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Purpose: To evaluate the indications for and the outcomes from distal pancreatectomy.Methods: Retrospective chart review of 171 patients who underwent distal pancreatectomy at Brigham and Women's Hospital between January 1996 and August 2005.Results: Nearly one-third of distal pancreatectomies were performed as part of an en bloc resection for a contiguous or metastatic tumor. Fifty-six percent of the patients underwent a standard distal pancreatectomy +/- splenectomy (group 1), whereas 44% of distal pancreatic resections included additional organs or contiguous intraperitoneal or retroperitoneal tumor (group 2). The overall post-operative complication rate was 37%; the most common complication was pancreatic duct leak (23%). When compared to patients undergoing standard distal pancreatectomy, those with a more extensive resection including multiple viscera and/or metastatic or contiguous tumor resection had no significant difference in overall complication rate (35% v. 39%, p = 0.75), leak rate (25% v. 20%, p = 0.47), new-onset insulin-dependent diabetes mellitus (3% v. 4%, p = 1.0), and mortality (2% v. 4%, p = 0.656).Conclusion: This series includes a large number of patients in whom distal pancreatectomy was performed as part of a multivisceral resection or with en bloc resection of contiguous tumor. Complications were no different in these patients when compared to patients undergoing straightforward distal pancreatectomy. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate contemporary outcomes associated with the management of gallbladder cancer. The medical records of 48 consecutive patients with gallbladder cancer treated at our institution from January 1981 through November 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 24 months) and the log-rank test. Prognostic factors were analyzed using Cox regression. Mean patient age was 68 years. Sixty percent of patients were female. Thirty-nine patients (81%) underwent laparotomy or laparoscopy. Eighteen patients (38%) underwent complete resection (10 simple cholecystectomies and 8 radical cholecystectomies). There were no procedure-related deaths. The overall 5-year survival rate was 13%. Patients who underwent complete resection had a higher 5-year survival rate (31%) than patients who underwent palliative surgery or no surgery (0%; P<0.05). For patients who underwent radical cholecystectomy, the 5-year survival rate was 60%. For the 18 patients who underwent curative resection, positive lymph node metastasis and patient age over 65 were factors predictive of significantly worse survival. Overall survival rates for patients with gallbladder cancer remain poor. Although radical surgery can be performed safely, it is associated with long-term survival only in a highly select subset of patients with gallbladder cancer. [Copyright &y& Elsevier]

Small bowel malignancies are rare. The aims of this study were to evaluate the outcomes associated with surgical therapy for small bowel cancers and to define prognostic factors. The medical records of 96 consecutive patients with primary small bowel cancer (excluding lymphoma) treated at our institution over a 20 year period were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 57 months). Mean patient age was 56 years, and 58% of patients were male. Sixty percent of patients had an adenocarcinoma, 21% had a sarcoma, and 19% had a carcinoid tumor. The percentages of patients who underwent complete (curative) resection were 51%, 90%, and 50% for those with adenocarcinoma, sarcoma, and carcinoid tumor, respectively. For patients with adenocarcinoma who underwent curative resection, tumor (T) and node (N) stages were significant prognostic factors predicting overall survival. For patients with sarcomas who underwent curative resection, tumor grade was a significant prognostic factor predicting overall survival. The prognosis for patients with small intestinal carcinoid tumors is uniformly favorable. The prognosis for patients with sarcomas and adenocarcinomas is generally poor, although long-term survival is achieved by patients with favorable prognostic factors. [Copyright &y& Elsevier]

Benign duodenal neoplasms (BDNs) are uncommon, and their optimal management remains undefined. We analyzed all cases of BDN treated at our institution during a 10-year period (January 1990 through January 2000). Data are expressed as median (range). Sixty-two patients were treated for BDNs. The results of histologic examination of their lesions were as follows: 36 adenomas, eight Brunner''s gland tumors, 10 inflammatory polyps, two hamartomas, and six others. Forty-seven patients were treated nonoperatively, and 15 patients underwent surgery. Lesion characteristics leading to surgical intervention included large polyp diameter and submucosal penetration detected on endoscopic ultrasound imaging. There were no treatment-related deaths. Major morbidity occurred in 2% of patients who underwent endoscopic resection and in 33% of patients who underwent surgery (P = 0.002). Among patients treated for adenomas, seven (19.4%) had a recurrence at a median of 12 (4 to 48) months. Most BDNs can be managed with minimal morbidity using endoscopic techniques. Systematic follow-up of patients treated for adenomas is required. ( J Gastrointest Surg 2003;7:536–541.) [Copyright &y& Elsevier]

Background: The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer. Study design: Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months. Results: Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers. Conclusions: Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal. (J Am Coll Surg 2004;199:880-886. [Copyright &y& Elsevier]

Background: The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. Study Design: Four complex operations performed by surgeons of varying experience—a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience—were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. Results: The sessions focused on operative technique—both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident''s technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions: Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development. [ABSTRACT FROM AUTHOR]

Introduction: Surgical teams must deal regularly with unanticipated events in the operating room (OR). We sought to understand the etiology and resolution of these events using a qualitative assessment. Methods: To increase the likelihood of capturing an event, we video-recorded and transcribed 8 complex, high-acuity operations, representing 36 hours of patient care. Deviations, defined as episodes of decreased patient safety and/or delays, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the system, team or individual provider. Results: 24 deviations (14 safety-compromising, 5 delays, 5 both) occurred, at a rate of approximately once every 1.5 hours. All except one were compensated such that patient harm was averted. These deviations were often multifactorial (mean 2.2 factors each). As shown in the Table, problems with communication, coordination, and organizational structure (e.g. inopportunely timed hand-offs) appeared repeatedly at the root of both types of deviations. Mediation of safety compromises was most frequently accomplished with leadership and/or vigilance, while delays tended to be resolved with improved teamwork. Conclusions: Unanticipated events are common in the OR. Contrary to popular belief, these events do not reflect human fallibility mitigated by a well-designed system. Rather, deviations result from poor system design and sub-optimal team dynamics, with caregivers then compensating to avoid patient harm. Such resilience has been recognized in other high-risk work environments. These results underscore the need for system redesign and improved team training to improve patient safety. [Copyright &y& Elsevier]