Assessing the effect of the critical view of safety criteria on simulated operative decision-making: a pilot study.

BACKGROUND: Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its impact on intraoperative decision-making among trainees is unclear. METHODS: General surgery interns (n = 10) viewed a training module on the CVS criteria and then independently reviewed 20 cholecystectomy videos lasting 1 min each edited at various points of CVS dissection to include examples of both adequate and inadequate dissections. Participants were asked to identify the following CVS criteria for each video-(1) clearance of fat from the hepatocystic triangle; (2) exposure of the cystic plate; and (3) two and only two structures entering the gallbladder-and then decide if the structures were safe to divide. RESULTS: Inter-rater agreement for each CVS criteria varied: (1) (k = 0.2510), (2) (k = 0.2771), and (3) (k = 0.4298) as did the decision to divide critical structures (k = 0.371). Individual mean rate of dividing structures ranged 5-50% and did not correlate with the total number of CVS criteria identified by each participant (Spearman's rho = 0.247, p = 0.492). Division of structures with incomplete CVS identification occurred in 15% of cases and was isolated to one participant in the majority of cases (88%). Among these cases, omission of the cystic plate dissection occurred in every instance. CONCLUSIONS: Identification of CVS criteria was not uniform with the least amount of agreement on adequate hepatocystic and cystic plate dissection. Individual variation also exists between identification of CVS criteria and likelihood to divide structures. Video-based assessments that include intraoperative decision-making can help assess individual perceptions of safe practices without the risk of harm to the patient.

Association of patient age with high-risk pathologic features in papillary thyroid cancer.

BACKGROUND: Certain patient demographics and histopathologic features are risk factors for papillary thyroid cancer (PTC) recurrence after initial treatment. Our objective was to determine whether very young age is associated with aggressive pathologic features in patients with PTC. MATERIALS AND METHODS: A retrospective analysis was performed for PTC patients who underwent surgical treatment at the University of Michigan between 2006 and 2012. Patients with known distant metastases were excluded. Demographics, high-risk pathologic features (capsular or vascular invasion, extrathyroidal extension, lymph node metastases, and extranodal extension), and disease recurrence were analyzed. RESULTS: 632 PTC patients were included in the analysis. Median age was 49 y (range 10-87). Tumors in patients aged <25 y had higher rates of extranodal extension (P = 0.002) compared with patients aged 25-44 y. Patients aged <25 y had more vascular invasion (P < 0.001) and lymph node metastasis (P = 0.001) than tumors in patients aged between 45-75 y. Patients aged >75 y had higher rates of vascular invasion (P < 0.001) and extrathyroidal extension (P = 0.001) compared with patients aged 45-75 y and more extrathyroidal extension (P < 0.001) than patients aged 25-44 y. There were no differences in tumor characteristics between the <25 and >75 age groups. CONCLUSIONS: PTC patients aged <25 y of age or older than 75 y exhibit higher rates of aggressive histopathologic features compared to PTC patients aged between 25-75 y.