lower densities of CD4+ and CD20+ cells. Both CD11c+ and CD8+ cells were consistently and intimately associated with the basal aspect of lobule epithelium. Significantly higher densities of CD4+, CD8+, CD20+, and CD45+ cells were observed in lobules with lobulitis. In contrast, densities of monocytes/macrophages and dendritic cells did not vary with lobulitis. In normal breast tissue, myeloid and lymphoid cells are present and localized to lobules, with cytotoxic T and dendritic cells directly integrated with epithelium. Lobules with lobulitis have significantly more adaptive immune (B and T) cells, but no increase in dendritic cells or monocytes/macrophages. These findings indicate an active and dynamic mucosal immune system in normal breast tissue.
Breast Cancer Research and Treatment 03/2014; · 4.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the use of 2 inexpensive laparoscopic trainers (iTrainers) constructed of easily attainable materials and portable tablets (iPads).
Two different laparoscopic trainers were constructed using a cardboard box, thumbtacks, and Velcro tape (box trainer). A separate box was constructed using the same supplies with a 3-ring binder (binder trainer). An iPad was used as the camera and monitor for both trainers. A total of 10 participants, including 4 junior surgical residents, 4 senior surgical residents, and 2 surgical staff, completed 3 Fundamentals of Laparoscopic Surgery (FLS) tasks using the 2 "iTrainers." Participants then completed the same tasks on a traditional FLS box trainer. All 10 participants were asked to complete a 13-question survey after the exercises.
All the participants (100%) had access to an "iPad" for the visualization component. The 10 participants completed all 3 tasks on all 3 trainers. Senior residents outperformed junior residents on 6 of the 9 total tasks. Attending surgeons outperformed all residents on all tasks and trainers. Survey results revealed the cardboard box "iTrainer" to be the most practical and easiest to construct.
"iTrainers" are an inexpensive and easy-to-construct alternative to traditional box trainers that might have construct validity as demonstrated in this trial. The box trainer might be easier to construct and have more similarities to the FLS trainer than the binder iTrainer.
[Show abstract][Hide abstract] ABSTRACT: To assess national practice patterns regarding use of perioperative antibiotics by surgeons performing breast operations requiring drainage tubes.
The members of the American Society of Breast Surgeons (ASBrS) were surveyed regarding use of perioperative antibiotics for breast operations requiring drains, with or without immediate tissue expander or implant reconstruction.
Of 2,857 ASBrS members contacted, 917 (32 %) responded; all self-identified as surgeons. Of 905 evaluable respondents, most described themselves as general surgeons (46 %) or breast surgeons (46 %). For cases in which drains are anticipated, most respondents (86 %) reported routine use of preoperative prophylactic antibiotics, with 99 % selecting cephalosporins. Use of antibiotic >24 h postoperatively varied by whether or not reconstruction was performed. In nonreconstruction cases, the majority (76 %) reported "never/almost never" prescribing antibiotics beyond the 24-h postoperative period, but 16 % reported "always/almost always." In reconstruction cases, the majority (58 %) reported routine antibiotic use beyond 24 h, and the primary driver of the decision to use antibiotics was reported to be the plastic surgeon (83 %). Among those reporting use at >24 h, the duration recommended for nonreconstruction cases was "up to 1 week" in 38 % and "until drains removed" in 39 %; this was similar for reconstruction cases.
Cephalosporins are utilized uniformly as preoperative antibiotic prophylaxis in breast operations requiring drains. However, use of postoperative antibiotic prophylaxis is strongly dependent on the presence of immediate breast reconstruction. Consensus is lacking on the role of postoperative antibiotic prophylaxis in breast operations utilizing drains.
Annals of Surgical Oncology 07/2012; 19(10):3205-11. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Long-term outcomes of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs performed by supervised surgical trainees are absent.
Retrospective review of TEP inguinal hernioplasties performed by trainees at our institution.
From 1995 to 2009, a total of 1,479 inguinal hernia repairs on 976 patients were performed by supervised surgical trainees. The mean patient age was 54 years (range 5-86). Men (97%), direct defects (51%), and bilateral repairs (52%) predominated. Recurrent hernias compromised 17%. Four (.4%) patients were converted to open surgery because of scarring. Postoperative complications consisted of urinary retention (8%), seroma (3%), and hematoma (2%). Trainee participation included interns (46%), PGY-2s (10%), PGY-3s (2%), PGY-4s (3%), and PGY-5s (39%). With a mean follow-up of 6.1 years, recurrence and bothersome groin pain rates were 2.6% and 1.5%, respectively.
With adequate supervision, surgical trainees can safely perform the TEP repair with good long-term outcomes.
American journal of surgery 03/2011; 201(3):379-83; discussion 383-4. · 2.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Contralateral exploration during laparoscopic totally extraperitoneal (TEP) inguinal herniorrhaphy allows for the repair of incidentally found hernias. Nonetheless, some patients with a negative contralateral exploration subsequently develop a symptomatic hernia on that side. We pondered the incidence of contralateral metachronous hernia development and whether prophylactic "repair" in these circumstances would be beneficial.
A retrospective analysis of patients who underwent laparoscopic TEP exploration at our institution was performed. Demographic, operative and follow-up information was obtained through medical record review, physical examination and telephone/mailed survey.
From 1995 to 2009, a total of 1,479 inguinal herniorrhaphies on 976 patients were performed by a single staff surgeon. Bilateral exploration was completed in 923 (95%) of these patients, of whom bilateral repair was performed on 503 (55%). The study cohort comprises the 409 (42%) patients having a unilateral repair with a negative contralateral exploration and no previous contralateral hernia repair (n = 11). With a median follow-up of 5.9 years (range 0-14), 33 (8.1%) hernias developed on the previously "healthy" side, yielding incidence rates at 1, 5 and 10 years of 1.6, 5.9 and 11.8%, respectively. The median time to hernia development was 3.7 years (range 0.1-12.4). Of the 30 inguinal hernias that have been repaired, 25 (83%), 3 (10%) and 2 (7%) were of indirect, direct and pantaloon types, respectively.
When considering prophylactic repair during TEP explorations, a yearly risk of 1.2% of developing a contralateral hernia after negative exploration needs to be balanced against the low but potential risk of groin pain following prophylactic repair.