Background The average cost of running an operating room (OR) is approximately $37.00 a minute. Therefore, every effort should be made to start in a timely manner. There are several factors at play that can cause OR delays. Attaining consistent start times is a multidisciplinary task, which requires good communication and rewards for efficiency. Methods At our institution, a “star system” was implemented to improve compliance with timely start times. All OR staff (scrub tech, OR nurse, anesthesiologist, and physician) get 1 star for every on time start. Once a person attains 10 stars, they are awarded a $20 gift card to a local bakery/coffee shop. Results There was a significant difference in the 3 months pre- and post-implementation of the star system in regard to starting on time (54% vs. 71%, P-value .047), and there were significantly less late starts within 6-10 minutes (14% vs. 4%, P-value = <.01). There was no statistically significant difference in late starts >11 minutes or when comparing days of the week. The most common reasons for delay are as follows: surgeon running late (23%), anesthesiologist tardiness (11%), patient is late (9%), preoperative orders, or test not completed (7%). Conclusion The significant increase in the number of cases that start on time after implementation of the star system leads us to believe that late start times are multifactorial, and that incentives are a positive way to encourage the OR team to start on time.
We report a case of a patient who presented with biliary colic while in Tijuana, Mexico. Laparoscopic cholecystectomy was attempted but abandoned and only a biopsy of the gallbladder was performed with pathologist reporting gallbladder adenocarcinoma. Upon return to the United States, extensive evaluation was undertaken including imaging, biopsy, and ultimately two separate exploratory surgeries revealing no neoplasm. Only at the second surgical exploration did we discover a benign cholecystoduodenal fistula successfully treated with completion fenestration cholecystectomy, pyloric exclusion, loop gastrojejunostomy, and duodenostomy tube through the gallbladder remnant into the fistula itself. This is a unique surgical treatment of a rare problem made even more confusing by an erroneous pathology report from another country.
There is a steady rise in incidence of malignant salivary gland tumors in the United States, with mucoepidermoid carcinoma (MEC) the most frequent. Although 40% of MECs are found in the parotid gland, these lesions possess the capacity to develop anywhere along the aerodigestive tract. Here, we present a case of recurrent tongue MEC in a young adult female patient with history of lung malignancy and multiple brain metastases. Without a universally accepted management protocol for recurrent MECs, the current clinical practice uses tumor grade, location, and clinical progression to determine both prognosis and goals of care. The patient had transoral laser excision of the first MEC lesion in 2013. Her tongue MEC recurred 3 years later with 2 distinct lesions. One was discovered on physical examination and computed tomography and the other diagnosed intraoperatively 1 month later. These lesions were located on a previously unaffected portion of dorsal tongue base. These lesions were completely excised in the operating room. The patient currently remains on chemotherapy. This underscores the importance for developing a guideline that delineates the most efficacious surveillance and treatment plans for recurrent MECs.
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