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BACKGROUND: The National Comprehensive Cancer Network recommends surgical resection for stage I small cell lung cancer (SCLC). Despite these recommendations and the curative potential of such surgery, many continue to underutilize surgery. Our aim is to investigate factors that contribute to underutilization of surgery for stage I SCLC. METHODS: The National Cancer Database was queried to identify patients with SCLC stage I-IV from 2004 to 2018. Staging was defined by the American Joint Committee on Cancer guidelines. Cochran-Armitage analysis was performed to analyze trends in surgical treatment for patients diagnosed with stage I SCLC. Multivariable logistic regression assessed relationships between patient factors and surgical treatment. RESULTS: A total of 296,583 patients were diagnosed with SCLC. Of the stage I patients (n = 13,003), only 29.4.% (n = 3823) underwent surgery. Trend analysis demonstrated increased frequency of surgical treatment for stage I SCLC over years 2004 to 2017, from 14.9% to 39.6% (P < .0001). Factors that were associated with underutilization of surgery for stage I SCLC include African American race, lower median income, nonprivate insurance or Medicare, community facility, and geographic regions other than the Northeast. CONCLUSIONS: Surgical treatment for stage I SCLC remains underutilized and our study identifies notable associated factors. The recognition of these factors may help patients overcome barriers to receiving recommended treatments, improve guideline adherence, and overall quality of care for stage I SCLC patients.
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Disparidades em Assistência à Saúde , Neoplasias Pulmonares , Estadiamento de Neoplasias , Pneumonectomia , Carcinoma de Pequenas Células do Pulmão , Humanos , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Carcinoma de Pequenas Células do Pulmão/cirurgia , Carcinoma de Pequenas Células do Pulmão/patologia , Masculino , Feminino , Idoso , Pneumonectomia/estatística & dados numéricos , Pneumonectomia/métodos , Estados Unidos , Pessoa de Meia-Idade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Estudos RetrospectivosRESUMO
CONTEXT.: Robotic-assisted navigation bronchoscopy (R-ANB) is used to target peripheral pulmonary nodules that are difficult to biopsy using conventional approaches. Frozen sections are requested to confirm these lesions have been localized and/or to diagnose neoplasms that can be immediately resected. OBJECTIVE.: To estimate diagnostic concordance between frozen section diagnosis (FSD) and formalin-fixed tissue diagnosis (FFTD) in biopsies obtained with R-ANB, calculate the sensitivity and specificity of FSD and FFTD for a diagnosis of malignancy, and evaluate whether the residual tissue that can be fixed in formalin after frozen section still has sufficient material for molecular studies. DATA SOURCES.: The results of consecutive FSD rendered on biopsies performed with R-ANB during a 30-month period were used to calculate the metrics listed above. FFTD and/or the diagnoses rendered on computed tomography-guided core biopsy subsequently performed in patients with negative R-ANB and/or lung resections in patients with malignancies were used as true-positive results. The overall concordance between FSD and FFTD in 226 lesions from 203 patients was 72%. Frozen section diagnosed 76 of 123 malignancies with 100% specificity and 68% sensitivity. Adequate material was available in 92% of biopsies where next-generation sequencing and other molecular studies were requested. CONCLUSIONS.: Intraoperative consultations are helpful to diagnose a variety of lung lesions and help surgeons confirm that targets have been accurately reached by R-ANB. Malignancies can be diagnosed with 100% specificity but only 68% sensitivity. The performance of frozen section did not interfere with the subsequent analysis of tissue with molecular studies in most cases.
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BACKGROUND: The growing adoption of robotic-assisted surgery mandates residents must acquire robotic skills. No standardized curriculum for robotic surgery exists. Therefore, programs have developed their own curricula, which are often unstructured and based on resource availability. With this strategy programs may not adhere to scholarly approaches in curriculum development. We aimed to obtain a multi-institutional needs assessment to address training needs and identify integral components of a formalized robotic surgery curriculum. METHODS: A 10-question survey was distributed to general surgery residents. A separate 7-question survey was sent to robotic faculty surgeons at 3 institutions. Survey questions queried demographics, opinions regarding robotic training, proficiency definitions, and identification of procedures and instructional strategies for a curriculum. Mann- Whitney U test and Fisher's exact test were performed to compare responses amongst residents and faculty. Spearman's correlation was used to identify relationships between experience or post-graduate year (PGY) with response selection. RESULTS: Both residents and faculty believed robotic training should start in the PGY1 (55.1% vs 52%; pâ¯=â¯0.58). Faculty recognized robotic training to be more important compared to residents (84% vs 58.1%; p < 0.05). Both groups considered a minimum of 21 to 40 robotic cases to be sufficient exposure during training (pâ¯=â¯0.30). Cholecystectomy (82.4% vs 72%; pâ¯=â¯0.261), ventral hernia repair (89.2% vs 88%; pâ¯=â¯1.0), inguinal hernia repair (91.9% vs 92%; pâ¯=â¯1.0), and right colectomy (83.8% vs 80%; pâ¯=â¯0.7) were considered to be the most appropriate robotic procedures during training. Both groups concurred that bedside (91.9% vs 100%; pâ¯=â¯0.33) and console skills training (97.3% vs 100%; pâ¯=â¯1.0), small group simulation (94.6% vs 72% pâ¯=â¯0.005), and independent practice (87.8% vs 92% pâ¯=â¯0.73), were instructional strategies vital to a curriculum. Faculty considered online didactic modules (96% vs 59.5%; p < 0.05) to be more important, whereas residents favored small group experiences for fundamental skills (94.6% vs. 72%; p < 0.05) and procedure-based simulation (96% vs 64%; p < 0.05). CONCLUSIONS: Our targeted needs assessment identified requisite components of a robotics curriculum, which are feasible and accepted by both residents and faculty. Medical educators can use this as a resource to develop a formal robotics training curriculum.
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Cirurgia Geral , Internato e Residência , Procedimentos Cirúrgicos Robóticos , Cirurgiões , Humanos , Procedimentos Cirúrgicos Robóticos/educação , Avaliação das Necessidades , Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina/métodos , Docentes , Cirurgia Geral/educaçãoRESUMO
Lung cancer remains the leading cause of cancer-related deaths. Early tissue diagnosis followed by timely therapeutic procedures can have a significant impact on overall survival. While robotic-assisted lung resection is an established therapeutic procedure, robotic-assisted bronchoscopy is a more recent diagnostic procedure that improves reach, stability, and precision in the field of bronchoscopic lung nodule biopsy. The ability to combine lung cancer diagnostics with therapeutic surgical resection into a single-setting anesthesia procedure has the potential to decrease costs, improve patient experiences, and most importantly, reduce delays in cancer care.
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Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Nódulo Pulmonar Solitário , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Nódulo Pulmonar Solitário/diagnóstico , Nódulo Pulmonar Solitário/cirurgia , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Pulmão/patologia , Biópsia , Broncoscopia/métodosRESUMO
OBJECTIVES: Lobectomy may unnecessarily resect healthy lung parenchyma in Stage 1A non-small cell lung cancers (NSCLC). Segmentectomies may provide a lung-sparing option. VATS segmentectomies can be technically challenging; robotics may have features that provide advantages in performing segmentectomies. We describe the association of the robot on national trends in segmentectomies. METHODS: The National Cancer Database (2010-2017) was queried for patients with Stage 1A NSCLC who underwent lobectomies and segmentectomies. The proportion of segmentectomies vs. lobectomies and the proportion of robotic vs. VATS segmentectomies was calculated annually. RESULTS: The proportion of segmentectomies increased compared to lobectomies for all surgical approaches but remained constant for minimally-invasive approaches. The proportion of robotic segmentectomies increased over the years compared to VATS segmentectomies. Descriptive statistics are reported as numbers and proportions. Trends in the proportions of lobectomies and segmentectomies were compared using Chi-squared test for categorical variables and unpaired t-test for independent means. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics Software version 24 (IBM Corp, Armonk, NY). CONCLUSIONS: We demonstrate an increasing trend and proportion of robotic segmentectomies being performed in comparison to VATS segmentectomies. The robotic platform may facilitate the performance of more segmentectomies for early-stage NSCLC.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Robótica , Humanos , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Mastectomia Segmentar , Cirurgia Torácica Vídeoassistida , Estudos RetrospectivosRESUMO
Objective: Sputum is a source of exfoliated respiratory epithelial cells transformed early in lung carcinogenesis. Malignant cells are hypomethylated and contain less genomic 5-methylcytosine (5mC). Validating a test that recognizes and quantifies aberrantly hypomethylated cells in sputum, we assessed its potential as a screening tool for detecting early-stage non-small cell lung cancer. Methods: Cells extracted from sputum were immunofluorescence labeled with an anti-5-methylcytosine antibody and counterstained with 4',6-diamidino-2-phenylindole (DAPI) delineating global nuclear DNA (gDNA). Via confocal scanning and 3-dimensional image analysis, fluorescence 5mC and DAPI signals were measured in segmented cell nuclei, and a 5mC/DAPI co-distribution map was generated for each imaged cell. Cells were classified as hypomethylated based on 5mC load and 5mC/DAPI co-distribution. The proportion of hypomethylated epithelial cells in the sputum determines whether a patient has lung cancer. Results: A total of 88 subjects were enrolled: 12 healthy subjects; 34 high-risk subjects with benign chronic lung disorders (10 with chronic obstructive pulmonary disease, 24 with idiopathic pulmonary fibrosis), and 43 subjects with non-small cell lung cancer (27 with stage I-II and 16 with stage III-IV). The test identified early-stage non-small cell lung cancer and distinguished it from the high-risk group with 95.8% (95% confidence interval, 78.9-99.9) sensitivity and 41.2% (95% confidence interval, 24.6-59.3) specificity applying only 5mC, 95.8% (95% confidence interval, 78.9-99.9) sensitivity and 26.5% (95% confidence interval, 12.9-44.4) specificity using solely 5mC/DAPI index, and 100% (95% confidence interval, 98.7-100) sensitivity and 26.1% (95% confidence interval, 26.2-27.8) specificity with the combined parameters. Conclusions: We tested and validated a novel, noninvasive, highly sensitive screening test for non-small cell lung cancer. With the use of sputum, our test may impact lung cancer screening, evaluation of pulmonary nodules, and cancer surveillance algorithms.
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BACKGROUND: Cardiac surgery patients with a prolonged stay in the intensive care unit (ICU) are at high risk for acquired malnutrition. Medical nutrition therapy practices for cardiac surgery patients are unknown. The objective of this study is to describe the current nutrition practices in critically ill cardiac surgery patients worldwide. METHODS: We conducted a prospective observational study in 13 international ICUs involving mechanically ventilated cardiac surgery patients with an ICU stay of at least 72 h. Collected data included the energy and protein prescription, type of and time to the initiation of nutrition, and actual quantity of energy and protein delivered (maximum: 12 days). RESULTS: Among 237 enrolled patients, enteral nutrition (EN) was started, on average, 45 h after ICU admission (range, 0-277 h; site average, 53 [range, 10-79 h]). EN was prescribed for 187 (79%) patients and combined EN and parenteral nutrition in 33 (14%). Overall, patients received 44.2% (0.0%-117.2%) of the prescribed energy and 39.7% (0.0%-122.8%) of the prescribed protein. At a site level, the average nutrition adequacy was 47.5% (30.5%-78.6%) for energy and 43.6% (21.7%-76.6%) for protein received from all nutrition sources. CONCLUSION: Critically ill cardiac surgery patients with prolonged ICU stay experience significant delays in starting EN and receive low levels of energy and protein. There exists tremendous variability in site performance, whereas achieving optimal nutrition performance is doable.
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Procedimentos Cirúrgicos Cardíacos , Estado Terminal , Humanos , Estado Terminal/terapia , Ingestão de Energia , Apoio Nutricional , Nutrição Enteral , Unidades de Terapia IntensivaRESUMO
BACKGROUND: Fellows have been uniquely affected by the widespread changes in educational structure, mandatory limitations in elective procedural volume, and hiring freezes during the COVID-19 global pandemic. STUDY DESIGN: A voluntary and anonymous survey was distributed to all Graduate Medical Education fellows at a tertiary medical center querying perspectives on clinical and didactic training and job placement. RESULTS: A total of 47 of 121 fellows (39%) completed the survey. The majority were in a medical (43%) or surgical specialty (34%) followed by critical care (13%) and procedure-based (11%) fellowships. Approximately 59% of surveyed fellows felt their programs were providing a virtual curriculum that would train them just as well as the in-person curriculum. Twenty-eight (60%) fellows were in their final or only year of training. Of the 25 fellows who were seeking employment, 52% have experienced difficulty in finding a job due to hiring freezes and 40% have encountered challenges with job interview cancellations and changes to virtual interview formats. CONCLUSION: Almost half of surveyed fellows reported an educational deterioration due to COVID-19 and graduating fellows seeking employment felt hindered by both the virtual interview format and widespread hiring freeze. Fellows are both unique and vulnerable as they balance the solidification of clinical training with securing employment during these tumultuous and unprecedented times.
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COVID-19/epidemiologia , Educação de Pós-Graduação em Medicina/normas , Bolsas de Estudo , Adulto , California/epidemiologia , Emprego/estatística & dados numéricos , Feminino , Humanos , Masculino , Pandemias , SARS-CoV-2 , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The COVID-19 pandemic has impacted surgical training nationwide. Our former curricula will likely not return, and training will need to adapt, so we are able to graduate residents of the same caliber as prior to the pandemic. METHODS: A survey evaluating perceptions of changes made in surgical training was conducted on surgery residents and attendings. RESULTS: Disaster medicine training has become more relevant and 85% residents and 75% attendings agreed it should be incorporated into the curriculum. Safety of family was the most significant concern of residents. Virtual curriculum was perceived to be acceptable by 82% residents and only 22% attendings (p < 0.01). Residents (37%) were less concerned than attendings (61%) of falling behind on their overall training (p = 0.04). Both groups agreed operative skills would be adversely affected (56%vs72%; p = 0.37). CONCLUSIONS: To maintain an effective surgical curriculum, programs will need to implement new educational components to better prepare residents to become surgeons of the future.
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Atitude do Pessoal de Saúde , COVID-19/prevenção & controle , Educação a Distância/métodos , Cirurgia Geral/educação , Internato e Residência/métodos , Adulto , COVID-19/psicologia , California , Currículo , Educação a Distância/normas , Docentes de Medicina/psicologia , Família , Humanos , Internato e Residência/normas , Pessoa de Meia-Idade , Segurança , Estudantes de Medicina/psicologia , Cirurgiões/educação , Cirurgiões/psicologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Mentoring is an essential component of cardiothoracic surgery training, yet trainees report varied experiences despite substantial efforts to enhance mentorship opportunities. This study aimed to evaluate mentorship effectiveness and identify gaps in mentorship education. METHODS: A survey was distributed to cardiothoracic surgical trainees in Accreditation Council for Graduate Medical Education-accredited programs (n = 531). Responses to 16 questions concerning trainee experiences, expectations, and perspectives on mentorship were collected. An 11-component mentorship effectiveness tool generated a composite score (0 to 55), with a score of 44 or lower indicating less effective mentorship. RESULTS: Sixty-seven residents completed the survey (12.6%), with most (83.6%) reporting a current mentor. Trainees with mentors cited "easy to work with and approachable" (44 of 58; 75.9%) as the major criterion for mentor selection, whereas trainees without a mentor reported an inability to identify one who truly reflected the resident's needs (6 of 11; 45.5%). Resident age, gender, race or ethnicity, marital status, family status, postgraduate year, and training program type or size were not associated with having a mentor (P = .15 to .73). The median mentorship effectiveness score was 51 (interquartile range, 44, 55). More than one-third of residents (25 of 67) had either no mentor (n = 6) or less effective mentorship (n = 16), or both (n = 3). Resident and program characteristics were not associated with mentorship effectiveness (P = .39 to .99). Finally, 61.2% of residents had not received education on effective mentorship, and 53.8% did not currently serve as a mentor. CONCLUSIONS: Many resident respondents have either no mentor or less effective mentorship, and most reported not having received education on mentorship. Addressing these gaps in mentorship training and delivery should be prioritized.
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Procedimentos Cirúrgicos Cardíacos/educação , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência/métodos , Tutoria/métodos , Mentores/estatística & dados numéricos , Atitude do Pessoal de Saúde , Humanos , Estudos RetrospectivosRESUMO
Paraesophageal hernia repair is a technically challenging operation. Factors that influence morbidity of the operation include the timing of the operation, surgical approach, and patient factors. Medical complications are the most common and usually are respiratory or cardiac related. Perforation, subcutaneous emphysema, pneumothorax, shortened esophagus, and presence of a large hernia all complicate paraesophageal hernia repair. Various strategies of intraoperative management are described. Management of leaks and perforations identified postoperatively are dictated by the clinical status of the patient. Early identification and expeditious intervention are paramount in the overall management of complications.
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Perfuração Esofágica/terapia , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/terapia , Fundoplicatura/métodos , Gastroplastia/métodos , Humanos , Doença Iatrogênica , Laparoscopia , Tratamento de Ferimentos com Pressão Negativa , Pneumotórax/terapia , Recidiva , Estudos Retrospectivos , Stents , Estômago/lesões , Enfisema Subcutâneo/terapia , Resultado do TratamentoRESUMO
BACKGROUND: Our objective was to determine how surgical approach impacts overall survival and postoperative outcomes when comparing robotic-assisted minimally invasive esophagectomy (RAMIE), minimally invasive esophagectomy (MIE), and open esophagectomy (OE). METHODS: The National Cancer Database was queried for patients diagnosed with pathologic Stage 0 to III esophageal cancer from 2010 to 2015. Primary outcome measures evaluated were length of stay, 30-day unplanned readmissions, mortality rates at 30 and 90 days, and overall survival rates. The surgical cohorts underwent 1:1 propensity score matching, and Kaplan-Meier survival estimates were compared by surgical approach. Cox proportional hazards regression was utilized to estimate factors associated with overall survival. RESULTS: Of 5,553 patients that met criteria, 28.4% were MIE, 7.8% RAMIE, and 63.8% OE. From 2010 to 2015, an increasing trend was seen for both minimally invasive approaches, with MIE surpassing the number of OEs. Unplanned 30-day readmissions and 30-day and 90-day mortality rates were not significantly different between the different groups. Median length of stay was significantly shorter in MIE (9 [interquartile range (IQR), 8 to 14] days) and RAMIE (9 [IQR, 7 to 14] days), compared with OE (10 [IQR, 8 to 15] days; p < 0.001). MIE and RAMIE had comparable survival rates compared with OE, with no significant differences in median overall survival estimates after propensity score matching (log-rank p = 0.603), with a trend for increased survival in MIE (adjusted hazard ratio, 0.97; 95% confidence interval, 0.89 to 1.06; p = 0.530) and RAMIE (hazard ratio, 0.81; 95% confidence interval, 0.69 to 0.95; p = 0.012). Both minimally invasive approaches had a significantly higher median lymph node counts (MIE: 15 [IQR, 9 to 22]; RAMIE: 17 [IQR, 11 to 24]; OE: 13 [IQR, 8 to 20]), which may highlight important differences in postoperative upstaging. CONCLUSIONS: Trends in MIE use is surpassing the open approach. Minimally invasive approaches are becoming the preferred approach, with noninferior long-term results compared with OEs. A significantly higher lymph node yield was seen for RAMIE and MIE.
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Carcinoma de Células Escamosas do Esôfago/cirurgia , Esofagectomia/métodos , Pontuação de Propensão , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Carcinoma de Células Escamosas do Esôfago/diagnóstico , Carcinoma de Células Escamosas do Esôfago/mortalidade , Esofagectomia/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/mortalidade , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
HYPOTHESIS: Examination of 14 or more nodes is the optimal criterion to accurately stage node-negative colorectal cancer and predict outcome. DESIGN: Case series. SETTING: Three university-affiliated community medical centers. PATIENTS: A total of 2149 individuals with apparently localized, invasive colorectal cancer examined between January 1, 1990, and December 31, 2002. INTERVENTION: Study of tumor registry data. MAIN OUTCOME MEASURES: Nodal status and disease-specific survival. RESULTS: The number of nodes examined ranged from 0 to 97 (mean +/- SD, 18 +/- 15 nodes). The mean number of nodes examined in node-positive individuals was 21.0 vs 16.6 in node-negative individuals (P<.001). The mean number of nodes examined at medical center A was 22.3; center B, 17.9; and center C, 14.0. The mean number of nodes examined for T3 and T4 tumors at center A was 26; center B, 20; and center C, 16 (P<.001). The node-positive rate for all T3 and T4 lesions was 49.7% at center A, 57.8% at center B, and 50.0% at center C (P<.001). Despite significant differences in the mean number of nodes examined between medical centers, the overall survival in patients with node-negative colorectal cancer in the 3 medical centers was not statistically different (P = .79). The criterion of examining 14 or more nodes distinguished between individuals at low risk for recurrence and those at increased risk. CONCLUSIONS: Variability exists between medical centers in the pathological analysis of colorectal cancer specimens. However, within an institution, examining a mean of 14 or more nodes accurately stages apparently node-negative colorectal cancer and accurately predicts outcome.