Background: Minimally invasive esophagectomy (MIE) has been performed at specialized centers for 15 years, but few studies have looked at outcomes in patients with locally advanced cancers, and few studies have provided longterm survival comparison with Ivor Lewis esophagectomy (ILE) to determine oncologic benefit or equivalence of MIE. Hypothesis: Minimally invasive esophagectomy for locally advanced esophageal carcinoma has similar oncologic outcomes to traditional open ILE with less associated short-term morbidity and mortality. Design: Retrospective comparison of patients with stage II or III esophageal carcinoma undergoing 3-field MIE compared with open ILE. Setting: University medical center. Patients: From 1995 to 2009, 64 patients who underwent MIE (33 patients) or ILE (31 patients) with clinical stage II or III esophageal cancer were compared. Main Outcome Measures: Primary end points included operative performance, morbidity, mortality, hospital stay, and survival. Results: No differences were noted between the groups in demographics, neoadjuvant therapy use (P=.22), resection completeness (R0:R1) (P=.57), length of stay (P=.59), intensive care unit stay (P=.36), anastomotic leak (P=1.0), pulmonary morbidity (P=.26), and mortality (P=1.0). Median follow-up was 19 months for MIE and 17 months for ILE. Survival at 2 years was 55% for MIE (18 of 33 patients) and 32% for ILE (10 of 31 patients) while diseasefree survival was 55% for MIE (18) and 26% for ILE (8). Conclusions: Our survival analysis shows divergent curves that favor MIE but have not yet reached statistical significance. The oncologic outcomes of MIE are comparable to that of ILE 2 years after resection.
Limb preservation for the severely deformed, infected, and unstable Charcot neuroarthropathic ankle is challenging. Nonoperative management may not adequately control evolving deformities, leading to nonhealing ulcerations, osteomyelitis, and amputation. Ninety percent of foot and ankle Charcot neuroarthropathy operations involve the ankle joint, 36 yet only 10% of Charcot cases occur at the ankle/ subtalar joint, 35 suggesting the difficulties with nonoperative treatment. Operative reconstruction for the neuroarthropathic ankle is appropriate for unstable, limb-threatening deformity or infection. Despite operative advancements, 43% of Charcot ankle/hindfoot fusions may have postoperative complications. 44 Intramedullary (IM) nail fixation is common for neuroarthropathic ankle reconstruction uncomplicated by wounds, infection, severe deformity, or bone loss. Coating IM nail fixation with cement-containing antibiotics may successfully treat osteomyelitis. 24,27,37,39,40,41 External fixation is an alternative method with comparable limb salvage results,
Introduction: Focused Cardiac Ultrasound (FoCUS) is a relatively new technology that requires training and mentoring. The use of a FoCUS simulator is a novel training method that may prompt greater adoption of this technology by physicians at different levels of training and experience. The objective of this study was to determine if simulation training using an advanced echo simulator (Real Ultrasound®) is a feasible means of delivering training in FoCUS. Methods: Twenty-five residents and attending physicians participated in this study. After performing a pretest, training on the Real Ultrasound® was administered. Improvement was assessed immediately after simulator training. Additionally, some participants were retested six months after training to determine whether learned skills were retained. Results: Of the 25 participants recruited, all completed the pretest phase, and 17 completed the training and immediate posttest assessment. At pretest, the median angular deviation of acquired images from anatomically correct was 37°, which improved to 30° after training (p<0.002). Technical skill was largely maintained at six months of follow-up, with a median angle error of 27 and 31°, respectively (p=0.093) in 8 participants who completed the post and six-month retention assessments. The median pretest image interpretation score improved from 55% to 70% (p=0.028); median post and six month scores in the 8 participants were 72 and 68%, respectively (p=0.735). Conclusions: Simulation training in FoCUS significantly improves skills in image acquisition. These skills appear to be retained over time. This study adds support for the use of advanced echocardiographic simulators to enhance formal FoCUS training in a real-world setting.
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