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INTRODUCTION: Due to the high morbidity associated with esophagectomies, patients are often directly admitted to intensive care units (ICUs) for postoperative monitoring. However, critical complications can arise after this initial ICU stay. We hypothesized that the timing of ICU stay was not optimal for the care of patients after esophagectomy and aimed to determine when patients are at risk for developing critical complications. METHODS: We searched the National Safety and Quality Improvement Program for patients who underwent an esophagectomy between 2016 and 2021. The outcome of interest was the interval between surgery and first critical complication. A critical complication was defined as one likely to require intensive care, including respiratory failure, septic shock, etc. Multivariate regression was performed to identify the risks of complications. RESULTS: This study included 6813 patients from more than 70 institutions. Within the first 30 d postesophagectomy, 21.59% of patients experienced at least one critical complication. Half of first critical complications occurred after postoperative day 5, and 85.05% of them occurred after postoperative day 2. Risk factors for critical complications included age greater than 60 y, preoperative comorbidities, and open surgical approach. Malignancies were associated with a significantly lower incidence of critical complications. CONCLUSIONS: Critical complications occurred beyond the immediate postesophagectomy period. Therefore, low-risk patients undergoing minimally invasive esophagectomies can be safely monitored outside the ICU, allowing for better patient care and resource utilization.
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Esofagectomia , Unidades de Terapia Intensiva , Complicações Pós-Operatórias , Humanos , Esofagectomia/efeitos adversos , Esofagectomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Feminino , Unidades de Terapia Intensiva/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso , Fatores de Risco , Estudos Retrospectivos , Fatores de Tempo , Tempo de Internação/estatística & dados numéricos , Neoplasias Esofágicas/cirurgiaRESUMO
INTRODUCTION: Hiatal hernia commonly occurs in adults. Although most patients are asymptomatic, some experience reflux symptoms or dysphagia. These patients are frequently managed with acid suppression and lifestyle changes. However, medical management does not provide durable relief for some patients; therefore, surgical repair is considered. Routine preoperative investigations include esophagoscopy, esophagography, and manometry. We investigated the role of preoperative motility studies for the management of these patients when partial fundoplication is planned. METHODS: We performed a retrospective review of 185 patients who underwent elective minimally invasive hiatal hernia repair with partial fundoplication between 2014 and 2018. Patients were divided into two groups based on whether a preoperative motility study was performed. The primary outcomes were postoperative dysphagia, complications, postoperative interventions, and use of proton pump inhibitors. RESULTS: Ninety-nine patients underwent preoperative manometry and 86 did not. The lack of preoperative manometry was not associated with increased postoperative morbidity, including leak rate, readmission, and 30-d mortality. The postoperative dysphagia rates of the manometry and nonmanometry groups were 5% (5/99 patients) and 7% (6/86 patients) (P = 0.80), respectively. Furthermore, seven of 99 (7%) patients in the manometry group and 10 of 86 (12%) (P = 0.42) patients in the nonmanometry group underwent interventions, mainly endoscopic dilation, postoperatively owing to symptom recurrence. CONCLUSIONS: Forgoing preoperative manometry was not associated with significant adverse outcomes after minimally invasive hiatal hernia repair. Although manometry is reasonable to perform, it should not be considered a mandatory part of the preoperative assessment when partial fundoplication is planned.
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OBJECTIVE: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage. RESULTS: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.
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Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Pneumonectomia , Cirurgia Torácica Vídeoassistida , Complicações Pós-Operatórias , Tempo de InternaçãoRESUMO
OBJECTIVE: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions. SUMMARY BACKGROUND DATA: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors. RESULTS: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007). CONCLUSIONS: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida/métodos , Neoplasias Pulmonares/cirurgia , Análise de SobrevidaRESUMO
BACKGROUND: Sleeve gastrectomy is an effective surgical treatment for morbid obesity. The major technical risk of this procedure is staple line dehiscence. Some surgeons are reluctant to place a nasogastric tube (NGT) blindly due to the perceived risk of damage to the staple line. We sought to determine whether such concern was warranted. METHODS: A porcine tissue model (Animal Technologies, Inc., Tyler, TX) was used. Sleeve gastrectomy was performed using a flexible gastroscope as a guide for the Endo GIA stapler (Covidien, New Haven, CT) in an identical fashion used in our patients. The specimen was then placed in a plastic model of the thorax (VATS Trainers, LLC. Lansing, MI). The NGT was blindly advanced to 55 cm for a total of 50 passes, and to 75 cm for another 50 passes. Endoscopy with water submersion was performed to evaluate for injury or leak. RESULTS: After multiple passes of the NGT, no significant injuries, leaks, or perforations were observed to the gastric model, except for several small petechiae of the gastric mucosa, the largest measuring approximately 3 mm. None were of full thickness or penetrated the mucosa. The staple line showed no evidence of trauma. CONCLUSION: In this porcine model, blind NGT placement was not associated with significant mucosal injury or any damage to the sleeve gastrectomy staple line.
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Gastrectomia , Intubação Gastrointestinal/métodos , Grampeamento Cirúrgico , Deiscência da Ferida Operatória/prevenção & controle , Animais , Gastrectomia/instrumentação , Gastrectomia/métodos , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/instrumentação , Deiscência da Ferida Operatória/etiologia , SuínosRESUMO
We present measurements of quantized conductance in electrostatically induced quantum point contacts in bilayer graphene. The application of a perpendicular magnetic field leads to an intricate pattern of lifted and restored degeneracies with increasing field: at zero magnetic field the degeneracy of quantized one-dimensional subbands is four, because of a twofold spin and a twofold valley degeneracy. By switching on the magnetic field, the valley degeneracy is lifted. Because of the Berry curvature, states from different valleys split linearly in magnetic field. In the quantum Hall regime fourfold degenerate conductance plateaus reemerge. During the adiabatic transition to the quantum Hall regime, levels from one valley shift by two in quantum number with respect to the other valley, forming an interweaving pattern that can be reproduced by numerical calculations.
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OBJECTIVE: Up to 15% of lung cancer patients have multiple suspicious nodules. While some of these nodules may represent metastatic lung cancer, others represent synchronous multiple primary lung cancer (SMPLC). The incidence of SMPLC ranges from 0.8% to 8.4% and appears to be increasing. Inconsistent identification of SMPLC can be detrimental for patients who are misdiagnosed as having intrapulmonary metastasis and not offered stage-based treatment. We sought to identify the contemporary incidence of SMPLC at a tertiary institution. METHODS: From January 2018 to September 2019, patients who underwent lung cancer resection were retrospectively reviewed. Patients with SMPLC were identified using the modified Martini-Melamed criteria. RESULTS: During the 21-month period, 227 patients underwent lung cancer resection. There were 47 patients (20.7%) who had 119 pathologically confirmed SMPLC. Most patients had ipsilateral tumors (n = 24, 51.1%) with at least 1 adenocarcinoma (n = 40, 85.1%). Considering histologic subtyping, 38 (80.9%) had histologically distinct tumors. Overall and cancer-specific survival at 4 years was 86% and 90%, respectively. Only patients with 3 or more SMPLC had poor 4-year overall (P = 0.002) and cancer-specific survival (P = 0.043) compared with those with 2 SMPLC. Patient demographics, histology, tumor location, and highest pathologic staging did not affect survival outcomes. CONCLUSIONS: Using a strict inclusion criterion, the incidence of SMPLC is higher than previously reported. SMPLC patients have favorable survival outcomes, suggesting that they behave like primary lung cancer, not intrapulmonary metastasis. Awareness of SMPLC by thoracic surgeons is critical in optimizing outcomes in this patient population.
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Neoplasias Pulmonares , Neoplasias Primárias Múltiplas , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiologia , Detecção Precoce de Câncer , Estudos Retrospectivos , Incidência , Prognóstico , Neoplasias Primárias Múltiplas/epidemiologia , Neoplasias Primárias Múltiplas/cirurgia , Neoplasias Primárias Múltiplas/diagnósticoRESUMO
Background: The incidence of synchronous multiple primary lung cancer (SMPLC) is increasing, occurring in up to 20% of lung cancer patients. Accurately identifying SMPLC can be challenging, and failure to recognize SMPLC results in poor outcomes. We sought to assess the staging accuracy of patients with SMPLC at our tertiary institution. Methods: We retrospectively reviewed all patients who were evaluated for lung cancer resection between January 2018 to September 2019. Patients with SMPLC were identified using the modified Martini-Melamed criteria. Preoperative imaging, clinical assessment, and pathologic interpretation were reviewed and compared to the final staging assigned by a multidisciplinary lung cancer tumor board to determine accuracy. Results: Out of 227 patients presenting for lung cancer resection, 47 patients with 119 SMPLC were identified, of which 38 (80.9%) were incorrectly staged by at least one report. Incorrect staging was most common by computed tomography (CT) reports (n=33/47, 70.2%), followed by positron emission tomography-CT (PET-CT) reports (n=28/45, 62.2%), surgeons' clinical assessment (n=10/47, 21.3%), and histopathology reports (n=8/47, 17.0%). CT reports, when incorrect, under-staged 97.0% (n=32) of patients. PET-CT reports, when incorrect, over-staged 25.0% (n=7) of patients by reporting the second primary nodule to be "consistent with metastasis". Histopathology reports, when incorrect, over-staged 87.5% (n=7) of patients despite lack of lymph node involvement. Conclusions: Patients with SMPLC are at risk of receiving incorrect treatment based on radiographic and histopathologic staging reports alone. The observed staging inaccuracies are concerning, necessitating increased awareness among physicians caring for lung cancer patients.
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Nearly a third of patients with primary lung cancer present with malignant central airway obstruction (MCAO), and some of them appear to have advanced disease. In these patients, accurate staging is crucial. Although the literature extensively outlines the role of interventional bronchoscopy in palliation, its contribution to refining the staging of patients with MCAO is noteworthy. Here, we present a case of a patient initially diagnosed with stage IV cancer due to a left mainstem tumor causing complete lung collapse. He was referred to our institution for palliative treatment of his cough. Following interventional bronchoscopy, the patient's staging was revised to T1a, and subsequently, he underwent lobectomy without complications.
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Literary reception is a special case of language processing. The judgment of literature reveals deep social patterns with embodied cognition. In this study, we investigate how differences in literary quality resonate in the human brain. Modifying a series of stimuli previously used in studies of the emotional potential of Harry Potter, we alternate passages from the original novels with passages from imitative and intentionally poorly written fanfiction. EEG data shows how the three text types are processed differently by the brain. Comparing the brain activity of the readers for the various text types, we see a difference in the absolute power but not in the relative power of the frequency bands. Reading badfiction evokes the lowest activity. However, the functionality of this activity is the same for all texts since the relative power of the frequency bands does not differ. When comparing the participant groups, we observe the opposite situation. Here, different relative powers of the frequency bands reflect different judgments and reading habits of participants. For example, fans of Harry Potter, regular readers of fantasy texts, and generally frequent readers read the texts more attentively, which is reflected in a pronounced relative activity of the theta and alpha frequency bands. Non-frequent readers and readers who are not devoted to Harry Potter and fantasy in general have increased activity in the delta frequency band. This suggests their saliency detection is more prominent because they are less familiar with reading or the subject matter. To support our findings, we use the EEG data without averaging over stimuli and participants, capturing the participants' responses on the level of individual stimuli. A Kohonen self-organizing map trained on this more extensive data finds reliably detectable differences in the responses to passages from the original Harry Potter novels and fan- and badfiction. Our study allows for an interpretation of an adaptive brain response. Readers who enjoy Harry Potter or have experience with the fantasy genre show different reactions from those who do not. Thus, badfiction appears to be processed differently by the human brain, but not for all readers in the same way.
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Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.
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Lipoid pneumonia occurs due to the accumulation of lipids within the lung tissue. Autopsy series have reported an incidence of 1.0-2.5% in adult and 8.8% in children. Lipoid pneumonia can be from an exogeneous or an endogenous source. Exogenous lipoid pneumonia is often associated with aspiration of fatty materials, whereas endogenous lipoid pneumonia is associated with an accumulation of lipid-rich debris from destroyed alveolar cells. We describe a 75-year-old man who presented with spiculated lung nodules found incidentally on abdominal CT. Reviews of systems were positive for weight loss, and a history of constipation. A PET/CT revealed spiculated nodules with positive fluorodeoxyglucose (FDG) uptakes. A wedge resection was performed with histopathologic findings consistent with exogenous lipoid pneumonia with granulomatous reaction. We report clinical, radiological, and pathological features of exogenous lipoid pneumonia secondary to chronic aspiration mimicking invasive adenocarcinoma. A high index of suspicion for exogenous lipoid pneumonia should be maintained, especially when evaluating patients with abnormal chest radiographic findings and risk factors for aspirations.
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Pneumonia Lipoide , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Adulto , Idoso , Criança , Fluordesoxiglucose F18 , Humanos , Pulmão/patologia , Masculino , Pneumonia Lipoide/complicações , Pneumonia Lipoide/etiologia , Fatores de RiscoRESUMO
Rationale: Prolonged air leak (PAL) after partial lung resection can occur owing to surgical complications or in the presence of residual thoracic space. The former type results in drainage-independent PAL (DIPAL), whereas the latter type results in drainage-dependent PAL (DDPAL). DDPAL is described after thoracentesis in patients with nonexpandable lung, where the thoracostomy tube can be discontinued safely despite an ongoing air leak. This distinction is clinically relevant, as in the presence of DDPAL, tube thoracostomy can be safely discontinued without the need for further interventions. Objectives: To determine the frequency and clinical relevance of DDAPL and DIPAL in patients with PAL after partial lung resection. Methods: We prospectively identified consecutive patients with PAL after partial lung resection. Pleural manometry was performed 3-5 days after surgery. Pleural pressure was measured for 20 minutes after clamping the thoracostomy tube. DDPAL was diagnosed if the end-expiratory pleural pressure remained stable after plateauing in the absence of respiratory symptoms. Results: Of 225 patients who underwent lung resection, we identified 22 (10%) who had PAL. Twenty patients had adequate pleural manometry readings. The majority, 16/20 (80%), had DDPAL and had lower median hospital length of stay than those with DIPAL (6.9 vs. 11 days; P = 0.02). All patients with DIPAL required reexploration surgery, whereas only one patient with DDPAL underwent reexploration surgery. Conclusions: Most PALs after partial lung resection are DDPAL. Patients with DDPAL have lower hospital length of stay and less need for reexploration surgery than those with DIPAL.
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Pneumonectomia , Complicações Pós-Operatórias , Drenagem/efeitos adversos , Humanos , Pulmão/cirurgia , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Complicações Pós-Operatórias/etiologia , Estudos ProspectivosRESUMO
Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.
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Adenocarcinoma/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia , Complicações Pós-Operatórias/terapia , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Resultado do TratamentoRESUMO
To care and treat patients with esophageal cancer, one must first understand the epidemiology of Barrett's esophagus (BE). BE is defined as the intestinal metaplasia occurring within the esophagus from normal squamous epithelium to abnormal specialized columnar epithelium. BE, while first described by Allison in 1948, was attributed to Norman Barrett in 1950, who reported a case of chronic peptic ulcer in the lower esophagus that was covered by columnar epithelium.
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Adenocarcinoma/epidemiologia , Esôfago de Barrett/epidemiologia , Carcinoma de Células Escamosas/epidemiologia , Neoplasias Esofágicas/epidemiologia , Esôfago/patologia , Lesões Pré-Cancerosas/epidemiologia , Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Carcinoma de Células Escamosas/patologia , Progressão da Doença , Neoplasias Esofágicas/patologia , Humanos , Metaplasia , Lesões Pré-Cancerosas/patologia , Estados Unidos/epidemiologiaRESUMO
Optimal treatment of esophageal cancer is a complex process dependent on many factors, including stage at diagnosis, medical fitness, physician judgment, and expertise. Despite significant advances in understanding of this cancer, survival remains low. Identifying patients with early-stage disease can enhance their outcomes dramatically. On a broader scale, staging is critical in advancing the quality of care delivered to these patients now and in the future. This article is designed to review clinicians' expertise with staging and to elaborate on the nuances frequently encountered when doing so.
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Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Neoplasias Esofágicas/patologia , Adenocarcinoma/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Neoplasias Esofágicas/diagnóstico , Humanos , Estadiamento de NeoplasiasRESUMO
The utility of thoracoscopic lung surgery is well established, however, reoperation for pulmonary resections has not been thoroughly studied. We sought to evaluate patient perioperative outcomes following redo thoracoscopic pulmonary resections for malignancy by comparing first and second ipsilateral operations. We included patients undergoing redo thoracoscopic pulmonary resections for clinically recurrent disease following prior lung resection for malignancy from January 1, 2011 to May 31, 2019. Nonmalignant indications were excluded. We analyzed type of procedure, diagnosis, rate of conversion to open, estimated blood loss, operating time, margin status, length of stay and complications. Forty-one patients met our inclusion criteria. The median age was 68 years (range 13-84) and 20 were women. Redo operations had longer lengths of stay with a trend toward higher rate of conversion to thoracotomy, but other perioperative outcomes were similar. No difference in outcomes was seen when patients were grouped by indication for reoperation (recurrence, multiple primaries, and metastasis) or approach of first operation (VATS vs open). However, patients undergoing an anatomic resection after a prior anatomic resection had more complications, higher blood loss, higher rate of conversions to thoracotomy, significantly longer length of stay and longer operative times than nonanatomic resections. Thoracoscopic reoperation for recurrent, metachronous, or metastatic cancer to the lung is a reasonable approach. However, the surgeon must recognize and counsel patients that in patients undergoing a redo anatomic resection, thoracoscopic reoperations are more difficult with more adverse outcomes.
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Neoplasias Pulmonares , Pneumonectomia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida , Toracotomia/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
With advancing endoscopic technology and screening protocols for Barrett disease, more patients are being diagnosed with early-stage esophageal cancer. These early-stage patients may be amendable to endoscopic therapies, such as endomucosal resection and ablation. These therapies may minimize morbidity, but the elevated risk of recurrence cannot be overlooked. This article reports outcomes and recommendations for surveillance and management of recurrent esophageal cancer following endoscopic therapies.
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Assistência ao Convalescente/métodos , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/terapia , Esofagoscopia , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/terapia , Técnicas de Ablação/métodos , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas/patologia , Esofagectomia/métodos , Humanos , Recidiva Local de Neoplasia/patologia , Estadiamento de NeoplasiasRESUMO
Duty-hour restrictions have implications on trainee operative exposure necessary to meet minimum case-volume requirements. We utilized a previously validated simulation model to evaluate the effect of program volume, trainee numbers and complement, and rotation schedule on the probability of achieving adequate esophagectomy case numbers for cardiothoracic surgery trainees. A ProModel simulator centered on probabilistic distributions of operative cases was utilized. Historical data from five 2-year cardiothoracic surgery training programs were obtained from 2016-2018 and used as inputs to the simulator that generated 10,000 "trainee 2-year periods" per program. Programs varied in annual average esophagectomy volume (12-91 per year), with 2-4 trainees graduating over a 2-year training period. If esophagectomy cases were distributed solely based on scheduling and institutional volume, only 60% of evaluated programs could adequately expose all trainees in esophagectomy to meet case requirements. The 3 programs with adequate esophagectomy volumes had averaged 3.3 times (range 3.0-3.6) the minimum number of board-required cases for their programs' trainees. The ability of programs to provide trainees with adequate esophagectomy volume is challenging based on institutional volume and scheduling. Through simulation, we demonstrate that programs need >2 times the expected minimum number of esophagectomies to ensure that >90% of trainees meet case-volume requirements. Programs may consider strategies such as allowing trainees to select cases based on personal need, train fewer fellows, or enable trainees to seek subspecialty exposure externally to achieve minimum esophagectomy case-load requirements.
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Internato e Residência , Cirurgia Torácica , Competência Clínica , Educação de Pós-Graduação em Medicina , Esofagectomia/efeitos adversos , Humanos , Resultado do TratamentoRESUMO
On the eve of the First World War, a wealthy director of a company, Antoine-Lucien Boyer, has created at Manitot, a small village close to Paris on the riverside of the Seine opposite to Giverny, the first camp of coaching for athletes. Famous boxers like Billy Papke, Georges Carpentier, Eugène Criqui, and Bernard or runners like Jean Bouin have spent a while to prepare their competitions. Taking the opportunity of being at the countryside, these athletes did angling, rowing, and hunting in parallel to their specific sport preparation. Using different sources like newspapers (L'Auto, L'écho des sports), but also books and archives (public and privates), we aim at relating the history of this first sport camp of coaching and will try to understand the reasons of the landowner for launching this experience. Furthermore, we will review the methods of training and highlight a specifically French approach, based on an eclectic training method determined by health more than by performance.