Rewarding On Time Start Times in Operating Rooms Improves Efficiency.

BACKGROUND: The average cost of running an operating room (OR) is approximately $37.00 a minute. Therefore, every effort should be made to start in a timely manner. There are several factors at play that can cause OR delays. Attaining consistent start times is a multidisciplinary task, which requires good communication and rewards for efficiency. METHODS: At our institution, a "star system" was implemented to improve compliance with timely start times. All OR staff (scrub tech, OR nurse, anesthesiologist, and physician) get 1 star for every on time start. Once a person attains 10 stars, they are awarded a $20 gift card to a local bakery/coffee shop. RESULTS: There was a significant difference in the 3 months pre- and post-implementation of the star system in regard to starting on time (54% vs. 71%, P-value .047), and there were significantly less late starts within 6-10 minutes (14% vs. 4%, P-value = <.01). There was no statistically significant difference in late starts >11 minutes or when comparing days of the week. The most common reasons for delay are as follows: surgeon running late (23%), anesthesiologist tardiness (11%), patient is late (9%), preoperative orders, or test not completed (7%). CONCLUSION: The significant increase in the number of cases that start on time after implementation of the star system leads us to believe that late start times are multifactorial, and that incentives are a positive way to encourage the OR team to start on time.

One Hole, Two Tubes, and a Tijuana Pathology Report: A Case Report of Cholecystoduodenal Fistula Mistaken for Gallbladder Cancer.

We report a case of a patient who presented with biliary colic while in Tijuana, Mexico. Laparoscopic cholecystectomy was attempted but abandoned and only a biopsy of the gallbladder was performed with pathologist reporting gallbladder adenocarcinoma. Upon return to the United States, extensive evaluation was undertaken including imaging, biopsy, and ultimately two separate exploratory surgeries revealing no neoplasm. Only at the second surgical exploration did we discover a benign cholecystoduodenal fistula successfully treated with completion fenestration cholecystectomy, pyloric exclusion, loop gastrojejunostomy, and duodenostomy tube through the gallbladder remnant into the fistula itself. This is a unique surgical treatment of a rare problem made even more confusing by an erroneous pathology report from another country.

Case Report: Recurrent Mucoepidermoid Carcinoma of the Tongue in Adult Female Patient With Lung Cancer.

There is a steady rise in incidence of malignant salivary gland tumors in the United States, with mucoepidermoid carcinoma (MEC) the most frequent. Although 40% of MECs are found in the parotid gland, these lesions possess the capacity to develop anywhere along the aerodigestive tract. Here, we present a case of recurrent tongue MEC in a young adult female patient with history of lung malignancy and multiple brain metastases. Without a universally accepted management protocol for recurrent MECs, the current clinical practice uses tumor grade, location, and clinical progression to determine both prognosis and goals of care. The patient had transoral laser excision of the first MEC lesion in 2013. Her tongue MEC recurred 3 years later with 2 distinct lesions. One was discovered on physical examination and computed tomography and the other diagnosed intraoperatively 1 month later. These lesions were located on a previously unaffected portion of dorsal tongue base. These lesions were completely excised in the operating room. The patient currently remains on chemotherapy. This underscores the importance for developing a guideline that delineates the most efficacious surveillance and treatment plans for recurrent MECs.

Soft Tissue Sarcoma With Tongue Metastasis: A Case Report and Literature Review.

Soft tissue sarcomas are rare malignant tumors that develop from mesenchymal cells. Metastasis is predominantly hematologic, with the lungs being the most common site. Metastasis to the oral cavity is a rare occurrence. The most common primary tumors to metastasize to the oral cavity are adenocarcinoma of the lung, breast, and kidney. This report describes a case of a 41-year-old man who was diagnosed with myxofibrosarcoma of the lower extremity and underwent neoadjuvant chemoradiation followed by surgical resection. Two years later, he presented with metastasis to the tongue and lungs. The literature on tongue metastasis of soft tissue sarcoma is reviewed and discussed. Surgeons providing care to patients with a soft tissue sarcoma should maintain a strong clinical suspicion for distant metastases in patients with this type of tumor.