Neoadjuvant therapy and major arterial resection for potentially reconstructable arterial involvement by stage 3 adenocarcinoma of the pancreas.

BACKGROUND: Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR). METHODS: This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date. RESULTS: 87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41). CONCLUSIONS: AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.

Taking a Chance or Playing It Safe: Reframing Risk Assessment Within the Surgeon's Comfort Zone.

OBJECTIVES: The purpose of this study was to explore how risk is perceived and experienced by the surgeon and how risk is actively managed in individual practice. BACKGROUND: Risk in surgery has been examined from system-wide and personality perspectives. Although these are important, little is known about the perspective of the individual surgeon. METHODS: A constructivist grounded theory study was conducted to explore surgeons' perspectives on risk in the context of their personal "Comfort Zones." Semistructured, 60-minute interviews were conducted with 18 surgeons who were purposively sampled for sex and subspecialty with a snowballing strategy applied to sample for differences in reputation (conservative vs aggressive). Data were collected and analyzed in an iterative manner until thematic saturation was reached. RESULTS: Surgeons described cases that were inside or outside of their personal comfort zones. When considering cases at the boundary of their comfort zones, participants described a variety of factors that could make them feel more or less comfortable. Specific strategies used to modulate this border were also described. Two perspectives on risk taking became apparent: the procedure-centric perspective described how surgeons viewed their colleagues whereas the surgeon-centric perspective described how surgeons viewed themselves. CONCLUSIONS: A framework for understanding surgeon's unique assessment of risk was elaborated. Increased awareness of the factors and strategies identified in this study can foster critical self-reflection by surgeons of their own risk assessments and those of their colleagues, and provide avenues for more explicit educational strategies for surgical training.

Coaching Surgeons: Is Culture Limiting Our Ability to Improve?

OBJECTIVE: To explore surgeons' perceptions of and potential concerns about coaching. BACKGROUND: There is growing recognition that the traditional model of continuing professional development is suboptimal. This has led to increasing interest in alternative strategies that take place within the actual practice environment such as coaching. However, if coaching is to be a successful strategy for continuing professional development, it will need to be accepted by surgeons. METHODS: This was a qualitative interview-based study using a constructivist grounded theory approach. Participants included 14 surgeons from University of Toronto-affiliated hospitals. RESULTS: Participants expressed 3 main concerns about coaching: questioning the value of technical improvement ("As you get older if you don't have the stimulation from surgery to get better or to do things that are different and you are so good at so much, why bother [with coaching]?" P009), worry about appearing incompetent ("I think it would be perceived as either a sign of weakness or a sign of inability" P532), and concern about losing autonomy ("To me that would be real coaching where it's self-identified, I'm motivated, I find the person and then they coach me" P086). CONCLUSIONS AND RELEVANCE: Coaching faces unique challenges in the context of a powerful surgical culture that values the portrayal of competency and instills the value of surgical autonomy. This study suggests that hanging on to these tightly held values of competency and autonomy is actually limiting the ways, and extent to which, surgeons can improve their practice.

Management and outcomes for children with pyloric stenosis stratified by hospital type.

BACKGROUND: Access to health care has been a source of controversy and public attention in health policy. The issues of access to and utilization of the healthcare system by infants and children is less well documented. Moreover, the impact on outcomes of race, ethnicity, and economic status in infants is vaguely addressed. METHODS: We performed a retrospective analysis of children who had undergone pyloromyotomy from July 31, 1998 to July 31, 2008 at our public hospital and university teaching hospital. Data abstracted included gestational age at delivery, birth weight, gender, race, insurance status, age at presentation, symptom duration, preoperative ultrasound (US), operative date, laboratory evaluations, as well as preoperative, postoperative, and total length of stay (LOS). RESULTS: The mean total preoperative LOS was twice as long at our public hospital than our private hospital (1.78 d versus 0.85 d, P=0.003). Similarly, the mean total length of stay was 0.87 d longer at our public hospital (3.87 d versus 3 d), which trended toward significance (P=0.06). Significantly, 72% (27/33) patients at the private hospital had their US either as an out-patient or on the day of admission, while only 58% (28/48) had an US performed as expeditiously at the public hospital (P=0.03, chi(2) analysis). CONCLUSIONS: Care at our public hospital leads to delayed diagnosis and treatment, resulting in longer preoperative and total LOS in infants with pyloric stenosis, most likely related to the timing of the preoperative US. Efforts should be made to encourage patients to use the outpatient clinic facilities for their ill infants, or for physicians at public hospitals to expedite the US process once the diagnosis of pyloric stenosis is entertained.

Management and outcomes for children with acute appendicitis differ by hospital type: areas for improvement at public hospitals.

BACKGROUND: Access to health care is a well-recognized issue in health policy, but use once patients have entered the health care system is uncommonly addressed. METHODS: We performed a retrospective review of children between 2 and 17 years of age with pathologically confirmed appendicitis at our public city hospital and private university hospital and compared management and outcomes. RESULTS: Among patients with acute appendicitis, the median length of stay was a day longer in the public hospital (2 days vs 1 day, P = <.001) despite a similar complication rate (12% vs 11%). More computed tomography (CT) scans were performed at the public hospital (36% vs 21%, P = .02) with a trend toward less use of ultrasound (US) (54% vs 65%, P = .13). CONCLUSIONS: Children at the public city hospital have a longer length of stay and undergo more expensive imaging. These findings may provide areas for improvement to optimize the care of children with appendicitis at government-funded institutions.

Understanding the Use and Perceived Impact of a Medical Podcast: Qualitative Study.

BACKGROUND: Although podcasts are increasingly being produced for medical education, their use and perceived impact in informal educational settings are understudied. OBJECTIVE: This study aimed to explore how and why physicians and medical learners listen to The Rounds Table (TRT), a medical podcast, as well as to determine the podcast's perceived impact on learning and practice. METHODS: Web-based podcast analytics were used to collect TRT usage statistics. A total of 17 medical TRT listeners were then identified and interviewed through purposive and convenience sampling, using a semistructured guide and a thematic analysis, until theoretical sufficiency was achieved. RESULTS: The following four themes related to podcast listenership were identified: (1) participants thought that TRT increased efficiency, allowing them to multitask, predominantly using mobile listening platforms; (2) participants listened to the podcast for both education and entertainment, or "edutainment"; (3) participants thought that the podcast helped them keep up to date with medical literature; and (4) participants considered TRT to have an indirect effect on learning and clinical practice by increasing overall knowledge. CONCLUSIONS: Our results highlight how a medical podcast, designed for continuing professional development, is often used informally to promote learning. These findings enhance our understanding of how and why listeners engage with a medical podcast, which may be used to inform the development and evaluation of other podcasts.

Fake It 'Til You Make It: Pressures to Measure Up in Surgical Training.

PURPOSE: Expectations of certainty and confidence in surgical culture are a source of internal conflict for surgeons and learners, with surgeons describing a pressure to project an image that is, at times, inconsistent with how they feel internally. The authors explored surgical residents' perceptions of "impression management" and its effects on surgical judgment and decision making. METHOD: The authors used a constructivist grounded theory approach to conduct and analyze 15 semistructured interviews with general surgery trainees at an urban Canadian academic health center between 2012 and 2014. Interviews explored impression management in the context of resident learning and performance. Analysis was inductive, whereby emergent themes contributed to a developing conceptual framework, and deductive, using an existing theory of impression management. RESULTS: Residents described sensing an "expectation" to portray an image aligned with the ideal surgical stereotype of confidence and certainty, and shared strategies used to mirror this image. Impression management strategies were used to portray an image of competence, with the aim to improve access to teaching and evaluations. Unintended consequences of impression management on decision making, patient safety, and resident wellness were identified. CONCLUSIONS: These findings contribute to a deeper understanding of the potential impact of the sociocultural context on residency training, and provide a language allowing for more explicit discussions about the impact of surgical culture on trainee behaviors. Translation includes formal instruction of these concepts in the curriculum so that trainees better recognize, reflect on, and cope with the pressures to perform in front of others.

Docemur Docemus: Peer-Assisted Learning Improves the Knowledge Gain of Tutors in the Highest Quartile of Achievement but Not Those in the Lowest Quartile.

OBJECTIVES: Peer-assisted learning (PAL) is a form of collaborative learning where members of a peer group act as teachers for each other. A reciprocal PAL program was designed to investigate whether there were differential gains in knowledge acquisition among tutors compared with tutees. DESIGN: Bayesian statistical analysis was used to quantitatively assess the effect of tutor status on performance in a knowledge-based examination. Subgroup analysis according to student achievement and question difficulty was performed. PARTICIPANTS AND SETTING: Final year undergraduate medical students in a 5-year degree program (n = 126). RESULTS: The overall probability of getting a correct answer on the knowledge examination was 49.7%. For questions on topics where a student had acted as a tutor this improved to 57.3%. However, students who performed in the upper quartile had a greater percentage gain in the probability of a correct answer in topics that they had taught vs students who performed in the lowest quartile. CONCLUSIONS: There was demonstrable overall knowledge gain associated with acting as a tutor in a PAL program but the greatest gain occurred in students of highest academic ability.

Planning to avoid trouble in the operating room: experts' formulation of the preoperative plan.

OBJECTIVE: The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. DESIGN: HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. SETTING: Division of General Surgery, University of Toronto. PARTICIPANTS: HPB surgeons affiliated with the University of Toronto. RESULTS: A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. CONCLUSION: These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy.

Here we present a case of successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy. The fistula was created when urethroscopic repair of a urethral stricture was attempted. Due to the anatomy of the lesion and previous urinary diversion, it was deemed possible to spare this patient diverting colostomy or surgical repair of the fistula. The result was successful closure of the fistula, which was confirmed on retrograde urethrogram. While we do not support the routine use of non-operative management for recto-urethral fistulas we have demonstrated that there are circumstances where it can be safely applied.

A large struma ovarii tumor removed via laparoscopy in a 16-year-old adolescent.

Struma ovarii is rare ovarian tumor that is characterized by the presence of at least 50% thyroid tissue on histologic examination. This usually benign neoplasm is predominantly found in women between the ages of 40 and 60 years and infrequently in the pediatric age group. In the foregoing report, we present an unusual case of a large struma ovarii in a 16-year-old adolescent girl with abdominal pain and increasing abdominal girth. Removal of the mass was achieved via a laparoscopic approach. We conclude that the diagnosis of struma ovarii should be considered in adolescent girls presenting with large cystic ovarian masses and that a laparoscopic approach to management is the treatment of choice.