Emotional Regulation in Surgery: Fostering Well-Being, Performance, and Leadership.

Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level.

The role of endoscopic ultrasound and cyst fluid analysis in the initial evaluation and follow-up of incidental pancreatic cystic lesions.

PURPOSE: To assess the role of endoscopic ultrasound (EUS) in the initial evaluation and follow-up of incidental pancreatic cystic lesions (PCL). METHODS: Retrospective analysis of patients with incidental PCL on imaging who were evaluated by EUS and had a minimal follow-up of 1 year. RESULTS: There were 62 patients (40 females and 22 males). The mean patient age was 67.7 years (range, 30-89). The Median follow-up was 24 months (range, 12-72). The mean PCL size was 21.6 mm. In all, 13 patients underwent surgery (20.9%). Diagnosis included a mucinous cystic tumour (7), mucinous adenocarcinoma (2), intraductal papillary mucinous neoplasm (1) and a cystic neuroendocrine tumour (1). The overall malignancy rate among patients who underwent surgery was 15.3% (two patients). The mean carcinoembryonic antigen (CEA) level from PCL fluid analysis was also significantly higher in surgically treated group (7760) vs. the stable group (184.7) vs. the enlarging PCL group (361.1). A CEA level above 192 ng/ml predicted mucinous PCL with a sensitivity of 90%. CONCLUSIONS: EUS with cystic fluid analysis can be successfully used to rule out pancreatic neoplasms and to follow-up incidentally discovered PCL.

A Rare Case of Histiocytic Sarcoma Secondary to Gastrointestinal Stromal Tumor in the Stomach: Transdifferentiation or Synchronicity?

Histiocytic sarcoma is a rare malignant histiocytic neoplasm composed of cells with morphologic and immunophenotypic features of mature tissue histiocytes. It occurs anywhere in the body and behaves aggressively. However, its etiology is unknown. Here, we report a 68-year-old female who developed histiocytic sarcoma following chemotherapy with imatinib (Gleevec) for gastrointestinal stromal tumor. Possible mechanisms of transdifferentiation from gastrointestinal stromal tumor to histiocytic sarcoma are discussed based on the features of our case and other two similar cases in the literature.

Internal iliac vein transposition for vascular reconstruction after resection of an external iliac vein leiomyosarcoma.

Primary vein leiomyosarcoma is rare type of a vascular sarcoma and arises from the spindle cells of the venous wall. The tumor may present difficulty of vascular reconstruction after en block resection. We present a case of internal iliac vein transposition for vascular reconstruction after resection of an external iliac vein leiomyosarcoma.To our knowledge, this is first report of the external iliac vein replacement with the ipsilaterally transposed internal iliac vein.

Mesenteric fibromatosis mimicking a gastrointestinal stromal tumor.

Mesenteric fibromatosis is a locally aggressive tumor of the mesentery with a high propensity for bowel involvement. Mesenteric fibromatosis often mimics gastrointestinal stromal tumors in size, location and immunohistochemical features. We report the case of a 30-year-old male who underwent resection of a mesenteric tumor, initially diagnosed as gastrointestinal stromal tumor. The tumor was categorized as high-risk and the patient was treated with chemotherapy. Two years later the patient was found to have a mass in the mesentery and restarted on chemotherapy. The tumor did not respond to medical management. The patient underwent a second en bloc resection and pathology results were conclusive for mesenteric fibromatosis. This case highlights the significance of accurately differentiating mesenteric fibromatosis from gastrointestinal stromal tumor. Making a concrete diagnosis is often difficult because both gastrointestinal stromal tumors and mesenteric fibromatosis share a number of morphological and immunohistochemical features including CKIT expression.

A Collaborative To Evaluate And Improve The Quality Of Surgical Care Delivered By The Military Health System.

In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.

Giant type III well-differentiated neuroendocrine tumor of the stomach: A case report.

INTRODUCTION: We describe a case of a large type III neuroendocrine tumor of the stomach. Management and current literature are reviewed. PRESENTATION OF CASE: A 37year old female presented with upper gastrointestinal bleed and epigastric pain. Further workup demonstrated a large ulcerated gastric mass near the GE junction. Computer tomography scan and endoscopic ultrasound showed a 10cm mass with no evidence of distant disease. Fine needle aspiration pathology was consistent with a well differentiated neuroendocrine tumor (Ki67 index<2%), with elevated levels of chromogranin A and serotonin levels but normal gastrin. The patient underwent an uneventful total gastrectomy. Final pathology analysis reported a higher KI67 index (7.54%) and a final pathology of grade 2 type III, T3 N3, neuroendocrine tumor of the stomach. The chromogranin levels normalized and no recurrent disease has been detected in one year follow up. DISCUSSION: Gastric neuroendocrine tumors are extremely rare, accounting for 4% of all neuroendocrine tumors of the body and 1% of all neoplasms of the stomach. Based on histomorphologic characteristics and pathogenesis, gastric neuroendocrine tumors are classified into four types with differing prognosis and behavior. Current literature describes type 3 gastric neuroendocrine tumors as larger than 2cm. However, there is no precedent in the literature for a tumor of this size. CONCLUSION: The incidence of gastric neuroendocrine tumors has been increasing during the last decade, underscoring the need to improve our understanding of their biology and behavior. When identified histologically, patient outcomes depend on appropriate determination of tumor biology and subsequent choice of treatment.

Minimizing shear and compressive stress during pancreaticojejunostomy: rationale of a new technical modification.

The failure of the pancreaticojejunal anastomosis remains an important and potentially lethal postoperative complication after pancreaticoduodenectomy. During the pancreaticojejunostomy, creation of compressive and shear forces during suture placement and knot tying may cause deformation of and cutting through the fragile pancreatic parenchyma. We sought to understand the mechanics of needle-pancreas interaction and make adjustments to our pancreaticojejunostomy technique so that the creation of shear and compressive stress could be minimized. We provide a detailed description, a mathematical model, and analysis of the outcomes of our new technical modifications.

Surgical management of the succinate dehydrogenase-associated familial paraganglioma syndromes.

Paragangliomas are rare neuroendocrine tumors arising from the neural crest cells in the extra-adrenal location. Paragangliomas can be sporadic or associated with a range of endocrine and genetic syndromes in 25% to 30% of all cases. Specifically, succinate dehydrogenase gene mutations are involved in the development of paraganglioma syndromes type 1 through type 4. In this article, we will describe 2 cases of succinate dehydrogenase-associated familial paraganglioma syndrome and provide a review of the existing literature on the condition's etiologic factors, diagnosis, and management.

Performance improvement: getting an early start.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the Surgical Care Improvement Program (SCIP) can be utilized to develop quality initiatives to improve surgical care. Understanding the fundamentals of quality measures provides insight to the six Accreditation Council on Graduate Medical Education (ACGME) competencies. Resident education needs a robust exposure to quality measures, such as NSQIP and SCIP to prepare surgeons for tomorrow's healthcare system. METHODS: The resident champion (RC) position is a dedicated research year between the PGY-2 and PGY-3 as a way to introduce residents to NSQIP and the importance of quality improvement. The resident partners with the NSQIP clinical reviewer to analyze data, develop quality improvement projects, implement these initiatives, and re-examine quality performance. RESULTS: Over the last 24 months, there have been numerous performance improvement initiatives and projects implemented at our facility as a direct result of the RC's efforts and their participation within the performance improvement committees. In addition, the projects led to multiple presentations at national conferences. CONCLUSIONS: A dedicated year in performance improvement has benefited our residents with a working knowledge of quality measures and our institution with multiple projects that have yielded significant improvements in the quality of patient care.

Images in surgery: retroperitoneal ganglioneuroma.

Ganglioneuroma is a differentiated tumor of the sympathetic nervous system. We describe a case of retroperitoneal ganglioneuroma without vascular invasion that was resected using laparotomy access. We also provide a short review of the ganglioneuroma as a clinical entity.

Raising the thinker: new concept for dissecting the cystic pedicle during laparoscopic cholecystectomy.

Imprecise dissection due to poor visualization of anatomic structures is among the major causes of biliary injuries during laparoscopic cholecystectomy. Developing new illustrational and rendering techniques represents an important part in decreasing visual deception and subsequent bile duct injuries. We use the model of one of the most well-known pieces of art, Rodin's The Thinker, to visualize the gallbladder and cystic pedicle structures. This minimizes visual deception before dissection, especially in cases with obscured structures. Our method, raising The Thinker, is based on the remarkable similarity between the sculpture and the topographic anatomy of the gallbladder. The method can be used not only for better orientation and visualization during laparoscopic cholecystectomy but also as a tool to complement the teaching of laparoscopic biliary anatomy to surgical residents and medical students.

HPB surgery can be safely performed in a community teaching hospital.

INTRODUCTION: There is ongoing debate about feasibility of performing hepatobiliopancreatic (HPB) cases in low-volume, community hospitals. We decided to analyze outcomes of HPB surgical cases done in our community hospital and compare it with published data from academic centers and/or national data. MATERIALS AND METHODS: We reviewed all HPB cases (liver, pancreas, and bile duct cases) performed in an 8-year-period (2001-2009) by HPB-fellowship-trained general surgeon (P.F.S.) at the Danbury Hospital, CT, USA. All electronic files of the patients, who underwent HPB surgery, were reviewed, and all pertinent clinical information was retrieved. Complications and mortality were recorded for length of hospital stay and 30 days after discharge. All complications were graded according to Clavien classification. Pancreatic specific complications--pancreatic fistula/leak and delayed gastric emptying--were graded using International Study Group on Pancreatic Fistula and International Study Group of Pancreatic Surgery definitions. RESULTS: There were 140 HPB cases. These included 33 pancreatoduodenectomies, 29 distal pancreatectomies, 52 hepatic cases, and 26 cases of other cases involving pancreas and biliary tract. Overall complication rate was 36.4%. Using Clavien classifications, there were 26 grade 1 complications, 21 grade 2 complications, and four grade 3 complications. Two patients underwent reoperation for postoperative complications. Overall mortality was 0.7% (one patient). Pancreas-specific complications included 6% pancreatic leak rate after pancreatoduodenectomy and 24.1% leak rate for distal pancreatectomy. CONCLUSION: HPB surgery could be safely performed in community setting, with morbidity and mortality comparable to high-volume centers.

Hepatic intraductal oncocytic papillary carcinoma.

The authors report a case of hepatic intraductal oncocytic papillary carcinoma, a very rare subtype of hepatic papillary cholangiocarcinoma with only 8 cases reported so far in the English literature.