Prevalence of teaching sentinel lymph node biopsy for breast cancer in general surgery residency programs

PURPOSE: Sentinel lymphadenectomy (SLNB) for the evaluation of clinically negative lymph nodes in women with invasive breast cancer is rapidly gaining acceptance within the surgical community. The purpose of this study was to document the prevalence of teaching SLNB to residents in general surgery training programs in the United States. METHODS: The Fellowship and Residency Electronic Interactive Database (FREIDA) was searched for a listing of all general surgery residency programs. A short questionnaire was mailed to the program director of each residency program listed. The program directors were asked whether general surgery residents are taught the technique of performing SLNB for breast cancer, and how the procedure is performed at their institutions. RESULTS: Of the 255 surgical programs listed in FREIDA, 191 or 75% responded to the survey. Of responding programs, 92% are currently teaching surgical residents SLNB, whereas 4% plan on adding SLNB to the curriculum within the next academic year. A total of 74% of programs are performing SLNB as part of an organized hospital protocol, whereas 40% routinely follow SLNB with an axillary node dissection. A total of 89% of the programs use both sulfur colloid radioisotope and isosulfan blue dye, whereas 7% use dye alone, and 4% use only radioisotope. CONCLUSIONS: The practice of performing SLNB for the purpose of detecting occult nodal metastases in breast cancer is being taught at most surgery training programs in this country. In the less than 6 years since the modification of this technique for the treatment of breast disease, it has become the standard of care for treating women with invasive breast cancer with clinically negative axillary lymph nodes at training hospitals in the United States.     

Assessing retroperitoneal lymphadenectomy experience in United States urological residency programs

PURPOSE: Surgical experience is important for the mastery of operative procedures. We evaluated the current United States urological surgical resident training in performing retroperitoneal lymph node dissection. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education Residency Review Committee for Urology operative log reports from 2000 through 2004 were reviewed. We analyzed resident retroperitoneal lymph node dissection experience as surgeon and first assistant by examining CPT codes for retroperitoneal lymph node dissection (CPT codes 38780, 38570 and 38572). RESULTS: The overall number of retroperitoneal lymph node dissections performed at urological residency training programs has increased from 2000 to 2004 (781 to 924). The average number of retroperitoneal lymph node dissections performed by graduating residents in 2001 and 2004 did not change significantly (3.5 vs 4.0). Half of all graduating urology residents in 2004 had performed 2 or fewer retroperitoneal lymph node dissections as the primary surgeon and 1 or none as the first assistant during their training program. However, a small percentage (10%) of graduating residents completed their respective programs with 9 or more retroperitoneal lymph node dissections as primary surgeon and 4 as first assistant. There were no laparoscopic retroperitoneal lymph node dissections logged by graduating residents from 2001 through 2004. CONCLUSIONS: Accreditation Council for Graduate Medical Education data suggest that many urology residents have minimal surgical exposure and training in retroperitoneal lymphadenectomy. These results indicate that alternative strategies should be explored not only to improve the residency training experience but also to determine minimum training criteria.     

Attitudes of applicants for surgical residency toward work hour limitations

BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked "reading in surgery" the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency.     

Cost/Accuracy Ratio Analysis in Breast Cancer Patients Undergoing Ultrasound-Guided Fine-Needle Aspiration Cytology,Sentinel Node Biopsy,and Frozen Section of Node

We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.     

Analysis of a survey on orthopaedic residency training for fracture treatment in Korea

IntroductionFracture surgery is the most frequently performed orthopaedic procedure and is considered an essential surgical procedure for orthopaedic surgeons in general. Although the approach and circumstances of orthopaedic residency training for fracture treatment may differ between countries, the goals of training, which is to educate the residents regarding the principles of the fracture treatment and foster conscientious orthopaedic specialists, remain unchanged. Thus, the aim of the this study was to determine a desirable course of orthopaedic residency training by investigating and analysing the reality of training associated with fracture surgery and treatment during the orthopaedic residency of 4th year orthopaedic residents in Korea.MethodsUsing a questionnaire survey, a one-on-one interview was proposed to 266 applicants following the secondary board examination of residents who had completed the orthopaedic residency training course; the survey was conducted on January 19, 2016. Responses from 152 applicants (response rate: 57%) who accepted to participate in the survey were statistically analysed.ResultsDuring residency training, clinicians underwent fracture-related training for 3.5 h on average per month. Training consisted of various approaches and included lectures by professors, case briefings, textbook reading, and field training in an operating room. The residents largely differed in terms of experience in conducting fracture surgery: 47 (31%) responded that they had never performed fracture surgery during the training period, whereas 21 (14%) answered that they had conducted fracture surgery over 20 times. Experience in performing the surgical procedure was the most valuable in fracture training.ConclusionTo optimize fracture education among orthopaedic residents, the professors at teaching hospitals should understand the realities of fracture education, dedicate sufficient time for internal and external fracture teachings, and allow residents to perform fracture surgeries hands-on under their supervision, and also attempt to foster a social atmosphere that encourages all three factors.     

Are you ready to become a robo-surgeon?

Robotic and minimally invasive surgery represents the future of modern surgical care. However, its role during the training of surgical residents has yet to be investigated. A previous study conducted by our group surveyed program directors at accredited general surgery training programs in the United States to determine the prevalence and application of robotics in their residency programs. This current study is a follow-up survey sent to residents across the United States to see whether they were being adequately trained and exposed to robotic surgery during their training. A survey was sent to 1800 general surgery residents, and their responses were tabulated and analyzed. Twenty-three per cent of the 1800 residents responded to our survey. An overwhelming 57 per cent of the responders indicated a high interest in robotic surgery. However, 80 per cent of the responders indicated not having a robotic training program. Robotic surgery has led to many promising advancements within the surgical subspecialties. With this emerging technology comes the need for a greater emphasis on the training of surgeons in robotics during their residency.     

Minimally invasive surgery for axillary dissection

Axillary dissection is the major cause of morbidity in breast cancer and primary cutaneous melanoma of the extremity. In the present study, we examine the potential benefits and advantages of endoscopic axillary lymph node dissection over conventional surgery. Twenty endoscopic axillary dissections and 10 lymph node samplings were performed in 10 cadavers (four male, six female). A preperitoneal distention balloon (PDB) system was used to dissect the axilla. In four of the cadavers, the procedure was followed by open surgery. The axillary contents were examined for lymphatic tissue by a pathologist. The endoscopic technique offered easy access to the axilla and clear visualization of the axillary vein, as well as the long thoracic and thoracodorsal nerves. Results were comparable to those achieved with the classic surgical dissection. Endoscopy is feasible for axillary lymph node dissection and sampling in cases of breast cancer and primary cutaneous melanoma of the extremity. Further studies in patients are needed to reach definitive conclusions. Received: 31 December 1996/Accepted: 12 September 1997     

The state of general surgery residency in the United States: program director perspectives, 2001

HYPOTHESIS: Current demographic patterns and lifestyle factors of general surgery residents may contribute to recent changes in recruitment patterns. DESIGN: Survey addressing the characteristics of general surgery residency, including demographic data, 3-year recruitment and retention trends, and working conditions of general surgery residents. PARTICIPANTS: A convenience sample of all residency program directors in attendance at the 2001 Surgical Education Week was given the opportunity to voluntarily complete the survey. RESULTS: A total of 109 program directors responded to the survey. Women constitute 25% of all current general surgery residents: 66% of the program directors perceived a decline in the number of applicants for general surgery residency. Recruitment patterns differ significantly between small (< or =4 categorical residents per year) and large (>4 categorical residents per year) residency programs. Residents at large programs averaged a 95-hour workweek, whereas those at small programs averaged an 88-hour workweek (P =.01). The mean 1-year attrition rate for general surgery residents was 20.2% in 2000, and attrition showed no relationship to program size, gender composition, or working conditions. CONCLUSIONS: Women remain underrepresented in general surgery residency. Recruitment and match statistics show some variation, but the relevance of a shrinking applicant pool to these changes is unclear. Resident working conditions remain a difficult issue, and attrition rates continue to be significant. A substantial research agenda remains in graduate surgical education.     

Altering the career choice: Can we attract more women to vascular surgery?

Vascular surgery has relied upon the pool of general surgical residents for candidates for residency. This has significantly limited the pool of applicants. With the advent of new primary certificate training paradigms, we investigated factors that might alter the career choices for women medical students. A Web-based survey was conducted of third-year and fourth-year medical students at three university-affiliated programs. A total of 140 students completed the survey, which identified the third year of medical school as the primary year when students committed to a final career choice. Lifestyle issues were the primary deterrents, with long work hours and lack of time to see family negatively influencing students' interest in surgery. Eliminating the need for 5 years of general surgery and the opportunity for part-time training were cited as factors that would alter students' decisions to pursue vascular surgery. Ultimately, a positive rotation experience, lifestyle issues, and mentors impacted on final career decisions. To attract the best applicants to the field, we need to continue to be active in mentoring students and exploring alternative training paths and eventual career practices.     

Is the quality of surgical residency applicants deteriorating?

BACKGROUND: Among directors of general surgery residencies, there is a concern that the quality of medical students applying to surgical residencies is declining. METHODS: Quality of surgical applicants was assessed by several methods including subjective opinions determined by survey and by objective data including student United States Medical Licensing Examination (USMLE) scores of matched candidates. The number of applicants interviewed, total interviews granted, proportion of Alpha Omega Alpha (AOA) students, and the rank order of the candidates matched was obtained by survey. The survey included data on postgraduate year 1 (PGY-1) residents from July 1996 to July 1999. Three mailings were made to 226 US surgical residency programs. RESULTS: Data were obtained from 90 programs. Surgery program directors disagreed with a survey statement that overall quality of applicants had declined (P <0.01), but agreed with a statement that activities of medical schools to enroll graduating students into primary care had hurt recruitment (P <0.001). Objective data revealed no change in mean USMLE part I scores of PGY-1 residents over the 4 years (P = 0.265, power = 0.81). There was no change in proportion of matched residents who were AOA over time. The mean score of all new PGY-1 residents, the rank of the first matched resident, the rank of the last ranked resident, and proportion of AOA students was higher in programs with five or more categorical spots when compared with programs of at most four (P <0.001). Across all programs, there was a trend to go lower on the rank list to fill categorical positions over time (P <0.001). CONCLUSIONS: There is a perception that medical school policies act to discourage recruitment of quality medical students into general surgery programs, and surgery programs are going deeper into their rank lists to fill categorical positions. However, the average USMLE part I score of applicants to surgical residencies and proportion of AOA applicants has not decreased.     

乳腺癌腔镜腋窝淋巴结清扫手术方式选择及评价

溶脂法与非溶脂法腔镜腋窝淋巴结清扫在乳腺癌手术中的应用存在争议,也在不断的发展。非溶脂法腔镜腋窝淋巴结清扫在获得与溶脂法同样的腔镜放大视野、精细操作以及微创效果的同时,更符合常规开放手术中腋窝淋巴结处理的手术顺序,不受限于淋巴结大小,完整切除腋窝淋巴脂肪组织,可经乳晕切口顺畅取出手术标本,除了无法应用于内下象限肿瘤的保乳手术外,其避免了溶脂法腔镜腋窝淋巴结清扫的争议点。手术时间的延长及部分乳腺外科医生缺乏腔镜基础训练是限制非溶脂腔镜腋窝淋巴结清扫广泛应用的主要因素,相信随着手术器械的不断进步及外科规培制度的落实,这一技术会有更广阔的应用空间。     

The Safety and Accuracy of Sentinel-Node Biopsy in Early-Stage Invasive Breast Cancer—Turkish Experience

The purpose of this prospective study was to investigate the correlation of sentinel lymph node (SLN) and axillary lymph node (ALN) metastasis in early-stage invasive breast cancer in a single institution. One hundred and fifteen patients with early-stage invasive breast cancer first underwent SLND followed by an appropriate surgical procedure (modified radical mastectomy, lumpectomy + axillary dissection, simple mastectomy + mammoplasty). In this series, a radioactive agent (technetium) was used to investigate the sentinel lymph node/nodes. In 28 (24.3%) patients, metastases were found in both SLN and axillary dissections. There were no metastases in either of these procedures in 69 (60%) patients. SLN metastasis was found in 13 (11.3%) patients, but no axillary metastasis was found. No skip metastasis was detected. Five patients in whom the sentinel node was not found were also negative for axillary metastasis. As the studies progress in this direction, it might be possible to avoid axillary dissection in patients with early breast cancer in whom metastasis in SLN cannot be detected. We believe this will reduce morbidity from breast cancer surgeries.     

Surgical complications after thyroid surgery performed in a cancer hospital.

OBJECTIVE: This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy in a cancer hospital with residency training. STUDY DESIGN: A retrospective chart and complications review of 1020 patients (1990-2000) underwent to thyroidectomy. RESULTS: At our cancer hospital, 1020 patients underwent thyroidectomy. The main postoperative complications consisted of transient hypocalcemia in 134 (13.1%) patients, permanent hypocalcemia in 26 (2.5%) patients, transient vocal cord palsy in 14 (1.4%) patients, and permanent vocal cord palsy in 4 (0.4%) patients. The type of thyroidectomy, neck dissection, and paratracheal lymph node dissection were significantly associated with transitory and permanent hypocalcemia. CONCLUSION: Thyroid surgery can be performed safely in a surgical residency training program under direct supervision of an experienced surgeon with little morbidity to the patients. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients who underwent total thyroidectomy.     

Vascular surgical training of general and vascular surgery residents

Objective: The opinions of general surgery program directors (SPDs) and vascular surgery program directors (VPDs) regarding vascular surgery training of general surgery residents and the construct of the vascular surgery residency were compared.Methods: Questionnaires were mailed to 55 VPDs and 290 SPDs in 1987 and 1988, and to 80 VPDs and 277 SPDs in 1995. Both questionnaires included questions regarding attitudes about vascular surgical competence, operative experience, future vascular practice opportunities of general surgery residents, and the impact of a vascular surgery residency on general surgery resident education. In addition, the 1995 survey included questions regarding the duration, content, and prerequisite versus requisite experience for the vascular surgery residency.Results: Significant differences in opinions between SPDs and VPDs persisted regarding vascular surgery training of general surgery residents. SPDs were more likely to feel that general surgery graduates are fully competent in vascular surgery, should be exposed to more complex vascular surgery during training, and should be granted unlimited vascular surgical privileges on entering practice. Most VPDs felt that general surgery graduates lack competence in vascular surgery, should be exposed to less complex vascular surgery during training, and should have limited vascular surgery privileges in practice. Both groups of program directors agreed about the construct of vascular surgery residencies and that such residencies have had a favorable impact on general surgery resident education. Both SPDs and VPDs were willing to consider creative restructuring of vascular surgery residencies to accommodate governmental restrictions on funding of graduate medical education.Conclusions: External pressures forcing residency reform may provide an opportunity for SPDs and VPDs to creatively work with regulatory bodies to resolve differences in expectations of vascular surgery education and practice. (J Vasc Surg 1996;24;1057-63.)     

The safety and accuracy of sentinel-node biopsy in early-stage invasive breast cancer--Turkish experience.

The purpose of this prospective study was to investigate the correlation of sentinel lymph node (SLN) and axillary lymph node (ALN) metastasis in early-stage invasive breast cancer in a single institution. One hundred and fifteen patients with early-stage invasive breast cancer first underwent SLND followed by an appropriate surgical procedure (modified radical mastectomy, lumpectomy + axillary dissection, simple mastectomy + mammoplasty). In this series, a radioactive agent (technetium) was used to investigate the sentinel lymph node/nodes. In 28 (24.3%) patients, metastases were found in both SLN and axillary dissections. There were no metastases in either of these procedures in 69 (60%) patients. SLN metastasis was found in 13 (11.3%) patients, but no axillary metastasis was found. No skip metastasis was detected. Five patients in whom the sentinel node was not found were also negative for axillary metastasis. As the studies progress in this direction, it might be possible to avoid axillary dissection in patients with early breast cancer in whom metastasis in SLN cannot be detected. We believe this will reduce morbidity from breast cancer surgeries.     

Selecting the best and brightest: A comparison of residency match processes in the United States and Canada

BACKGROUND:

Selecting candidates for plastic surgery residency training remains a challenge. In the United States, academic measures (United States Medical Licensing Exam Step I scores, medical school class rank and publications) are used as primary criteria for candidate selection for residency. In contrast, Canadian medical education de-emphasizes academic measures by using a pass-fail grading system. As a result, choosing residents from many qualified applicants may pose a challenge for Canadian programs without objective measures of academic success.

METHODS:

A 25-question online survey was distributed to program directors of Canadian plastic surgery residency-training programs. Program directors commented on number of yearly residents and applicants; application sections (ranked in importance using a Likert scale); interview invitation and rank-order list determination; and their satisfaction with the selection process.

RESULTS:

Ten Canadian plastic surgery program directors responded (90.9% response rate). The most important application components determining invitation to interview were letters of reference from a plastic surgeon (mean importance of 5.0 on the Likert scale), clinical electives in plastic surgery (mean 4.6) and electives with their program (mean 4.5). Applicants invited for interview were assessed on the quality of their responses to questions, maturity and personality. The majority of program directors agreed that a clinical elective with their program was important for consideration on their rank-order list. Program directors were neutral on their satisfaction with the selection process.

CONCLUSION:

Canadian plastic surgery residency programs emphasize clinical electives with their program and letters of reference from colleagues when selecting applicants for interviews. In contrast to their American counterparts, Canadian program directors rely on clinical interactions with prospective residents in the absence of objective academic measures.     

Attitude of Prospective Surgical Residents Regarding Surgery for Morbid Obesity

Background: Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity. Methods: An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity. Results: 57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%. Conclusions: Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.     

Mastectomy and concomitant sentinel lymph node biopsy for invasive breast cancer

BACKGROUND: Although sentinel lymph node biopsy (SNLB) has become a standard ancillary to breast conservation, there remains a hesitancy to perform SLNB concomitant with mastectomy primarily because of concerns regarding reoperation for a positive SLN. METHODS: A retrospective review of 51 patients who underwent SLN biopsy concomitantly with mastectomy for invasive breast cancer was performed. In addition, a survey was sent to surgical oncologists who routinely perform SLNB in conjunction with mastectomy. RESULTS: The SLN was identified in 98% of patients, and an average of 2.4 SLNs/patient were removed. The SLN was positive in 14 patients (27%). Ten patients underwent axillary lymph node dissection as a second procedure; an average of 15.4 +/- 6 nodes were cleared, and there were no complications. Although techniques vary greatly among surgeons, the majority believe that a subsequent ALND procedure does not carry additional risk of morbidity. CONCLUSIONS: Mastectomy and concomitant SLNB is a safe option for well-selected breast cancer patients. Results appear acceptable using a variety of techniques. Patients with a positive SLN can safely undergo completion axillary lymph node dissections. This includes patients who have undergone immediate reconstruction, but proper planning is needed to minimize potential risks.     

Predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer

BACKGROUND: Accurate intraoperative diagnosis of axillary malignancy facilitates completion axillary lymph node dissection (ALND) at the time of initial surgery. The capability to address both the primary tumor and axillary disease in a single procedure offers several advantages. This study was designed to define the predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer and to evaluate the ability of the technique to facilitate accurate synchronous ALND. METHODS: A consecutive cohort of patients with breast cancer at an Army medical center underwent intraoperative touch preparation analysis of sentinel lymph nodes concordant with initial excision. Those found to have sentinel nodes positive by touch preparation analysis underwent ALND at the initial procedure. Patients with negative sentinel nodes by touch preparation analysis, but positive by final pathology, underwent subsequent ALND. Results of the touch preparation analysis were compared with the final pathology. RESULTS: Over a 16-month period, 71 consecutive patients with breast cancer underwent initial excision and touch preparation analysis of 162 sentinel lymph nodes. Final pathology confirmed axillary metastasis in 32% (23 of 71) of patients. Of these, intraoperative touch preparation analysis identified 48% (11 of 23). There were no false positives or unnecessary axillary dissections based upon touch preparation results. Per sentinel node, the positive predictive value was 100%, the sensitivity was 47%, and the specificity was 100%. On a per patient basis, the positive predictive value was 100%, and the sensitivity and specificity were 48% and 100%, respectively. CONCLUSIONS: Intraoperative touch preparation analysis is an effective adjunct to sentinel lymph node biopsy. In our series, it facilitated a definitive cancer operation at the time of initial surgery in nearly 50% of patients, and ensured that no patient underwent an unnecessary axillary dissection.