Archives of Surgery最新文献

OBJECTIVE To examine the long-term outcome of patients with early breast cancer with hematoxylin-eosin-negative sentinel lymph nodes (SLNs) who did not undergo completion axillary lymph node dissection. DESIGN, SETTING, AND PATIENTS Patients with invasive breast cancer surgically treated between May 1, 1995, and December 31, 2002, with SLN biopsy alone without axillary lymph node dissection who had hematoxylin-eosin-negative SLNs were identified. MAIN OUTCOME MEASURES Patient and tumor characteristics, adjuvant treatment, disease recurrence, and survival were recorded. A multivariable analysis model was used to identify significant variables associated with disease-free survival and overall survival. RESULTS A total of 811 patients were included, with a median follow-up of 103.1 months (range, 12.2-182.8 months). The mean patient age was 57.8 years (range, 26-91 years), the mean tumor size was 1.5 cm (range, 0.1-7.5 cm), and the median number of SLNs obtained was 2 (range, 1-8). Seventy-six patients (9.4%) developed disease recurrence; there were 2 patients (0.2%) with isolated axillary recurrences, 40 (4.9%) with local recurrences, 4 (0.5%) with local and regional recurrences, 22 (2.7%) with distant recurrences, and 8 (1.0%) with both local and distant recurrences. The median time to recurrence was 57.2 months (range, 3.1-163.3 months), with 5-year and 10-year disease-free survival rates of 95.1% and 89.9%, respectively. One hundred one patients (12.5%) died; only 15 (1.8%) had distant metastatic disease at the time of death. Patients were significantly more likely to have disease recurrence if they had high-grade tumors (P = .004). Older age and larger tumor size were significant predictors of worse overall survival on multivariate analysis (P < .001 and P = .01, respectively). CONCLUSIONS This study reports the long-term follow-up of patients with breast cancer and hematoxylin-eosin-negative, tumor-free SLNs, showing a remarkably low axillary recurrence of 0.2% and high disease-free survival. Long-term results of SLN biopsy alone are excellent, and the addition of immunohistochemistry analysis does not contribute to survival.

HYPOTHESIS Although the risks for operating room distractions and interruptions (ORDIs) are acknowledged, most research on this topic is unrealistic, inconclusive, or methodologically unsound. We hypothesized that realistic ORDIs induce errors in a simulated surgical procedure performed by novice surgeons. DESIGN, SETTING, AND PARTICIPANTS Eighteen second-year, third-year, and research-year surgical residents completed a within-subjects experiment on a laparoscopic virtual reality simulator. Based on 9 months of operating room observations, 4 distractions and 2 interruptions were designed and timed to occur during critical stages in simulated laparoscopic cholecystectomy. The control factor was the absence or presence of ORDIs, with order randomly counterbalanced across the subjects. MAIN OUTCOME MEASURES The primary outcome measure was surgical errors measured by the simulator as damage to arteries, bile duct, or other organs. The second outcome measure was whether the participants remembered a prospective memory task assigned prior to the procedure and important to operative conduct. RESULTS Major surgical errors were committed in 8 of 18 simulated procedures (44%) with ORDIs vs only 1 of 18 (6%) without ORDIs (P = .02). Interrupting questions caused the most errors. Sidebar conversations were the next most likely distraction to lead to errors. Ten of 18 participants (56%) forgot the prospective memory task with ORDIs, while 4 of 18 (22%) forgot the task without ORDI (P = .04). All 8 surgical errors with ORDIs occurred after 1 PM (P = .001). CONCLUSIONS Typical ORDIs have the potential to cause operative errors in surgical trainees. This performance deficit was prevalent in the afternoon.