An evaluation of hernia education in surgical residency programs.

PURPOSE: The purpose of this study was to evaluate surgical residents' educational experience related to ventral hernias. METHODS: A 16-question survey was sent to all program coordinators to distribute to their residents. Consent was obtained following a short introduction of the purpose of the survey. Comparisons based on training level were made using χ(2) test of independence, Fisher's exact, and Fisher's exact with Monte Carlo estimate as appropriate. A p value <0.05 was considered significant. RESULTS: The survey was returned by 183 residents from 250 surgical programs. Resident postgraduate year (PG-Y) level was equivalent among groups. Preferred techniques for open ventral hernia varied; the most common (32 %) was intra-abdominal placement of mesh with defect closure. Twenty-two percent of residents had not heard of the retrorectus technique for hernia repair, 48 % had not performed the operation, and 60 % were somewhat comfortable with and knew the general categories of mesh prosthetics products. Mesh choices, biologic and synthetic, varied among the different products. The most common type of hernia education was teaching in the operating room in 87 %, didactic lecture 69 %, and discussion at journal club 45 %. Number of procedures, comfort level with open and laparoscopic techniques, indications for mesh use and technique, familiarity and use of retrorectus repair, and type of hernia education varied significantly based on resident level (p < 0.05). CONCLUSION: Exposure to hernia techniques and mesh prosthetics in surgical residency programs appears to vary. Further evaluation is needed and may help in standardizing curriculums for hernia repair for surgical residents.

Abdominal wall closure: resident education and human error.

PURPOSE: Secure abdominal wall closure for laparotomy incisions is paramount in prevention of hernia formation. Despite the importance, abdominal closure is often delegated to the resident surgeon. The purpose of this study was to assess residents' formal training, knowledge, and technique in abdominal wall closure. METHODS: All surgical residents in our training program participated in a skills laboratory and completed a questionnaire. The skills portion involved closure of a 10-cm incision on a simulated abdominal wall. Participants were timed, videotaped, and graded using a standardized grading system. Lengths of the suture bites were measured. Regression analysis was used to compare results based on number of closures. A P-value of <0.05 was considered significant. RESULTS: Ten surgical residents participated. The average time for closure was 4:23 min (range 3:08-5:65 min). The average distance between the bite and the incision was 0.9 cm and between bites was 0.8 cm. All knots were satisfactory and intact following closure. Participants' experience varied with a range from 0 to 230 previous abdominal closures. All residents chose to perform closure in a continuous fashion using a slowly absorbing suture. All but one resident stated that sutures should be placed 1 cm from the incision with 1 cm advances. Only one resident knew the correct suture-to-wound length ratio for closure, and only four residents were familiar with the literature about abdominal wall closure. With increasing closure experience, there was significant improvement in time and motion of suturing (P = 0.02), respect of tissue (P = 0.0002), instrument handling (P = 0.004), orientation of needle (P = 0.0076), and flow of closure (P = 0.046). Residents who had performed more closures took significantly larger suture bites (P = 0.03) with larger distances between bites (P = 0.03). CONCLUSIONS: Surgical technique improves with increased experience with abdominal closures; however, residents at all levels have the physical ability to adequately perform this task. Education regarding closure appears to be lacking, and further study warranted.

Toxic cure: Hyperfractionated radiotherapy with concurrent cisplatin and fluorouracil for Stage III and IVA head-and-neck cancer in the community.

PURPOSE: To evaluate efficacy and toxicity of the Duke University chemoirradiation regimen for locally advanced head-and-neck cancer in a regional community cancer center. METHODS AND MATERIALS: Between June 1998 and June 2002, 50 patients with Stage III or IVA squamous cell carcinoma of the head and neck were treated definitively with concurrent combined modality therapy (CMT). Patients received accelerated, hyperfractionated radiotherapy (AFRT), 1.2-1.25 Gy b.i.d., to a median prescribed dose of 70 Gy. Chemotherapy consisted of cisplatin 12 mg and fluorouracil 600 mg/m(2) daily for 5 consecutive days during Weeks 1 and 6, followed by two cycles after AFRT. Patients with N2-N3 neck disease (n = 21; 42%) were considered for neck dissection depending on their response to AFRT and chemotherapy. Twenty-nine patients with Stage III and IVA disease treated between 1991 and 1997 with definitive RT alone served as historical controls. RESULTS: Forty-nine patients (98%) in the CMT group completed the prescribed AFRT and 38 (76%) completed four cycles of chemotherapy. Three of 8 patients who underwent neck dissection had a pathologically complete response. The median follow-up for all patients was 23 months. The actuarial progression-free survival rate at 2 years was 75% for the CMT group vs. 40% (p <0.01) for the RT group. The overall survival rate was 80% and 43% (p <0.01), respectively, for the CMT and RT groups. Acute Radiation Therapy Oncology Group Grade 3 toxicities for the CMT group were mucosal (n = 50; 100%), skin (n = 9; 18%), and hematologic (n = 3; 6%). Late Grade 3-4 toxicities consisted of pharyngeal stricture (n = 7; 14%), laryngeal chondritis (n = 3; 6%), osteoradionecrosis (n = 2; 4%), and peripheral neuropathy (n = 1; 2%). CONCLUSION: This aggressive regimen of AFRT with concurrent cisplatin and fluorouracil with or without neck dissection is feasible in the community setting for patients with Stage III and IVA head-and-neck cancer. Early results indicated excellent survival, albeit with universal acute mucosal, and considerable, although acceptable, late toxicity.

Soft tissue sarcomas involving the pelvis.

BACKGROUND AND OBJECTIVES: Soft tissue sarcomas (STS) of the true pelvis are rare tumors and there is little information in the literature related to pelvic STS. The purposes of this review were to understand the anatomic extension of these tumors to better plan surgical treatment and to determine the outcome of these patients. METHODS: Eighteen consecutive patients presenting between 1987 and 1995 with soft tissue sarcomas involving the true pelvis were retrospectively reviewed at minimum follow-up of 18 months. Cross-sectional imaging was reviewed for each patient to determine the anatomical location of the lesions. RESULTS: The tumors were confined to the true pelvis in 4 patients, extended to the retroperitoneum in three cases, and extended to the thigh in 11 patients. Adjuvant radiation was administered to all but 2 patients who had received radiation to the region in the past and all patients underwent surgical resection (local resection in 13 patients and hindquarter amputation in 5 patients). Surgical resection had a high rate of morbidity and complications including positive resection margins in nine individuals. Of the 18 patients, 11 died at a mean time of 15.5 (2-58) months from surgery, 4 were alive with evidence of disease at a mean time of 44.3 (18-68) months, and 3 were alive with no evidence of disease at a mean time of 57 (43-71) months. CONCLUSIONS: Soft tissue sarcoma of the pelvis is fortunately a rare disease with a high risk of local and systemic disease progression despite treatment with irradiation and surgical resection.

Breast cancer treatment and chemoprevention.

OBJECTIVE: To outline modern principles of surgery, radiation therapy, and systemic treatment of breast cancer, and to review preliminary data on breast cancer prevention. QUALITY OF EVIDENCE: A MEDLINE search was conducted from 1966 to the beginning of 1999; most of the studies reviewed are randomized clinical trials. MAIN MESSAGE: Breast conservation surgery should be offered to all women with early breast cancer because studies demonstrate survival rates equivalent to those with mastectomy. If mastectomy is chosen, breast reconstruction should be offered. Most women with breast cancer are treated systemically with either chemotherapy or tamoxifen, or both, and mortality is substantially reduced. Data indicating that tamoxifen prevents breast cancer are promising; more studies with both tamoxifen and raloxifene are under way. All women should be strongly encouraged to enter clinical trials. CONCLUSIONS: Because many issues face women recently diagnosed with breast cancer, they often seek out family physicians as advisors to help negotiate a complex treatment path. The possibility of preventing breast cancer will undoubtedly raise questions among family members of women with breast cancer that should appropriately be answered and referred, if necessary, by family physicians.

Breast conservation surgery for breast cancer at a regional medical center.

BACKGROUND: This study examined trends in breast conservation surgery (BCS) at our hospital and factors associated with BCS. METHODS: We retrospectively reviewed breast cancer surgeries in patients eligible for BCS (size <4 cm, N0, N1) from 1990 through 1996 (n = 634). We calculated the yearly prevalence of BCS and used multiple logistic regression (MLR) to determine tumor, patient, and surgeon factors associated with BCS. RESULTS: BCS increased from 17% in 1990 to 41% in 1996. Women with T1a and T1b tumors were 3.8 and 2.0 times, respectively, as likely to have BCS compared with those who had T2 tumors. Other factors associated with BCS included nonpalpable tumors, age <50, Medicare, Medicaid, or self-pay patients, and women whose surgeons graduated since 1961, with odds ratios of 1.8, 1.9, 2.4, and 2.3, respectively. CONCLUSION: Women with small, nonpalpable tumors, age <50, without private insurance, operated on by younger surgeons were more likely to receive BCS.

Fine-needle aspiration cytology and thyroid surgery in the community hospital.

BACKGROUND: To assess the use and usefulness of fine-needle aspiration cytologic biopsy (FNAB) of the thyroid in our hospital. METHODS: All cytology slides and charts of patients who had FNAB of the thyroid done in our hospital in 1993 were reviewed. Charts of all patients having thyroid surgery in our hospital in 1993 were reviewed to determine the pathological diagnosis and whether FNAB had been performed preoperatively. Finally, we reviewed all consecutive thyroid surgery cases for an 8-year period, and we calculated the yearly percentage of malignancy. RESULTS: Fifty-five FNAB were done in 53 patients. In 21 patients the FNAB gave indication for thyroid surgery, yet surgery was done in only 12 (57.1%). Forty-two patients had surgery for a thyroid nodule, but only 20 patients (47.6%) had a preoperative FNAB. There were 3 malignancies among the 20; 2 were correctly predicted by FNAB. The FNAB was correct in 18 of 20. In all, 378 thyroid operations were done from 1987 to 1994. The yearly proportion of thyroid malignancy ranged from 11% to 29%, but showed no change corresponding with increasing diagnostic sophistication. CONCLUSIONS: Fine-needle aspiration cytologic biopsy in the workup of patients with thyroid masses is strikingly underutilized in our institution. While accurate in 90% of cases where used, FNAB appears to play a minor role in the surgeon's decision regarding surgery. As a result of these findings, we developed a grading system for better communication of the FNAB report and a clinical guideline to improve the evaluation of patients with thyroid masses.

Patient, hospital, and surgeon factors associated with breast conservation surgery. A statewide analysis in North Carolina.

OBJECTIVE: The objective of this study was to determine the trend of breast conservation surgery (BCS) in North Carolina over a 6-year period and to identify patient, hospital, and surgeon factors associated with the use of BCS. SUMMARY BACKGROUND DATA: Despite evidence that BCS is an appropriate method of treatment for early stage breast cancer, surgeons in the United States have been slow to adopt this treatment method. METHODS: Cases of primary breast cancer surgery in all 157 hospitals in the state from 1988 to 1993, inclusive (N = 20,760), were obtained from the State Medical Database Commission, Area Resource File, American Hospital Association and State Board of Medical Examiner's Databases. Multiple logistic regression was used to generate odds ratios (ORs) and 95% confidence intervals (CIs) to determine factors associated with BCS. RESULTS: The rate of BCS doubled from 7.3% in 1988 to 14.3% in 1993, with an overall rate of 10.2% (2117/ 20.760). Multiple logistic regression identified the following factors associated with BCS: patient age younger than 50 years of age (OR = 1.7, 95% CI = 1.4, 2.1), patient age 50 to 69 years of age (OR = 1.2, 95% CI = 1.1, 1.4), private insurance (OR = 1.2, 95% CI = 1.0, 1.4), hospital bed size 401+(OR = 2.0, 95% CI = 1.6, 2.5), bed size 101 to 400 (OR = 1.7, 95% CI = 1.3, 2.1), and surgeon graduation from medical school since 1981 (OR = 1.6, 95% CI = 1.2, 2.0). CONCLUSIONS: Rates of BCS in North Carolina are low. Least likely to have BCS were women older than 70 years of age, without private insurance, treated at small hospitals by older surgeons. To increase the use of BCS, widespread education of surgeons, other health care providers, policy makers, and the general public is warranted.

Clinicopathologic factors and patient perceptions associated with surgical breast-conserving treatment.

BACKGROUND: Clinical studies have shown equivalent survival rates between breast-conserving surgery (BCS) and mastectomy in early breast cancer; however, rates for BCS remain low. The purpose of this study was to determine (a) the prevalence of BCS in a regional medical center, (b) clinicopathologic factors associated with BCS, and (c) patient perceptions of the treatment decision-making process. METHODS: We retrospectively reviewed 251 consecutive breast cancer cases during January 1990-December 1991; 77 patients were ineligible for BCS because of unfavorable pathology. We then interviewed 118 of the 160 women available for interview. RESULTS: BCS was performed in 31 of the eligible patients (18%). Multivariate analysis revealed that tumor size < 10 mm (p = 0.03) was the only significant predictive variable for BCS. Patient interviews revealed that 93% said their surgeon was the primary source of information regarding treatment options. Among 69% of the women whose surgeons reportedly recommended a particular option, 89% recommended mastectomy with 93% compliance, and 11% recommended BCS with 89% compliance. The BCS group more often obtained a second opinion (p = 0.04) and 60% said they made the decision themselves compared with only 37% of the mastectomy group (p = 0.05). CONCLUSION: Limiting BCS to women whose tumor size is < 10 mm is too restrictive; this excludes a large number of women who are clinically eligible for BCS. The surgical decision-making process for early-stage breast cancer is very much surgeon-driven, with a high degree of patient compliance.

Screening mammography: interpretation of the data.

The literature on screening mammography includes a plethora of conflicting articles. More recently, individuals and various medical organizations have recommended and established their own guidelines for screening mammography. A review of salient breast screening randomized clinical trials in women over and under the age of 50 years is provided and compared with the more recent results of the Canadian National Breast Screening Study. In women under the age of 50 years, screening mammography cannot be supported from the results of these trials. In women over the age of 50 years, screening mammography leads to a significant reduction in breast cancer mortality and should be strongly recommended.

Outcome and prognosis in retroperitoneal soft tissue sarcoma.

PURPOSE: To retrospectively evaluate the outcome of treatment and identify factors prognostic for survival and locoregional and distant disease control for patients with retroperitoneal soft tissue sarcoma. METHODS AND MATERIALS: The records of 104 patients with retroperitoneal soft tissue sarcoma (RSTS) managed with surgery and irradiation at Princess Margaret Hospital between 1975 and 1988 were retrospectively reviewed. Univariate log-rank analysis was used to evaluate potential prognostic factors. RESULTS: Presentation was new primary disease, 74; primary recurrence, 20; metastases, 10. Pathology was liposarcoma for 42, leiomyosarcoma for 22, malignant fibrous histiocytoma for 19, and 21 with other histologies. Grade was low for 36, high for 35, and 33 were not graded. Median tumor size was 17 cm. Grossly complete surgical excision was achieved for 45 (43%), of whom 6 (6%) also had clear surgical margins. Adjuvant postoperative irradiation was administered to 36 patients to a median dose of 40 Gy/20 fractions/4 weeks and 16 received adjuvant chemotherapy. Nine patients received no adjuvant postoperative radiotherapy. Gross residual tumor was present postoperatively in 57 patients. The overall 5- and 10-year survival rates were 36% and 14%, respectively. The locoregional relapse free rate (RFR) was 28% at 5 years and 9% at 10 years, and the distant RFR was 76% at 5 years and 60% at 10 years. For the 45 patients treated with complete excision, survival was 55% and 22% at 5 and 10 years, and locoregional RFR was 50% and 18% at 5 and 10 years. Univariate analysis demonstrated that complete surgical removal was the only factor significant for improved survival, locoregional RFR, and distant RFR. Liposarcoma histology predicted for improved survival (p = 0.02), and leiomyosarcoma histology for a lower distant RFR, compared to other histologies (p = 0.003). Patients under 62 years had an improved survival (p = 0.002) and local RFR (p = 0.02), and patients presenting with recurrent disease had improved survival (p = 0.03). Sex, tumor size, or grade, or the use of adjuvant chemotherapy were not predictive for any of the endpoints tested. Those who received adjuvant irradiation following gross surgical clearance experienced a prolonged median locoregional RFR over those who did not, and this approached statistical significance for those receiving radiation doses > 35 Gy. (103 months vs. 30 months, p = 0.06). Statistical significance was reached (p = 0.02) if only the infield RFR was considered. CONCLUSIONS: This study demonstrates that failure to achieve local control is the primary cause of treatment failure for patients with RSTS, and that postoperative irradiation in doses > 35 Gy after complete surgery delayed, but did not prevent local recurrence. Improvements in outcome for patients with RSTS will require alternate treatment strategies, and preoperative irradiation with an aggressive surgical attempt at complete excision is currently under investigation.

Endometrial cancer and abdominal wound recurrence.

A 65-year-old woman had a total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision for a Stage Ib, Grade 2 endometrial adenocarcinoma with extension to the middle third of the myometrium. No adjuvant treatment was given. She presented 7 years later with a large suprapubic mass and the entire lower central abdominal wall was removed and closed with Marlex mesh. Pathology revealed a moderately well-differentiated adenocarcinoma, very similar to the previous cancer with follow-up at 15 months revealing no evidence of recurrence. This case represents growth of implanted tumor cells in the incision that occurred 7 years previously at the time of an uneventful hysterectomy without tumor transgression. It is felt that there was intraoperative tumor cell extrusion through the cervical os with subsequent growth of viable tumor cells.

Smoking as an etiologic factor in the development of Warthin's tumor of the parotid gland.

In order to further examine a preliminary association between smoking and the subsequent development of Warthin's tumor, a case-control study was undertaken between the years 1980 and 1989. Consecutive patients with Warthin's tumor served as cases, and consecutive patients with pleomorphic adenomas served as controls. A positive history of smoking was defined as a patient with greater than a 10-pack year history. There were 28 cases and 69 controls (ratio: 1:2.5). The number of male to female patients with Warthin's tumor and pleomorphic adenoma was 22 to 6 (3.7:1) and 22 to 47 (1:2.1), respectively. The mean age at presentation with Warthin's tumor or pleomorphic adenoma was 60.7 years and 40.7 years, respectively. In those patients for whom a definite smoking history was known (93 patients), an odds ratio of 8.1 (p < 0.001) was calculated. In order to exclude sex as a possible confounder, the odds ratio in males only was 6.4 (p = 0.007). In order to exclude age as a possible confounder, the odds ratio in all patients over 45 years (48 patients) was 11.2 (p < 0.001). In summary, smokers have eight times the risk of developing a Warthin's tumor than nonsmokers. This case-control study suggests that smoking may be one of the etiologic factors associated with this benign salivary gland tumor.

Reasons for non-entry in randomized clinical trials for breast cancer: a single institutional study.

Reasons for patient non-entry in randomized clinical trials (RCTs) assessing oncologic treatment modalities are not well documented in the literature. We have prospectively recorded reasons for RCT non-entry in breast cancer patients at St. Michael's Hospital, Toronto. From September 1984 to November 1989, 592 consecutive patients were evaluated through the clinical trials office. One hundred six out of the 592 patients were placed into a RCT (17.9%). Protocol ineligibilities accounted for 273 non-entries (46.1%) and protocol eligible but not entered patients accounted for 213 (36.0%) non-entries. The most common reason for protocol ineligibility was advanced age (94 patients). The most common reason for protocol eligible but not entered patients was patient refusal (148 patients). A total of 272 patients in both non-entered groups were identified as having reasons for non-entry that were potentially correctable. In summary, protocol ineligibilities account for the majority of non-entered patients, but patient refusal accounted for the single largest group of potentially correctable non-entries. More dissemination about the merit of RCTs in the lay press and amongst primary care physicians must take place if we are to expediently and efficiently answer important oncologic questions.

Vagotomy and antrectomy revisited.

A retrospective review of 185 patients who underwent truncal vagotomy and antrectomy for duodenal ulcer disease was carried out to determine the mortality and morbidity of the procedure. There were no deaths within 30 days of operation and only one patient died while in the hospital (0.54%). Twenty-one patients (11.4%) suffered early morbidity, 3 of them requiring a second operation. Follow-up was obtained in 83 patients and averaged 13.5 years. According to Visick's classification 75 patients (90.4%) were in class I or II; 5 patients (6%) were in class III and 3 patients (3.6%) in class IV. A recurrent ulcer developed in 2 of the 83 patients. In contrast, after highly selective vagotomy, the literature supports an unacceptable incidence of recurrent ulcer. Therefore, we must not prematurely cast aside vagotomy and antrectomy; it still remains a safe and acceptable procedure for duodenal ulcer disease.

Lymphoma pancreatitis: a real entity.

Pancreatitis induced by malignant disease is uncommon. A case of lymphoma presenting as acute pancreatitis and subsequent pancreatic abscess is reported; this led to the patient's death, 6 weeks after the initial attack of pancreatitis. Five other reports are reviewed. The pancreatitis always preceded the diagnosis of lymphoma and the preoperative diagnosis was always difficult. Lymphoma pancreatitis should, therefore, be considered in the etiology of acute pancreatitis, especially if the more likely causes have been ruled out.

Multiple primary cancers in squamous cell cancer of the head and neck.

A retrospective review of 832 patients with squamous cell cancer of the head and neck between 1961 and 1985 was carried out to determine the incidence of multiple primary cancers (MPC) at the time of autopsy and the number who died of the second cancer. The overall risk of developing a second MPC of the head and neck, lung, or esophagus from treatment of first head and neck cancer to time of autopsy was 4.04% per year.