Objective performance indicators of cardiothoracic residents are associated with vascular injury during robotic-assisted lobectomy on porcine models.

Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.

Evaluation of a 3D-Printed Transoral Robotic Surgery Simulator Utilizing Artificial Tissue.

OBJECTIVES/HYPOTHESIS: Transoral robotic surgery (TORS) poses challenges for operators in training, with limited robot access on a platform requiring distinct surgical skills. Few simulators exist, and current virtual reality training modules exclude head and neck simulations. This study evaluates the construct validity for a novel low-cost TORS simulator. STUDY DESIGN: Single institution prospective observational study. METHODS: Using 3D-printed oral cavity structures and replaceable artificial tissue components, a modular TORS simulator was constructed for short-duration hands-on simulations with the da Vinci SI robot. Sixteen surgeons of differing robotic skill levels, no experience (novice), prior experience, and formal robot training, participated in simulated tonsil and tongue base tumor resections. Video recordings of each participant were graded by a blinded robotically trained surgeon using a 35-point Global Evaluative Assessment of Robotic Surgery (GEARS) criterion adapted for the TORS simulator. RESULTS: Operators reporting formal robotic training or prior robot experience achieved significantly higher mean total GEARS scores compared to novice operators (32 vs. 20.5; P < .001). Overall, mean total GEARS scores correlated with reported experience level; novice operators scored 54% of total points at 19 (4.5), operators with prior experience scored 82.3% of total points at 28.8 (2.6), and robotically trained operators scored 97.1% of total points at 34 (1.7). CONCLUSION: With a GEARS criterion, our simulator successfully differentiated novice from experienced and robotically trained operators of the da Vinci SI robot during simulated tonsillectomy and base of tongue resections. These findings support the construct validity of this prototype simulator and offer a foundation for further testing of predictive validity. LEVEL OF EVIDENCE: 2 Laryngoscope, 132:1588-1593, 2022.

A High-Fidelity, Tissue-Based Simulation for Cardiac Transplantation.

Several operations in cardiothoracic surgery have been accurately modeled with tissue-based simulations. These have been shown to be beneficial in the training of residents. Cardiac transplantation has not been simulated. We describe a high-fidelity, tissue-based simulation that can be used to teach trainees to perform a cardiac transplant. We modified the existing Ramphal Cardiac Surgery Simulator to accommodate cardiac transplantation. An attending cardiac surgeon successfully performed the simulated transplant, demonstrating each of the component tasks of the operation. We believe our simulation will enhance the training of cardiothoracic surgery residents.

Toward Transoral Peripheral Lung Access: Combining Continuum Robots and Steerable Needles.

Lung cancer is the most deadly form of cancer in part because of the challenges associated with accessing nodules for diagnosis and therapy. Transoral access is preferred to percutaneous access since it has a lower risk of lung collapse, yet many sites are currently unreachable transorally due to limitations with current bronchoscopic instruments. Toward this end, we present a new robotic system for image-guided trans-bronchoscopic lung access. The system uses a bronchoscope to navigate in the airway and bronchial tubes to a site near the desired target, a concentric tube robot to move through the bronchial wall and aim at the target, and a bevel-tip steerable needle with magnetic tracking to maneuver through lung tissue to the target under closed-loop control. In this work, we illustrate the workflow of our system and show accurate targeting in phantom experiments. Ex vivo porcine lung experiments show that our steerable needle can be tuned to achieve appreciable curvature in lung tissue. Lastly, we present targeting results with our system using two scenarios based on patient cases. In these experiments, phantoms were created from patient-specific computed tomography information and our system was used to target the locations of suspicious nodules, illustrating the ability of our system to reach sites that are traditionally inaccessible transorally.

Simulation-Based Training in Cardiac Surgery.

BACKGROUND: Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons. METHODS: Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals. RESULTS: The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean ± two SEs): cardiopulmonary bypass, 4.80 ± 0.12; coronary artery bypass grafting, 4.41 ± 0.19; aortic valve replacement, 4.51 ± 0.20; massive air embolism, 0.68 ± 0.14; acute intraoperative aortic dissection, 4.52 ± 0.17; and sudden deterioration in cardiac function, 4.76 ± 0.16. The transient detrimental effect of time away from training was also evident. CONCLUSIONS: Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons.

Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey.

BACKGROUND: The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience. METHODS: Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated. RESULTS: Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%). CONCLUSIONS: The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management.

Best practices across surgical specialties relating to simulation-based training.

INTRODUCTION: Simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best be leveraged for training. There is much to be learned from one another as we all strive to meet new requirements within the context of Undergraduate Medical Education, Graduate Medical Education, and Continuing Medical Education. METHOD: To address this need, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes consisting of key leaders in the field of simulation from 4 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology. CONCLUSION: An overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners is presented.

Tendons, Concentric Tubes, and a Bevel Tip: Three Steerable Robots in One Transoral Lung Access System.

Lung cancer is the most deadly form of cancer, and survival depends on early-stage diagnosis and treatment. Transoral access is preferable to traditional between-the-ribs needle insertion because it is less invasive and reduces risk of lung collapse. Yet many sites in the peripheral zones of the lung or distant from the bronchi cannot currently be accessed transorally, due to the relatively large diameter and lack of sufficient steerablity of current instrumentation. To remedy this, we propose a new robotic system that uses a tendon-actuated device (bronchoscope) as a first stage for deploying a concentric tube robot, which itself is a vehicle through which a bevel steered needle can be introduced into the soft tissue of the lung outside the bronchi. In this paper we present the various components of the system and the workflow we envision for deploying the robot to a target using image guidance. We describe initial validation experiments in which we puncture ex vivo bronchial wall tissue and also target a nodule in a phantom with an average final tip error of 0.72 mm.

Motion Planning for a Three-Stage Multilumen Transoral Lung Access System.

Lung cancer is the leading cause of cancer-related death, and early-stage diagnosis is critical to survival. Biopsy is typically required for a definitive diagnosis, but current low-risk clinical options for lung biopsy cannot access all biopsy sites. We introduce a motion planner for a multilumen transoral lung access system, a new system that has the potential to perform safe biopsies anywhere in the lung, which could enable more effective early-stage diagnosis of lung cancer. The system consists of three stages in which a bronchoscope is deployed transorally to the lung, a concentric tube robot pierces through the bronchial tubes into the lung parenchyma, and a steerable needle deploys through a properly oriented concentric tube and steers through the lung parenchyma to the target site while avoiding anatomical obstacles such as significant blood vessels. A sampling-based motion planner computes actions for each stage of the system and considers the coupling of the stages in an efficient manner. We demonstrate the motion planner's fast performance and ability to compute plans with high clearance from obstacles in simulated anatomical scenarios.

Training less-experienced faculty improves reliability of skills assessment in cardiac surgery.

OBJECTIVE: Previous work has demonstrated high inter-rater reliability in the objective assessment of simulated anastomoses among experienced educators. We evaluated the inter-rater reliability of less-experienced educators and the impact of focused training with a video-embedded coronary anastomosis assessment tool. METHODS: Nine less-experienced cardiothoracic surgery faculty members from different institutions evaluated 2 videos of simulated coronary anastomoses (1 by a medical student and 1 by a resident) at the Thoracic Surgery Directors Association Boot Camp. They then underwent a 30-minute training session using an assessment tool with embedded videos to anchor rating scores for 10 components of coronary artery anastomosis. Afterward, they evaluated 2 videos of a different student and resident performing the task. Components were scored on a 1 to 5 Likert scale, yielding an average composite score. Inter-rater reliabilities of component and composite scores were assessed using intraclass correlation coefficients (ICCs) and overall pass/fail ratings with kappa. RESULTS: All components of the assessment tool exhibited improvement in reliability, with 4 (bite, needle holder use, needle angles, and hand mechanics) improving the most from poor (ICC range, 0.09-0.48) to strong (ICC range, 0.80-0.90) agreement. After training, inter-rater reliabilities for composite scores improved from moderate (ICC, 0.76) to strong (ICC, 0.90) agreement, and for overall pass/fail ratings, from poor (kappa = 0.20) to moderate (kappa = 0.78) agreement. CONCLUSIONS: Focused, video-based anchor training facilitates greater inter-rater reliability in the objective assessment of simulated coronary anastomoses. Among raters with less teaching experience, such training may be needed before objective evaluation of technical skills.

"Boot camp" simulator training in open hilar dissection in early cardiothoracic surgical residency.

BACKGROUND: We evaluated focused training in lung hilar dissection with a reanimated porcine lung model in the boot camp setting. METHODS: A total of 64 first-year cardiothoracic surgical residents participated in four consecutive hours devoted to training in open hilar dissection as part of the Thoracic Surgical Directors Association boot camps. Each resident participated in two open hilar dissections. Component tasks were assessed on a 5-point rating scale for the first and second dissections. RESULTS: Immediate assessment performed after completion of the session showed improvements in all graded components. The mean total score on a 50-point scale improved significantly between the first and second repetition (36.03 ± 7.03 to 41.16 ± 6.95; p = 0.001). CONCLUSIONS: Focused massed (single-session) practice in the boot camp setting improved the ability of residents to perform hilar dissection on simulators using reanimated porcine lung models. Given these early successes in massed simulation-based surgical education, there is good reason to expect that deliberate and distributed practice on similar simulators would improve resident education in cardiothoracic surgery.

Rapid on-site pathologic evaluation does not increase the efficacy of endobronchial ultrasonographic biopsy for mediastinal staging.

BACKGROUND: Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) has been shown to be equivalent to mediastinoscopy in lung cancer staging for mediastinal node involvement. Rapid on-site evaluation (ROSE) to determine the adequacy of nodal sampling has been claimed to be beneficial. METHODS: A retrospective evaluation was performed in 170 patients who underwent EBUS-TBNA from July 2008 to May 2011. The patients were classified as having either high or low pretest probability for mediastinal disease based on history and radiographic imaging. ROSE was compared with the final pathology reports based on slides and cell blocks. RESULTS: One hundred thirty-one (77%) patients were classified as being in the high pretest cohort based on clinical staging. Of these, 101 (77%) patients had adequate tissue sampling based on ROSE, with 70 (69%) patients having positive mediastinal disease. In the 30 (23%) patients who had inadequate tissue by ROSE, the final analysis of all the prepared slides and cell blocks allowed for a diagnosis in all but 8 patients. The sensitivity and specificity of ROSE in the high pretest probability cohort were 89.5% and 96.4%, respectively, whereas the overall sensitivity and specificity of EBUS-TBNA was 92.1% and 100%, respectively. Despite having inadequate tissue on ROSE in 30 of 131 patients, sufficient tissue was available on final analysis for diagnosis in 22 of 30 patients. CONCLUSIONS: ROSE does not impact clinical decision making if a thorough mediastinal staging using EBUS is performed. Despite inadequate tissue sampling assessment by ROSE, a final diagnosis was made in most patients, potentially avoiding an additional surgical procedure to prove mediastinal disease.

The Joint Council on Thoracic Surgery Education coronary artery assessment tool has high interrater reliability.

BACKGROUND: Barriers to incorporation of simulation in cardiothoracic surgery training include lack of standardized, validated objective assessment tools. Our aim was to measure interrater reliability and internal consistency reliability of a coronary anastomosis assessment tool created by the Joint Council on Thoracic Surgery Education. METHODS: Ten attending surgeons from different cardiothoracic residency programs evaluated nine video recordings of 5 individuals (1 medical student, 1 resident, 1 fellow, 2 attendings) performing coronary anastomoses on two simulation models, including synthetic graft task station (low fidelity) and porcine explant (high fidelity), as well as in the operative setting. All raters, blinded to operator identity, scored 13 assessment items on a 1 to 5 (low to high) scale. Each performance also received an overall pass/fail determination. Interrater reliability and internal consistency were assessed as intraclass correlation coefficients and Cronbach's α, respectively. RESULTS: Both interrater reliability and internal consistency were high for all three models (intraclass correlation coefficients = 0.98, 0.99, and 0.94, and Cronbach's α = 0.99, 0.98, and 0.97 for low fidelity, high fidelity, and operative setting, respectively). Interrater reliability for overall pass/fail determination using κ were 0.54, 0.86, 0.15 for low fidelity, high fidelity, and operative setting, respectively. CONCLUSIONS: Even without instruction on the assessment tool, experienced surgeons achieved high interrater reliability. Future resident training and evaluation may benefit from utilization of this tool for formative feedback in the simulated and operative environments. However, summative assessment in the operative setting will require further standardization and anchoring.

Teaching behaviors in the cardiac surgery simulation environment.

OBJECTIVE: To understand how teaching behaviors contribute to simulation-based learning, we used a 7-category educational framework to assess the teaching behaviors used in basic skills training. METHODS: Twenty-four first-year cardiothoracic surgery residents and 20 faculty participated in the Boot Camp vessel anastomosis sessions. A portable chest model with synthetic graft and target vessels and a tissue-based porcine model simulated coronary artery anastomosis. After each 2-hour session on days 1 and 2, residents assessed teaching behaviors of faculty using a 20-item questionnaire based on the 5-point Likert scale. After session on day 1, faculty completed a self-assessment questionnaire. At 3 months, faculty completed self-assessment questionnaires regarding teaching behaviors in simulation and clinical settings. Each questionnaire item represents 1 or more teaching categories: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," "evaluation," "feedback," and "self-directed learning." RESULTS: Generally, resident ratings indicated that faculty showed positive teaching behaviors. Faculty self-assessment ratings were all lower (P < .025) than those assigned to them by the residents except for 1 component representative of "feedback," which approached significance (P = .04); 2 items, representative of "promoting understanding and retention" and "evaluation", had mean scores of less than 3. At 3 months, compared with self-assessment at Boot Camp, faculty ratings suggested improved teaching behaviors in their simulation settings in the following: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," and "evaluation." The simulation environment was perceived as more positive for technical skills training in certain aspects compared with clinical setting: instructor reviewed function and operation of equipment with learner before session (representative of "promoting understanding and retention") and instructor allowed the learner ample time to practice (representative of "control of session" and "promoting understanding and retention") (P < .025). CONCLUSIONS: Simulation-based skills training is perceived by residents to be associated with positive teaching behaviors. Faculty self-ratings indicate that they do not always use many of these teaching behaviors and that their performance can be improved. The simulation setting may provide greater opportunity for positive teaching behaviors compared with the clinical environment.

Management of stage IIIA non-small cell lung cancer by thoracic surgeons in North America.

BACKGROUND: Stage IIIA(N2) non-small cell lung cancer is a heterogeneous spectrum ranging from microscopic lymph node metastases to bulky multistation nodal disease. While some favor surgical resection after neoadjuvant therapy, others favor definitive chemoradiation for treatment. Our aim was to determine practice patterns of thoracic surgeons. METHODS: We invited 2,539 active surgeons identified on the Cardiothoracic Surgery Network as expressing interest in general thoracic surgery to participate in an anonymous Web-based survey. The participants evaluated clinical vignettes of a patient with single station N2 disease. RESULTS: In all, 513 surgeons (20%) responded, with 222 (43%) in academic practice. For microscopic N2 disease, 84% (n=430) preferred neoadjuvant therapy followed by surgery. For grossly involved N2 disease, 62% (n=318) favored neoadjuvant therapy followed by surgery if N2 disease was downstaged. In patients with normal pulmonary function tests, requiring pneumonectomy, in the presence of bulky, single station N2 disease, there was less consensus: 32% (n=163) favored neoadjuvant therapy followed by lobectomy (less radical surgery than initially predicted) if feasible and N2 disease had downstaged, 30% (n=159) favored neoadjuvant therapy followed by pneumonectomy if N2 disease downstaged, 12% (n=60) would favor surgery regardless of N2 disease downstaging, and 22% (n=114) favored definitive chemoradiation. If the patient did not have adequate pulmonary function for pneumonectomy but could tolerate lobectomy, 50% favored neoadjuvant therapy followed by reassessment for lobectomy and 41% favored definitive chemoradiation. CONCLUSIONS: There is no clear consensus on management of patients with stage IIIA lung cancer in the United States. Diversity of opinion is greatest in patients with more advanced lung cancer, and limited pulmonary function.

Evaluation of simulation training in cardiothoracic surgery: the Senior Tour perspective.

OBJECTIVE: The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery. METHODS: Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators. RESULTS: All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers. CONCLUSIONS: By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value.

Effectiveness and risks associated with intrapleural alteplase by means of tube thoracostomy.

BACKGROUND: The use of fibrinolytics has been described for the treatment of complex pleural processes. This has evolved from streptokinase to urokinase to alteplase. Intrapleural fibrinolysis has added an alternative to surgical intervention in patients with complex pleural processes. This study describes the use of alteplase as an alternative to surgical intervention for these processes. METHODS: From December 2004 to March 2009, 118 patients required alteplase for complex pleural processes. The type of tube thoracostomy, pleural process, antithrombotic type, international normalized ratio, prothrombin time, partial thromboplastin time, platelets, doses, and outcomes were reviewed for each patient. Complications and the need for additional interventions were evaluated. RESULTS: Patients received one to eight doses of intrapleural alteplase through a tube thoracostomy. Indications for intrapleural alteplase were empyema (n = 32; 27.1%), loculated pleural effusion (n = 44; 37.3%), hemothorax (n = 13; 11.0%), parapneumonic effusion (n = 25; 21.2%), and malignant effusion (n = 6; 5.1%). The success rate was 86.4% (102 of 118 patients). The incidence of bleeding was 8.5% (n = 10). Binary analysis did not demonstrate an increase in bleeding with abnormal coagulation variables. Of the patients with a bleeding complication, 7 required operative interventions. Twenty (16.9%) required a second tube thoracostomy for incomplete evacuation of the pleural process. Nine (7.6%) required an operative intervention for incomplete evacuation of the pleural process. CONCLUSIONS: Intrapleural alteplase appears to be effective in treating complex parapneumonic processes. Systemic anticoagulation, prothrombin time, partial thromboplastin time, international normalized ratio, and platelet count do not appear to be risk factors for bleeding complications. One or two doses of alteplase appear most successful.

Preclinical and pilot clinical studies of docetaxel chemoradiation for Stage III non-small-cell lung cancer.

PURPOSE: Local and distant failure rates remain high despite aggressive chemoradiation (CRT) treatment for Stage III non-small-cell lung cancer. We conducted preclinical studies of docetaxel's cytotoxic and radiosensitizing effects on lung cancer cell lines and designed a pilot study to target distant micrometastasis upfront with one-cycle induction chemotherapy, followed by low-dose radiosensitizing docetaxel CRT. METHODS AND MATERIALS: A preclinical study was conducted in human lung cancer cell lines NCI 520 and A549. Cells were treated with two concentrations of docetaxel for 3 h and then irradiated immediately or after a 24-h delay. A clonogenic survival assay was conducted and analyzed for cytotoxic effects vs. radiosensitizing effects of docetaxel. A pilot clinical study was designed based on preclinical study findings. Twenty-two patients were enrolled with a median follow-up of 4 years. Induction chemotherapy consisted of 75 mg/m(2) of docetaxel and 75 mg/m(2) of cisplatin on Day 1 and 150 mg/m(2) of recombinant human granulocyte colony-stimulating factor on Days 2 through 10. Concurrent CRT was started 3 to 6 weeks later with twice-weekly docetaxel at 10 to 12 mg/m(2) and daily delayed radiation in 1.8-Gy fractions to 64.5 Gy for gross disease. RESULTS: The preclinical study showed potent cytotoxic effects of docetaxel and subadditive radiosensitizing effects. Delaying radiation resulted in more cancer cell death. The pilot clinical study resulted in a median survival of 32.6 months for the entire cohort, with 3- and 5-year survival rates of 50% and 19%, respectively, and a distant metastasis-free survival rate of 61% for both 3 and 5 years. A pattern-of-failure analysis showed 75% chest failures and 36% all-distant failures. Therapy was well tolerated with Grade 3 esophagitis observed in 23% of patients. CONCLUSIONS: One-cycle full-dose docetaxel/cisplatin induction chemotherapy with recombinant human granulocyte colony-stimulating factor followed by pulsed low-dose docetaxel CRT is promising with regard to its antitumor activity, low rates of distant failure, and low toxicity, suggesting that this regimen deserves further investigation.

Cardiopulmonary bypass simulation at the Boot Camp.

OBJECTIVE: At Boot Camp, we evaluated a modular approach to skills mastery related to cardiopulmonary bypass and crisis scenarios. METHODS: With 32 first-year cardiothoracic surgery residents divided into 4 groups, 4 consecutive hours were devoted to cardiopulmonary bypass skills by using a perfused nonbeating heart model, computer-controlled CPB simulator, and perfused beating heart simulator. Based on the cardiopulmonary bypass simulator, each resident was assessed by using a checklist rating score on cardiopulmonary bypass management and 1 crisis scenario. An overall cardiopulmonary bypass score was determined. Economy of time and thought was assessed (1 = unnecessary/disorganized to 5 = maximum economy). At the end of the session, residents completed a written examination. Residents rated the sessions on cannulation skills, cardiopulmonary bypass knowledge, and cardiopulmonary bypass emergency and crisis scenarios on a 5-point scale (5 = very helpful to 1 = not helpful). RESULTS: Thirty residents completed cardiopulmonary bypass simulator exercises. For initiation and termination of cardiopulmonary bypass, most residents performed the tasks and sequence correctly. Some elements were not performed correctly. For instance, 3 residents did not verify the activated clotting time before cardiopulmonary bypass initiation. Four residents demonstrated inadequate communication with the perfusionist, including lack of assertiveness and unclear commands. In crisis scenarios management of massive air embolism (n = 8) was challenging and resulted in the most errors; poor venous drainage and high arterial line pressure scenarios were managed with fewer errors. For the protamine reaction scenario, all residents (n = 7) identified the problem, but in 3 cases heparin was not redosed before resuming cardiopulmonary bypass for right ventricular failure. The score for economy of time and thought was 3.83 ± 0.6 (range, 3-5). The score of the written examination was 90.0 ± 11.3 (range, 60-100), which did not correlate with the overall cardiopulmonary bypass score of 91.4 ± 7.1 (range, 80-100; r = 0.07). The session on acquiring aortic cannulation skills was rated 4.92, that for cardiopulmonary bypass knowledge was rated 4.96, and that for cardiopulmonary bypass crisis scenarios was rated 4.96. CONCLUSIONS: This Boot Camp session introduced residents early in their training to aortic cannulation, principles and management of cardiopulmonary bypass, and crisis management. Based on a modular approach, technical skills and knowledge of cardiopulmonary bypass can be acquired and assessed by using simulations, but further work with more comprehensive educational modules and practice will accelerate the path to mastery of these critical skills.