Implementation of a low-cost laparoscopic skills curriculum in a third-world setting.

BACKGROUND: Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa. STUDY DESIGN: The laparoscopic skills curriculum created and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice. RESULTS: Residents were tested on 3 separate tasks (cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year. CONCLUSIONS: Implementation of a low-cost laparoscopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings.

Branchial cleft cyst encircling the hypoglossal nerve.

Branchial cleft anomalies are a common cause of lateral neck masses and may present with infection, cyst enlargement or fistulas. They may affect any of the nearby neck structures, causing compressive symptoms or vessel thrombosis. We present a case of a branchial cleft cyst in a 10-year-old boy who had been present for 1year. At the time of operation, the cyst was found to completely envelop the hypoglossal nerve. While reports of hypoglossal nerve palsies due to external compression from cysts are known, we believe this to be the first report of direct nerve involvement by a branchial cleft cyst.

Cancer recurrence involving a TRAM flap and abdominal donor site following mastectomy and immediate breast reconstruction: a case report.

Local tumor recurrence after mastectomy with immediate reconstruction is rare. Most reported recurrences involve invasive or in situ ductal carcinoma and occur at the skin or subcutaneous tissues near the mastectomy site. We report a case of a patient with malignant phyllodes tumor that recurred after mastectomy with immediate pedicle transverse rectus abdominis myocutaneous flap reconstruction. The recurrent disease involved the mastectomy bed, transverse rectus abdominis myocutaneous flap, abdominal donor site, and precostal tunnel.

Novel neoadjuvant immunotherapy regimen safety and survival in head and neck squamous cell cancer.

BACKGROUND: Cellular immune suppression is observed in head and neck squamous cell cancer (HNSCC) and contributes to poor prognosis. Restoration of immune homeostasis may require primary cell-derived cytokines at physiologic doses. An immunotherapy regimen containing a biologic, with multiple-active cytokine components, and administered with cytoxan, zinc, and indomethacin was developed to modulate cellular immunity. METHODS: Study methods were designed to determine the safety and efficacy of a 21-day neoadjuvant immunotherapy regimen in a phase 2 trial that enrolled 27 therapy-naïve patients with stage II to IVa HNSCC. Methods included safety, clinical and radiologic tumor response, disease-free survival (DFS), overall survival (OS), and tumor lymphocytic infiltrate (LI) data collection. RESULTS: Acute toxicity was minimal. Patients completed neoadjuvant treatment without surgical delay. By independent radiographic review, 83% had stable disease during treatment. OS was 92%, 73%, and 69% at 12, 24, and 36 months, respectively. Histologic analysis suggested correlation between survival and tumor LI. CONCLUSION: Immunotherapy regimen was tolerated. Survival results are encouraging.

A phase 1 safety study of an IRX-2 regimen in patients with squamous cell carcinoma of the head and neck.

OBJECTIVES: Head and neck squamous cell carcinoma (HNSCC) is associated with profound defects in cellular immunity. IRX-2, a primary cell-derived biologic containing multiple cytokines, has enhanced immune responses and induced tumor rejection in preclinical studies. This phase 1 open label study aimed to determine the clinical and laboratory safety of an IRX-2 regimen in patients with HNSCC. METHODS: Patients with HNSCC who had failed surgery and/or radiation therapy were enrolled. IRX-2 was injected subcutaneously at 115 units per dose, 2 doses/d over 10 days, starting on day 4. Patients received low-dose cyclophosphamide infusion on day 1 and took oral indomethacin and zinc daily from day 1 through day 21. Safety and laboratory assessments were undertaken throughout the treatment and 4 weeks after completion of the regimen. RESULTS: A total of 13 patients with advanced disease were enrolled in the safety/intent-to-treat population; all experienced treatment-emergent adverse events (AEs). The most frequent AEs were blood and lymphatic disorders, followed by gastrointestinal disorders. Most AEs were mild to moderate in severity. Three patients discontinued the study due to an AE, including 2 deaths. Two patients died after the study period due to tumor progression. No death or discontinuation was considered related to the study drugs. Antitumor responses were noted by radiographic assessment. In the 8 patients who had antitumor data at day 21, 1 patient had complete response, 5 had stable disease, and 2 had progressive disease. CONCLUSIONS: The IRX-2 regimen was tolerated in patients with advanced HNSCC who failed surgery and/or radiation therapy. The safety and antitumor activity observed warrants further studies.

Oral/pharyngeal squamous carcinoma: treatment strategies.

Oral/pharyngeal squamous carcinoma is a largely preventable problem. Most patients have significant tobacco and alcohol histories. Treatment reflects the locally and regionally aggressive nature of these tumors. In advanced disease neither surgery nor radiation therapy can be used as a primary modality, and often combined treatment is necessary. Chemotherapy has a less well-defined role, but is increasing control rates in advanced tumors.