[Show abstract][Hide abstract] ABSTRACT: Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method.
A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer.
Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs.
Our classification method provides further clarity and systematic standardization for reporting TT complications.
World Journal of Surgery 07/2015; DOI:10.1007/s00268-015-3158-6 · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
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.
With IRB approval, we randomized patients undergoing bilateral mastectomy and reconstruction to drain antisepsis (treatment) for one side, with standard drain care (control) for the other. Antisepsis care included both: chlorhexidine disc dressing at drain exit site(s) and irrigation of drain bulbs twice daily with dilute sodium hypochlorite solution. Cultures were obtained from bulb fluid at 1 week and at drain removal, and from the subcutaneous drain tubing at removal. Positive cultures were defined as ≥1+ growth for fluid and >50 CFU for tubing.
Cultures of drain bulb fluid at 1 week (the primary endpoint) were positive in 9.9 % of treatment sides (10 of 101) versus 20.8 % (21 of 101) of control sides (p = 0.02). Drain tubing cultures were positive in 0 treated drains versus 6.2 % (6 of 97) of control drains (p = 0.03). Surgical site infection occurred within 30 days in 0 antisepsis sides versus 3.8 % (4 of 104) of control sides (p = 0.13), and within 1 year in three of 104 (2.9 %) of antisepsis sides versus 6 of 104 (5.8 %) of control sides (p = 0.45). Clinical infection occurred within 1 year in 9.7 % (6 of 62) of colonized sides (tubing or fluid) versus 1.5 % (2 of 136) of noncolonized sides (p = 0.03).
Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains, and reduced drain colonization was associated with fewer infections.
[Show abstract][Hide abstract] ABSTRACT: Background:
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.
We created a 20-session (3 hours each) simulation curriculum (with pre- and post-tests) and a 24/7 online audiovisual (AV) curriculum for surgery interns. Friday morning simulation sessions emphasize operative skills and judgment. AV clips (using operating room, whiteboard, and simulation center videos) take learners through 20 different general surgery operations with follow-up quizzes. We report our early experience with this novel setup.
Thirty-two surgical interns (2012-2013) attended simulation sessions on 20 separate subjects (hernia, breast, hepatobiliary, endocrine, etc). Post-test scores improved (P < .05) and trainees enjoyed using surgical skills for 3 hours each Friday morning (mean, >4.5; Likert scale, 1-5). The AV curriculum feedback is similar (mean, >4.3) and usage is available 24/7 preparing learners for both operating room and simulation sessions. Most simulation sessions utilize low-fidelity models to keep costs <$50 per session. Scores on our semiannual Surgical Olympics (mean score of 49.6 in July vs 82.9 in January; P < .05) improved significantly, suggesting that interns are improving their surgical skills and knowledge.
Residents enjoy and learn from the step-by-step, in-house, AV curriculum and both appreciate and thrive on the 'hands-on' simulation sessions mimicking operations they see in real operating rooms. The cost of these programs is not prohibitive and the programs offer simulated repetitions for duty-hour-regulated trainees.
Surgery 07/2014; 156(3). DOI:10.1016/j.surg.2014.04.049 · 3.38 Impact Factor
[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; 144(3). DOI:10.1007/s10549-014-2896-8 · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction/Background: Central venous line placement is a frequent and potentially dangerous procedure. Our medical center mandates all surgical interns must participate in an August or September Central Line Workshop (CLW) (two hours of online curriculum and three hours of hands-on workshop). They must then safely place a central line in a simulated setting (with a 100% score) for credentialing purposes. Our biannual Surgical Olympics Station #2A tests all interns on safe needle insertion (and accurate verbalization while doing so) into the right internal jugular (IJ) vein of a manikin. We hypothesized that following CLW completion and 6 months of intern training, our PG-1 surgery residents would perform more safely and speak with more knowledge when inserting the needle into the right IJ vein. Methods: Sixty surgical interns (2011-12 = 29, 2012-13 = 31) were tested in July of their first year for safe IJ insertion using a validated six section checklist (10 points maximum score): placing probe on skin properly (2 pts), IJ and carotid vessels oriented (1), needle tip visualized with US throughout insertion (2), no past pointing of needle (2), speaking clearly (1) and providing educational dialogue while inserting the needle. All interns subsequently took and passed the CLW course. All 60 interns then were re-tested on right IJ vein insertion in January of their intern year. Results: Overall, surgical interns performance in safely inserting a needle into the right IJ improved (Mean scores: July=5.8, January =7.33; p<0.05). Individually 39 interns improved (mean change +2.92), 10 scored the same and 11 scores dropped (mean change -1.64). Eight interns scored >=9/10 in July; 17 interns scored >=9/10 in January (p<0.05). Twenty interns scored <=4/10 in July whereas three scored <=4/10 in January (p <0.05). Global improvement (n=60 interns) was seen in all sectors of placement: probe on skin (change +14), vessels oriented (+18), needle tip visualized with US (+6), no past pointing of needle (+25), speech was clear (+3) and words spoken were educational (+30). Conclusion: Based on sequential tests in July and January, our Central Line Workshop combined with six months of surgical training, facilitates safer insertion of a needle into the right internal jugular vein. January interns rarely past point the needle under US guidance and offered more educational knowledge while performing IJ insertion. While encouraging, more education and follow-up testing seems necessary to consistently offer patients a surgical intern that is vigilant and safe. Disclosures: None.
Simulation in healthcare: journal of the Society for Simulation in Healthcare 12/2013; 8(6):587. DOI:10.1097/01.SIH.0000441664.61257.e5 · 1.48 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.
[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.
[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. DOI:10.1016/j.amjsurg.2010.08.019 · 2.29 Impact Factor