Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial.

BACKGROUND: Intermittent work breaks are common in fields with high workload but not yet for surgeons during operations. We evaluated the effects of intraoperative breaks during complex laparoscopic surgery (5 min every half hour) on the surgeon. METHODS: Fifty-one operations were randomized to a scheme with intraoperative breaks and release of the pneumoperitoneum (intermittent pneumoperitoneum (IPP)) or conventional conduct (CPP). Stress hormones and α-amylase were determined in the surgeon's saliva pre-, intra-, and postoperatively. Mental performance and error scores, musculoskeletal strain, and continuous ECG were secondary endpoints. RESULTS: Regular intraoperative breaks did not prolong the operation (IPP vs. CPP group: 176 vs. 180 min, p > 0.05). The surgeon's cortisol levels during the operation were reduced by 22 ± 10.3% in the IPP vs. the CPP group (p < 0.05). There were significantly fewer (p < 0.05) intraoperative events in the IPP vs. the CPP group, which yielded higher α-amylase peaks. The pre- to postoperative increase in the error rates of the bp-concentration test was fourfold reduced in the IPP group (p = 0.052). The relevant locomotive strain-scores were grossly reduced by IPP (p < 0.001). CONCLUSIONS: Our data support the idea that work breaks during complex laparoscopic surgery can reduce psychological stress and preserve performance without prolongation of the operation time compared with the traditional work scheme.

Combined PTEN and p27kip1 protein expression patterns are associated with obesity and prognosis in endometrial carcinomas.

PURPOSE: Phosphatase and tensin homologue deleted from chromosome 10 (PTEN) and p27(kip1) proteins are key players of the Akt pathway, which is nutritionally regulated by insulin receptor signaling and influenced by estrogens. In this study, the prognostic relevance of the PTEN/p27(kip1) protein expression in endometrial carcinoma in relationship to the body mass index (BMI) was determined. EXPERIMENTAL DESIGN: BMI and prognosis of 452 surgically treated patients with endometrial carcinoma were correlated with histologic subtype, International Federation of Gynecology and Obstetrics (FIGO) stage, and differentiation grade. The expression of PTEN and p27(kip1) was examined in 257 tumors by immunohistochemistry using a tissue microarray approach. RESULTS: Lack of PTEN was observed in 136 of 257 (53%) tumors and absence of p27(kip1) expression was observed in 106 of 225 (47%) tumors. Absence of both proteins was significantly associated with well-differentiated tumors [PTEN (P < 0.02) and p27(kip1) (P < 0.009)]. Differentiation grade, tumor stage, and histologic type were independent of an increased BMI. Importantly, tumors of obese women expressed significantly less PTEN (P < 0.008) and less p27(kip1) (P < 0.01) than tumors from nonobese patients. Combined absence of both PTEN and p27(kip1) expression characterized a group of 75 (32%) tumors with favorable clinical outcome, particularly in the FIGO stages I and II (P = 0.003) of obese patients. Cox regression analysis revealed that PTEN/p27(kip1) phenotype, FIGO stage, and histologic grade were independent predictors of prognosis in endometrioid endometrial carcinoma. CONCLUSIONS: Inactivation of PTEN/p27(kip1) proteins is a specific feature in the progression of endometrial carcinoma in obese patients. The phenotype of the combined loss of PTEN/p27(kip1) protein expression in obese patients is associated with a significantly better prognosis in endometrioid endometrial carcinoma.

Work breaks during minimally invasive surgery in children: patient benefits and surgeon's perceptions.

INTRODUCTION: We recently reported that 5-minute work breaks every 25 minutes during long lasting laparoscopy in children (intermittent pneumoperitoneum [IPP] scheme) decrease the surgeon's stress markers such as saliva cortisol and heart rate and improve time-concentration scores significantly. Data on the impact of breaks on the patient and on the surgeon's perception of breaks, however, are still lacking. MATERIALS AND METHODS: We present the comprehensive biometry data of a randomized trial including 26 patients operated with (IPP) and 26 patients without breaks (continuous pneumoperitoneum [CPP]). Moreover, we analyzed the surgeon's perception of the break scheme using behaviorally anchored 10-point rating scales. RESULTS: There were no significant intergroup differences in the pooled patients' hemodynamics including cardiac output, blood gas readings, and temperature during and after the operation. Infants <1 year of age undergoing IPP versus CPP produced significantly higher urine volumes (1.60 ± 1.8 vs. 0.67 ± 1.00 mL/h/m2, p < 0.05). The overall area under the curve (AUC) of their cardiac output was 106.7 ± 41.1 (IPP) versus 78.0 ± 41.3 (CPP). This difference became significant during long operations (p < 0.05 for AUC 150 to 270 minutes). Surgeon's break perception and acceptance: team communication shifted from an implicit "mute communication" to an explicit way "issues are outspoken" by +4.7 ± 2.6 (p < 0.05) with improved coherence between operator and assistants (+3.9 ± 2.1). However, when questioned whether there was one particular welcome (5.1 ± 1) or extremely disturbing (6.4 ± 2.4) break during the entire procedure, the latter yielded a higher score (p > 0.05). Acceptance varied according to the surgeon's own esteem of his/her work style. Operators with high self-ratings for "fast" were inclined to put up with shorter breaks ("fast" vs. "slow" = 3.5 ± 1.4 vs. 5.5 ± 0.7, p < 0.05). Overall the scheme was approved (5.9 ± 3.2). CONCLUSIONS: A break scheme has no detrimental effect on patient physiology and is beneficial in infants. It needs careful tailoring to both the surgeon's work situation and self-esteem to gain acceptance.