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BACKGROUND: Pancreatoduodenectomy, an advanced surgical procedure with a high complication rate, requires surgical skill in performing pancreaticojejunostomy, which correlates with operative outcomes. We aimed to analyze the correlation between pancreaticojejunostomy assessment conducted in a simulator environment and the operating room and patient clinical outcomes. METHODS: We recruited 30 surgeons (with different experience levels in pancreatoduodenectomy) from 11 institutes. Three trained blinded raters assessed the videos of the pancreaticojejunostomy procedure performed in the operating room using a simulator according to an objective structured assessment of technical skill and a newly developed pancreaticojejunostomy assessment scale. The correlations between the assessment score of the pancreaticojejunostomy performed in the operating room and using the simulator and between each assessment score and patient outcomes were calculated. The participants were also surveyed regarding various aspects of the simulator as a training tool. RESULTS: There was no correlation between the average score of the pancreaticojejunostomy performed in the operating room and that in the simulator environment (r = 0.047). Pancreaticojejunostomy scores using the simulator were significantly lower in patients with postoperative pancreatic fistula than in those without postoperative pancreatic fistula (P = .05). Multivariate analysis showed that pancreaticojejunostomy assessment scores were independent factors in postoperative pancreatic fistula (P = .09). The participants highly rated the simulator and considered that it had the potential to be used for training. CONCLUSION: There was no correlation between pancreaticojejunostomy surgical performance in the operating room and the simulation environment. Surgical skills evaluated in the simulation setting could predict patient surgical outcomes.

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BACKGROUND: Sarcoid-like reaction (SLR) is a histological pattern of granulomatous inflammation that is clinically differentiated from sarcoidosis. Since SLR is known to occur in several neoplasias and occasionally causes lymphadenopathy and mimics metastatic malignancy, it needs to be considered whether lymphadenopathy is due to metastasis or SLR for the choice of cancer treatment. Few cases of hepatocellular carcinoma (HCC) with SLR have been reported. Here, a case of HCC with lymphadenopathy diagnosed as SLR without metastasis is presented. CASE PRESENTATION: A 69-year-old woman was admitted to our hospital because of upper abdominal pain. She tested positive for hepatitis C virus ribonucleic acid. Imaging modalities showed an 81 × 65-mm-sized tumor with multiple nodules in segment 3 and a 17 × 12-mm-sized tumor in segment 5 with a common HCC enhancement pattern. In addition, a lymph node in the hepatoduodenal ligament was enlarged at 13 mm in size, suggesting the metastasis of HCC. Hepatectomy of the lateral segment and segment 5 and lymph node dissection in the hepatoduodenal ligament were performed. Both tumors in segments 3 and 5 were pathologically diagnosed as HCC without vessel invasion. The tumors contained necrotic cells and epithelioid cell granulomas with multinucleated giant cells, which is typically observed in sarcoidosis. The dissected lymph nodes also contained epithelioid cell granulomas, as well as giant cells with asteroid bodies. There was no malignancy in the lymph nodes. The pathological findings suggested the coexistence of malignancy and sarcoidosis. However, since the patient did not show any typical findings of pulmonary or cardiac sarcoidosis, the case was diagnosed as HCC with SLR in the primary lesion and regional lymph nodes. CONCLUSIONS: SLR needs to be considered in the differential diagnosis when a cancer patient develops lymphadenopathy. However, lymphadenopathy due to SLR is indistinguishable from that due to metastasis even when using multiple imaging modalities. Pathological examinations may be helpful for the diagnosis.

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PURPOSE: The aim of this study was to identify (1) the type of skill evaluation methods and (2) how the effect of training was evaluated in simulation-based training (SBT) in pediatric surgery. METHODS: Databases of PubMed, Cochrane Library, and Web of Science were searched for articles published from January 2000 to January 2017. Search concepts of Medical Subject Heading terms were "surgery," "pediatrics," "simulation," and "training, evaluation." RESULTS: Of 5858 publications identified, 43 were included. Twenty papers described simulators as assessment tools used to evaluate technical skills. Reviewers differentiated between experts and trainees using a scoring system (45%) and/or a checklist (25%). Simulators as training tools were described in 23 papers. While the training's effectiveness was measured using performance assessment scales (52%) and/or surveys (43%), no study investigated the improvement of the clinical outcomes after SBT. CONCLUSION: Scoring, time, and motion analysis methods were used for the evaluation of basic techniques of laparoscopic skills. Only a few SBT in pediatric surgery have definite goals with clinical effect. Future research needs to demonstrate the educational effect of simulators as assessment or training tools on SBT in pediatric surgery.

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