The Clandestine Operations Performed on President Grover Cleveland and the Rationale for Surgical Secrecy.

The 1893 operations to remove a maxillofacial tumor from President Grover Cleveland aboard a private yacht remained a secret until long after his unrelated death from heart disease. Many historical studies have suggested that Cleveland kept his health and surgical care confidential because of the fragility of the economy during the Panic of 1893. Although that observation is true, it does not fully address the underlying reason for why the public would react poorly to news about an operation on the president. The death of Ulysses S. Grant eight years prior unearthed the denial, stigma, and fear of cancer felt by many Americans. Despite revolutionary 19th century advances in anesthesia, pathology, and surgery, the social history of "cancerphobia" ran deep.

The Rise of the Surgeon in the Seventeenth Century Virginia Colony.

Life in the early American colonies presented unique challenges to the British colonists. There was an acute need for health-care providers in the early Virginia colony at Jamestown. Many of the medical men who first arrived at Jamestown were surgeons who adapted themselves to fit the medical needs of the community. These men trained in the British system where they sat beneath physicians in a hierarchy that did not consider surgeons to be doctors. Through their service to the colonists, early surgeons earned the reputation traditionally given to physicians in Great Britain. The colonists in Virginia respected the surgeons and viewed them as doctors, which allowed surgeons to stand on equal ground with physicians as the colonies grew to eventually become the United States of America.

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

BACKGROUND: The operating room is a dynamic environment in which proper teamwork is essential. After piloting a simulation-based interdisciplinary operative team training program, we examined the impact of these sessions on the participants. METHODS: Three interdisciplinary operating room teams participated in the training model. Each team of 3 or 4 members completed the training in a virtual minimally invasive operating room using a standardized operative scenario. Upon completion of the training, participants completed a voluntary and anonymous training effectiveness questionnaire. RESULTS: All 10 participants completed the training evaluation questionnaires. Across the 3 teams, all participants felt that the training was worthwhile and would participate again. Eight participants said that the session would change their practices in the operating room. All participants felt that the session was effective in promoting team communication skills and crisis-related teamwork. Nine of the 10 felt that the training model was effective in recognizing operating room errors. CONCLUSIONS: Implementing true interdisciplinary team training with a high-fidelity simulation can be accomplished effectively. Team training has the potential for facilitating positive behavioral changes in operating room personnel that are important for adaptive team function in a crisis situation.

Gamma-guided diagnostic peritoneal lavage for detection of bowel perforation.

HYPOTHESIS: Bowel perforation can be diagnosed by detection of orally administered technetium Tc 99m sulfur colloid ((99m)Tc SC) in diagnostic peritoneal lavage (DPL) fluid using a handheld gamma-detection probe. DESIGN: A canine intestinal-injury model was used to test the hypothesis. The (99m)Tc SC (55.5 MBq) was administered in 500 mL of saline via a nasogastric tube. A DPL with 500 mL of saline was performed at 60, 90, and 120 minutes after administration of (99m)Tc SC. The radioactivity in the DPL effluent was measured using a handheld gamma probe. A DPL effluent count that was 3 SDs above the background count was considered a positive test result. Twenty animals with perforation and 5 without perforation (negative control) were studied. RESULTS: There were no false-positive gamma-DPL test results. Sensitivity improved by time up to 90 minutes. The lowest positive count in the DPL effluent measured by the gamma probe corresponded to 0.2% of the administered activity. No radioactivity was detected in blood and urine samples or liver and spleen specimens. The sensitivity, specificity, accuracy, positive predictive values, and negative predictive values at 90 minutes were 95%, 100%, 96%, 100%, and 83%, respectively. CONCLUSIONS: gamma-Guided DPL is a highly sensitive and 100% specific test in the detection of small-bowel perforation. Clinical studies are warranted to determine the patient-specific factors affecting diagnostic accuracy.

Development of a novel in vitro human tissue-based angiogenesis assay to evaluate the effect of antiangiogenic drugs.

OBJECTIVE: To describe a novel in vitro human tissue-based angiogenic model that can predict an individual tumor's response to antiangiogenic drugs. SUMMARY BACKGROUND DATA: A number of in vitro and in vivo angiogenesis assays exist, but they do not provide potentially useful information for the treatment of an individual patient. Clonogenic assays have been used to evaluate the response of an individual's tumor to antineoplastic agents, but these tumor fragments are cultured in an environment that does not lead to neovessel growth. The authors have previously demonstrated that human vein disks or human tumor xenograft fragments incorporated into a 0.3% fibrin-thrombin clot will develop angiogenic vessel growth from the cut edge of the vessel disk or xenograft fragment. METHODS: Fresh human tumor or normal tissue disks (2 x 1 mm) from fresh surgical specimens were incorporated into fibrin-thrombin clots overlain with nutrient medium containing either 20% fetal bovine serum alone or in combination with Epothilone B, a tubulin inhibitor with antiangiogenic properties. Tissue disks were visually assessed over time to determine the percentage of wells that developed an angiogenic response. Neovessel growth, density, and length were graded at intervals using a semiquantitative visual neovessel growth-rating scheme (angiogenic index, 0-16 scale) devised in the authors' laboratory. RESULTS: Epothilone B treatment at doses of 10-6 mol/L and 10-8 mol/L decreased the number of wells that developed an invasive angiogenic response and limited the development of vessels that invaded the matrix. At these doses, Epothilone B also caused regression of vessels in wells that had been allowed to develop an angiogenic response. Treatment of tumors or normal tissues with Epothilone B at doses less than 10-8 mol/L was ineffective. CONCLUSIONS: Epothilone B may be an effective antiangiogenic agent in a variety of tumor types. The authors speculate that this in vitro model might provide useful information to the clinician on the effect of specific antiangiogenic agents on individual tumors. This may be particularly useful in patients with tumors that, as a group, are unresponsive to treatment with antineoplastic agents.

Colorectal cancer in patients younger than 40 years of age.

Previous studies have suggested a poor outcome for patients presenting with colorectal cancer under the age of 40 years. This study was conducted to evaluate the outcomes of these patients during a 10-year period at the Medical Center of Louisiana in New Orleans. A retrospective study was designed to review all patients under the age of 40 with a diagnosis of colorectal cancer from January 1990 to December 2000. There were 664 patients presenting with colorectal cancer during the 10-year period; of these 24 presented for surgery under the age of 40. There were 17 male and seven female patients. The median age was 35 years (range 22-39). Eleven (44%) patients had a positive family history of colorectal cancer. Seven lesions were right sided, one transverse, eight left sided, and eight rectal. Histologically 20 lesions were typical adenocarcinomas and four were mucinous. Twelve were stage IV, six stage III, five stage II, and one stage I. Twenty-one patients underwent resection, six with stoma formation; three patients had stoma formation only for a total of nine stomas (38%). The mean operative duration was 3.3 +/- 1.9 hours. The operative mortality was 4 per cent with a complication rate of 17 per cent. The eight rectal cancer patients received preoperative chemoradiation therapy (33%). Twelve (50%) patients with colon cancer received postoperative 5-fluorouracil-based chemotherapy. The mean survival for all patients was 24.7 +/- 23.2 months. Estimated 5-year survival using Kaplan-Meier analysis was 30 per cent. We conclude that colorectal cancer patients less than 40 years of age present at an advanced stage and tend to have a positive family history. In general patients tolerate surgery well, with stoma formation in more than one-third. Long-term survival is as predicted for their advanced stage of presentation. The study highlights the need for early diagnosis in this patient group.

Cytoreductive surgery in patients with advanced-stage carcinoid tumors.

The role of aggressive surgical resections as well as criteria for resectability in patients with advanced carcinoid tumors is not clearly defined. Thirty patients (17 male and 13 female) who were previously diagnosed to have "unresectable carcinoid disease" were treated using a multimodality approach over a period of 2 years. Extensive liver involvement was present in 28 of 30 (93%) of the cases. Small bowel involvement was noted in 22 of 30 (73%), and peritoneal/retroperitoneal/mesenteric invasion was observed in 15 of 30 (50%) of the cases. Three patients had remote metastases (brain, bone, and eye). Twenty of 30 (66%) patients had carcinoid syndrome with severely disabling symptoms. Eight patients (26%) had small bowel obstruction. All patients underwent at least one surgical exploration/intervention. Radiofrequency ablation (RFA) of one or more liver lesions was performed as an adjunct in 22 of 30 (73%) patients. Six patients (20%) had a second surgical procedure. There were 11 complications in eight patients (27%) after the initial operation. Median hospital stay for patients who underwent RFA only, RFA/liver resection, and liver resection with abdominal tumor debulking were 2, 4, 8, and 16 days respectively. Twenty-five of 30 patients (83%) showed symptomatic improvement. Mean pre- and postoperative Karnofsky physical performance scores were 55 and 85 respectively (P < 0.02). Small bowel obstruction was due to adhesions in five patients. All patients with intestinal obstruction had complete relief of their symptoms postoperatively. 5-Hydroxyindolacetic acid levels decreased by 50 per cent in all patients with follow-up determinations available. Aggressive surgical exploration and tumor debulking could be performed with significantly improved symptomatic outcome and relatively minor complications. Longer follow-up is needed for assessment of effect on survival.