Leaders by example: Best practices and advice on establishing a state-of-the art surgical simulation center that optimizes available resources.

BACKGROUND: The role of simulation-based education continues to expand exponentially. To excel in this environment as a surgical simulation leader requires unique knowledge, skills, and abilities that are different from those used in traditional clinically-based education. METHODS: Leaders in surgical simulation were invited to participate as discussants in a pre-conference course offered by the Association for Surgical Education. Highlights from their discussions were recorded. RESULTS: Recommendations were provided on topics such as building a simulation team, preparing for accreditation requirements, what to ask for during early stages of development, identifying tools and resources needed to meet educational goals, expanding surgical simulation programming, and building educational curricula. CONCLUSION: These recommendations provide new leaders in simulation with a unique combination of up-to-date best practices in simulation-based education, as well as valuable advice gained from lessons learned from the personal experiences of national leaders in the field of surgical simulation and education.

A needs assessment of education research topics among surgical educators in the United States.

BACKGROUND: There are currently no courses that focus specifically on surgical education research. A needs assessment of surgical educators is required to best design these courses. METHODS: A cross-sectional survey-based study on all faculty members of the Association for Surgical Education was done to determine their education research needs. RESULTS: The overall response rate was 15% and the majority of the 78 respondents were physicians (63%) in their mid- to late career stage (65%). Participants thought research topics should be taught at an advanced level in a workshop format. Senior educators were less interested than junior educators in learning to create conceptual frameworks (p = 0.038) and presenting their research at national meetings (p = 0.014). CONCLUSIONS: Surgical educators desire more training in education research techniques that are taught in a workshop format at a national surgical education meeting. These workshops may lay the groundwork for a nationally recognized certificate in surgical education research.

Difficult problems in thyroid cancer surgery.

The incidence of thyroid cancer has increased dramatically, yet the mortality has remained unchanged. There remain many challenges and "difficult problems" in diagnosing and treating patients with differentiated thyroid cancer (DTC). A significant percentage of patients with DTC will present with a thyroid nodule and an indeterminate fine needle aspiration biopsy underscoring the importance of proper evaluation and management. It is important when considering the extent of thyroidectomy and the management of lymph node metastases to balance the outcome of treatment in terms of recurrence and mortality with the morbidity of the procedure. Total thyroidectomy and lymphadenectomy for macroscopic lymph node metastases appear to be the optimal therapy for most patients with DTC. Preservation of function is a priority in managing patients with DTC invading the recurrent laryngeal nerve, trachea, esophagus, or the larynx.

Objective evaluation of the performance of surgical trainees on a porcine model of open colectomy.

BACKGROUND: Evaluation of surgical trainee operative performance is rarely objective. A rating system is proposed that assesses trainee performance objectively and quantifies technical improvement. METHODS: General surgery trainees were evaluated while performing porcine segmental colectomy. Initial instruction was provided for the critical operative steps. Evaluations were later repeated without additional instruction. Performance in 17 critical areas was scored. RESULTS: Twenty-three trainees were evaluated. Performance was divided into thirds, with a significant difference detected between tertiles (P < 0.001). Postgraduate year 2 trainees scored lower than those in years 3 and 4 (P < 0.001), but there was no difference between year 3 and 4 trainees (P = 0.557). Mean repeat scores were improved by 35 per cent, with most improvement at postgraduate year 2 level (71 per cent). Mean time taken to complete the operation was reduced by 23 per cent, with the largest reduction in the year 2 group. CONCLUSION: The results support the use of this rating system as a tool for the objective evaluation of trainee operative skill. Instruction in the performance of segmental colectomy using deconstructed, step-by-step direction improved the ability of junior trainees to complete the operation. This evaluation system may be useful in the assessment, instruction and technical development of surgical trainees.

Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery.

BACKGROUND: The risk factors and incidence of anastomotic leak following colorectal surgery are well reported in the literature. However, the management of the multiple clinical scenarios that may be encountered has not been standardized. METHODS: The medical literature from 1973 to 2007 was reviewed using PubMed for papers relating to anastomotic leaks and abdominal abscess, with a specific emphasis on predisposing factors, prevention strategies, and treatment approaches. A six-round modified Delphi research method was utilized to find consensus among a group of expert colorectal surgeons and interventional radiologists regarding standardized management algorithms for anastomotic leaks. RESULTS: Management scenarios were divided into those for intraperitoneal anastomoses, extraperitoneal (low pelvic) anastomoses, and anastomoses with proximal diverting stomas. Management options were then based on the clinical presentation and radiographic findings and organized into three interconnected algorithms. CONCLUSIONS: This process was a useful first step toward establishing guidelines for the management of anastomotic leak.

An investigation of epidemiologic factors associated with large nodular goiter.

BACKGROUND: Sporadic nodular goiter is a common problem in the United States and significant compressive symptoms may occur with progression to a critical size. METHODS: Potential epidemiological variables associated with the development of large unilateral (> or = 50 g) and bilateral (> or = 100 g) nodular goiter were investigated including: age, gender, race, body mass index (BMI), family history of thyroid disease, pregnancy at time of diagnosis, insurance status, and tobacco or alcohol use. Data were obtained from an IRB-approved thyroid database and retrospective chart review of consecutive patients operated on for nodular goiter from 1990 through 2005. A univariate and multivariate analysis of epidemiological variables in patients with "large" versus "small" nodular goiter was completed. RESULTS: Of the 488 patients operated on for nodular goiter, 113 (23%) were classified as "large," 43 with unilateral (mean 106 +/- 72 g) and 70 with bilateral enlargement (mean 173 +/- 92 g) and 375 (77%) were classified as "small," 179 with unilateral (18 +/- 10 g) and 196 with bilateral (37 +/- 24 g) enlargement. Based on univariate analysis, African-American race, age > or = 40 years, BMI > or = 30 kg/m2, and lack of insurance were associated with an increased risk of large nodular goiter (P < or = 0.001), whereas alcohol use was protective (P = 0.002). A multivariate analysis revealed that African-American race [adjusted odds ratio (adj. OR) 3.3, 95% CI = 2.0-5.4], age > or = 40 years (adj. OR 2.1, 95% CI = 1.2-3.8), and BMI > or = 30 kg/m2 (adj. OR 2.5, 95% CI = 1.5-4.0) were independently associated with large nodular goiter. No significant differences were observed in gender, family history of thyroid disease, pregnancy, or tobacco use (P > 0.1). CONCLUSIONS: African-American race, obesity, and increasing age are independent risk factors for the development of large nodular goiter. These results may be helpful in determining how best to monitor patients with nodular goiter, with earlier intervention to help prevent progressive enlargement and its sequelae.