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An adnexal mass is a common gynecological finding. Most adnexal masses are benign neoplasms, especially in premenopausal women. Yet, here we report a premenopausal woman with an adnexal mass that turned out to be an ovarian metastasis from colon cancer. This case emphasizes the importance of considering an ovarian metastasis in patients with (partially) solid adnexal masses and low serum CA125 levels. In addition, we identified the same KRAS mutation in the biopsied liver metastasis and resected right ovarian metastasis. This is in accordance with a previous molecular study of matched tumor pairs/trios of colorectal cancer patients with ovarian metastases, suggesting that mutated KRAS is a universal driver of the metastatic disease in women with KRAS-mutated colorectal cancer with ovarian metastases. More than half of all colorectal cancer patients with ovarian metastases harbor KRAS mutations. Future studies may investigate the efficacy of KRAS inhibitors in the treatment of these patients.
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BACKGROUND: It is frequently suggested that minimally invasive surgery (MIS) is harder to acquire than conventional surgery. To test this hypothesis, residents' learning curves of both surgical skills are compared. METHODS: Residents had to be assessed using a general global rating scale of the OSATS (Objective Structured Assessment of Technical Skills) for every procedure they performed as primary surgeon during a 3-month clinical rotation in gynecological surgery. RESULTS: Nine postgraduate-year-4 residents collected a total of 319 OSATS during the 2 years and 3 months investigation period. These assessments concerned 129 MIS (laparoscopic and hysteroscopic) and 190 conventional (open abdominal and vaginal) procedures. Learning curves (in this study defined as OSATS score plotted against procedure-specific caseload) for MIS and conventional surgery were compared using a linear mixed model. The MIS curve revealed to be steeper than the conventional curve (1.77 vs. 0.75 OSATS points per assessed procedure; 95% CI 1.19-2.35 vs. 0.15-1.35, p < 0.01). CONCLUSIONS: Basic MIS procedures do not seem harder to acquire during residency than conventional surgical procedures. This may have resulted from the incorporation of structured MIS training programs in residency. Hopefully, this will lead to a more successful implementation of the advanced MIS procedures.
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Competencia Clínica/estadística & datos numéricos , Procedimientos Quirúrgicos Ginecológicos/educación , Procedimientos Quirúrgicos Mínimamente Invasivos/educación , Evaluación Educacional , Histeroscopía/educación , Internado y Residencia , Laparoscopía/educación , Curva de AprendizajeRESUMEN
BACKGROUND: Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intraoperative use. METHODS: Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience. RESULTS: Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p=0.008, 95% confidence interval 0.44-1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors. CONCLUSION: Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.
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Competencia Clínica , Evaluación Educacional/métodos , Ginecología/educación , Internado y Residencia , Adulto , Femenino , Humanos , Internado y Residencia/normas , Conocimiento Psicológico de los Resultados , Modelos Lineales , Masculino , Países Bajos , QuirófanosRESUMEN
OBJECTIVE: To identify predictors of postsurgical adhesion formation in peritoneal fluid and plasma, and assess efficacy and safety of reteplase (recombinant plasminogen activator [r-PA]). DESIGN: Prospective randomized study. SETTING: University Medical Center. PATIENT(S): Twenty-six abdominal myomectomy patients with early second-look laparoscopy (ESL). INTERVENTION(S): Randomization to IP treatment with 1 mg reteplase in 300 mL Ringer's lactate or 300 mL Ringer's lactate only. Scoring of adhesions and collecting peritoneal fluid during both surgical procedures and collecting plasma samples at ten time points. MAIN OUTCOME MEASURE(S): Incidence, severity, and extent of adhesions at ESL. Concentrations of C-reactive protein (CRP), tissue-type plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), and fibrin degradation products (FbDPs). RESULT(S): Significant correlation between the extent of uterine adhesion formation and preoperative plasma levels of CRP (r(s) = 0.558), PAI-1 (r(s) = 0.413), and the change in tPA concentration in peritoneal fluid from initial surgery to ESL (Delta+PA: r(s) = -0.636). No significant differences in adhesion scores between treatment and control groups. CONCLUSION(S): Our finding that preoperative plasma CRP and PAI-1-levels are significantly correlated with extent of adhesion formation points to a role of chronic inflammation in the disease process. Results are highly indicative for the paradigm that adhesions are caused by an insufficiency in peritoneal fibrinolytic capacity. For successful adhesion prevention therapy relatively high amounts of r-PA are required.
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Leiomioma/cirugía , Activadores Plasminogénicos/uso terapéutico , Adherencias Tisulares/diagnóstico , Adherencias Tisulares/prevención & control , Neoplasias Uterinas/cirugía , Adulto , Líquido Ascítico/química , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Incidencia , Infertilidad Femenina/sangre , Infertilidad Femenina/patología , Infertilidad Femenina/cirugía , Leiomioma/sangre , Leiomioma/diagnóstico , Leiomioma/patología , Miometrio/cirugía , Proyectos Piloto , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/patología , Cuidados Preoperatorios/métodos , Pronóstico , Factores de Riesgo , Adherencias Tisulares/epidemiología , Adherencias Tisulares/etiología , Neoplasias Uterinas/sangre , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/patología , Adulto JovenRESUMEN
The complexity of acquiring minimally invasive surgical (MIS) skills, combined with smaller case volumes for residents have pushed the development of skills training facilities on simulators outside the operating room (OR). Medico-legal and financial constraints have stimulated this development even more. However, the implementation of simulator training into a residency curriculum is shown to be troublesome. MIS skills training is organized in a uniform and easily applicable way in the Dutch obstetrics and gynecology residency curriculum. Every resident is obliged to attend the same basic surgical skills course, named Cobra-alpha course, intentionally during postgraduate year (PGY) 1 or 2. Furthermore, surgical skills are trained, evaluated and expanded on simulators in teaching hospitals. Additional to the Cobra-alpha course, residents may attend advanced training courses and congresses focusing on laparoscopy and hysteroscopy. This organization guarantees a uniform introduction to MIS skills training for every resident. However, preconditions for continuous training and evaluation after this introduction have to be optimized.
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BACKGROUND: To evaluate the effect of a mentor traineeship in laparoscopic surgery in a teaching hospital. METHOD: This observational study was performed between January 1997 and December 2004 at Bronovo Hospital, The Hague, The Netherlands. Since January 2001, an advanced endoscopic gynecologist has mentored a trainee in laparoscopic surgery. Data on the trainee's procedures preceding (1997-2000) and during the mentor traineeship (2001-2004) were compared. The number and type of procedures performed, complications and conversions were derived from a prospectively kept database supplemented by a retrospective chart review. Operating times for total laparoscopic hysterectomy (TLH) were registered to establish the trainee's learning curve. RESULTS: Since the presence of a mentor, the trainee has performed significantly more advanced laparoscopic procedures. Despite the significant increase in advanced cases, the trainee's laparoscopic conversion rate to laparotomy remained stable between period 1 and period 2 (7.5 and 4.5%, respectively, p = 0.35, 95% CI -0.033 to 0.092); moreover, for level-3 procedures the conversion rate decreased (p < 0.001, 95% CI 0.30-0.71). Despite the increase in advanced cases, the total complication rate remained stable (3.2-4.5%, p = 0.62, 95% CI -0.07 to 0.04) including the number of level-3 complications (p = 0.63, 95% CI -0.4 to 0.3). A decreasing trend in operating time for TLH was found; however, this was not significant (Spearman correlation coefficient -0.421, p = 0.81). CONCLUSIONS: Mentor traineeship in gynecology enhanced the advanced laparoscopic caseload. With the increase in advanced procedures, no increase in conversion rate, complication rate or operating times for TLH was found. Due to the mentorship, patients were not exposed to increased complications and conversions, or to the disadvantages of a prolonged operating time. Predominantly, mentor traineeship facilitated the implementation of laparoscopic surgery into an established gynecological practice in a teaching hospital.
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Competencia Clínica , Educación Médica Continua , Procedimientos Quirúrgicos Ginecológicos/educación , Laparoscopía , Mentores , Estudios de Cohortes , Intervalos de Confianza , Femenino , Humanos , Histeroscopía , Masculino , Países Bajos , Observación , Estudios Retrospectivos , Apoyo a la Formación ProfesionalRESUMEN
OBJECTIVE: This study was conducted to assess the degree of diffusion of hysteroscopic surgery in gynaecological practice in The Netherlands in order to guide further implementation. The diffusion was objectified by defining the percentage of hospitals performing hysteroscopic procedures and the number of different procedures performed per gynaecologist. STUDY DESIGN: In 2003 all Departments of Gynaecology (n=102) in The Netherlands were sent a questionnaire. The questionnaire addressed the number and type of all hysteroscopic procedures that were performed in each hospital in 2002. Data from this study were compared to previously published data from 1997. RESULTS: Responses were received from 80% of all gynaecological departments in The Netherlands. Diagnostic hysteroscopy was performed in almost all hospitals in both 1997 and 2002. The percentage of hospitals that adopted polypectomy, myomectomy and endometrial ablation increased to more than 90% in 2002. The number of teaching hospitals that integrated diagnostic hysteroscopy, polypectomy and myomectomy (procedures required for graduation) into their operative spectrum increased to 100%. CONCLUSION: This survey indicates a growing trend of the diffusion of diagnostic and "basic" therapeutic hysteroscopic procedures in The Netherlands. However, figures upon more advanced hysteroscopic surgery are less optimistic.
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Difusión de Innovaciones , Histeroscopía/estadística & datos numéricos , Servicio de Ginecología y Obstetricia en Hospital/tendencias , Femenino , Encuestas de Atención de la Salud , Humanos , Países BajosRESUMEN
OBJECTIVE: To evaluate and update the current status of the implementation of operative laparoscopy in gynaecology in The Netherlands by assessing diffusion and acceptance of each specific procedure per hospital. STUDY DESIGN: In 2003 a questionnaire was sent to all hospitals (n = 102), which addressed the total number and type of laparoscopic procedures performed in 2002 stratified by level of difficulty (level 1: diagnostic laparoscopy, sterilization, tubal patency tests; level 2: adhesiolysis, ectopic pregnancy (EP), laparoscopic treatment of endometriosis, cystectomy, oophorectomy, LAVH, tubal surgery for infertility; level 3: myomectomy, total laparoscopic hysterectomy (TLH) and sacropexy). Data were compared to previously published data of 1994. RESULTS: Response rate was 79% (81/102). Diffusion and acceptance of level 2 procedures increased significantly, except endometriosis and tubal surgery for infertility. Diffusion of LAVH was only 58%. Four percent of hysterectomies were LAVH. TLH and sacropexy were not performed. The diffusion of myomectomy increased significantly (p = 0.01), whereas its acceptance remained low. CONCLUSIONS: Although the diffusion of operative procedures has increased over the last decade, acceptance is still limited, especially for laparoscopic hysterectomy. The implementation of operative gynaecological laparoscopy in The Netherlands seems to develop at a slow pace.
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Difusión de Innovaciones , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Femenino , Enfermedades de los Genitales Femeninos/cirugía , Encuestas de Atención de la Salud , Humanos , Países BajosRESUMEN
STUDY OBJECTIVE: To assess the current exposure to hysteroscopy in gynecologic residency and daily practice in The Netherlands. DESIGN: Survey (Canadian Task Force Classification III). SUBJECT: Postgraduate year 5 and 6 residents in Obstetrics and Gynecology and gynecologists who finished residency within 1998-2003 in The Netherlands. INTERVENTION: Residents and gynecologists received a survey regarding performance of hysteroscopy, self-perceived competency, and factors influencing hysteroscopic training. MEASUREMENTS AND MAIN RESULTS: Responses were received from 88% of the senior residents and 83% of the gynecologists. All respondents were interested in performing hysteroscopic surgery and performed the procedures taught during residency training. All respondents were interested in performing 1 or more advanced procedures. Depending on type of procedure, fewer respondents (0%-52%) were performing these procedures. Limitation of advanced hysteroscopic skills at the end of residency was found to be due to the lack of having been primary surgeon. It was felt that the preferred level of hysteroscopic surgery after residency could be reached best by hiring an advanced endoscopic gynecologist (49%). CONCLUSION: Implementation of basic, but not advanced, hysteroscopic procedures taught during residency in The Netherlands has been successful to date. Residents and gynecologists are also interested in performing advanced hysteroscopic surgery. However, only a minority of the respondents perform these procedures in their current practice. Residents attain proficiency in advanced hysteroscopic surgery if they have the opportunity to perform these procedures. To improve the exposure to residents and the integration into daily practice, it is of great importance that the skills among the surgical educators improve.
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Competencia Clínica , Procedimientos Quirúrgicos Ginecológicos/educación , Histeroscopía/métodos , Internado y Residencia , Adulto , Actitud del Personal de Salud , Estudios Transversales , Curriculum , Educación de Postgrado en Medicina/normas , Educación de Postgrado en Medicina/tendencias , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Países Bajos , Factores de RiesgoRESUMEN
OBJECTIVE: The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands. STUDY DESIGN: Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected. RESULTS: Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively (P<.001). Significantly more visceral lesions were found (P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively. CONCLUSION: Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.