Improving Surgical Training

Improving Surgical Training is a programme piloting an innovative, evidence-based approach to training. It was developed in response to the Shape of Training report which reviewed postgraduate training and recommended changes in medical education to meet the demands of the modern NHS. A series of initiatives have been developed to enhance the experience for surgical trainees not only to encourage a more focussed and supported method, but also to improve their job satisfaction. The initiatives have combined a greater emphasis on time for training provided by trainers with allocated time for training with multidisciplinary teamworking and the use of technology enhanced learning with simulation of both technical and non-technical skills. The pilot started in 2018 with core training in general surgery and has been expanded to include vascular surgery, urology and trauma and orthopaedics over the last 2 years. Initial feedback from both trainees, trainers and schools of surgery have identified different challenges to aid implementation. The programme is being very carefully evaluated by an independent company as well as careful oversight by the General Medical Council which are paramount to its success.     

口内入路下颌角弧线形截骨术

目的:探索更好的下颌角肥大截骨缩小术式。方法:为获得更好的术后效果,我们采用口内入路下颌角弧形截骨术,将弧形截骨线延长到颏神经处,并对颏结节进行打磨,使截骨线延续流畅,伴小颏者同时行隆颏或颏截骨前移。结果:自2002年以来,我科采用口内入路下颌角长弧线形截骨术矫正320例下颌角肥大患者,均取得了良好的效果。结论:口内入路延长弧形截骨术缩小下颌角可以获得更好术后效果。     

低位直肠癌保留神经的腹膜外侧方扩大清扫的效果分析

目的 探讨低位直肠癌保留神经的腹膜外侧方扩大清扫对患者术后生存率、排尿功能和性功能的影响。方法 回顾性分析我院1996年1月至2000年6月期间收治的392例进展期低位直肠癌实施保留神经的根治性切除术患者的临床资料，其中行腹腔内清扫173例，腹腔内加腹膜外侧方清扫219例，2组患者在年龄、性别、浸润肠壁深度及肿瘤病理组织学类型方面差异无统计学意义。结果 腹腔内加腹膜外侧方清扫组侧方淋巴结转移率为17．8％（39／219），侧方盆壁非连续性癌灶转移率为5，9％（13／219）。术后发生排尿功能障碍：腹腔内清扫组7例（4．0％），腹腔内加腹膜外侧方清扫组113例（51．6％），2组比较差异有统计学意义（P〈0．01）；性功能障碍：腹腔内清扫组93例男性患者中有12例（12．9％），腹腔内加腹膜外侧方清扫组119例男性患者中有62例（52．1％），2组比较差异有统计学意义（P〈0．01）；局部复发率：腹腔内清扫组为16．2％（28／173），腹腔内加腹膜外侧方清扫组为9．6％（21／219），2组比较差异有统计学意义（P〈0．05）；5年生存率：腹腔内清扫组为49．1％（85／173），腹腔内加腹膜外侧方清扫组为59．4％（130／219），2组比较差异有统计学意义（P〈0．05）。结论 低位直肠癌保留神经的腹膜外侧方扩大清扫，可以减少局部复发，提高患者5年生存率，但也会影响患者术后排尿和男性性机能。     

Predictability of retroperitoneal lymph node metastasis by using clinicopathologic variables in surgically staged endometrial cancer

The purpose of this study was to predict lymphatic involvement in endometrial cancer using clinicopathologic variables of patients treated with surgical staging. Overall, 461 patients treated with an initial surgical staging procedure including complete pelvic-para-aortic lymphadenectomy were included. The mean number of resected lymph nodes was 27 (median 26; range 15-83), and 54 patients (12%) had lymphatic involvement. Of these patients, 32 had only pelvic, 15 had both pelvic and para-aortic, and 7 had isolated para-aortic metastases. In the multivariate analysis, deep myometrial invasion (P= 0.02), lymphvascular space invasion (P= 0.001), positive peritoneal cytology (P= 0.002), and cervical involvement (P= 0.003) predicted retroperitoneal lymph node metastasis (RLN) significantly. Two hundred seventy-four patients (59.4%) had at least one of these poor prognostic factors identified by multivariate analysis. In this patient population, 53 (19.3%) had lymphatic involvement compared to 1 patient in the group of 187 patients with low-risk criteria. Ninety-eight percent of patients with RLN were predicted by this model, and with the advent of accurate diagnostic techniques, 40% of patients could be saved from undergoing lymphadenectomy.     

217例早期胃癌扩大胃切除与淋巴结清除术的回顾分析

目的评价早期胃癌不同扩大手术的实际意义，以选择合理的胃切除和淋巴结清除范围。方法以临床病理资料完整、施行规范D2及扩大手术的217例早期胃癌患者为研究对象。分析施行不同扩大手术的原因、淋巴结清除的必要性及第Ⅱ站淋巴结转移与临床病理因素的相关性。结果胃上部癌行全胃切除术6例，No．5、6淋巴结均未见转移；联合脾、脾动脉切除2例，No．10、11p、11d淋巴结均未见转移；胃下部癌联合横结肠系膜切除3例，No．15淋巴结未见转移。以上病例术中多数误认为进展期胃癌而扩大了胃切除或淋巴结清除范围，手术时间长，术中失血较多。胃下部癌清除的第Ⅱ站淋巴结中No．11p、12a、14v均未见转移；黏膜下癌（sm癌）中，No．7、8a淋巴结转移率明显高于黏膜内癌（m癌）（P〈0．05）；淋巴管癌栓阳性者No．7淋巴结转移较阴性者明显增多（P〈0．001），No．1、13淋巴结转移仅出现在淋巴结转移高危病例（sm、癌灶大于3．0cm、凹陷型，淋巴管癌栓阳性）。结论早期胃癌不需施行淋巴结扩大清除术和联合脏器切除。早期胃上部癌不需施行全胃切除术。早期胃下部癌中No．11p、12a、14v淋巴结不需清除．但对胃下部癌淋巴结转移高危病例，应行标准D2淋巴结清除术。     

Bioequivalence, pharmacokinetic and pharmacodynamic response to combined extended release formulations of felodipine and metoprolol in healthy volunteers

Objective: The primary aim of this study was to investigate whether bioequivalence is achieved for a new fixed combination of extended-release (ER) felodipine and controlled-release (CR/ZOK) metoprolol␣compared with the free combination of felodipine ER metoprolol CR/ZOK. The second aim was to study whether there was an interaction in pharmacokinetics and pharmacodynamics between felodipine and metoprolol when administered as ER formulation. Methods: Two four-way cross-over studies were performed in 36 young subjects and 24 elderly subjects with frequent measurement of drug plasma concentrations, blood pressures and heart rate. The pharmacokinetic analysis included enantioselective analysis in six subjects. Results: Bioequivalence between the fixed combination and the free combination was observed for the two drugs (mean difference 27%) except for a minor deviation regarding C_max of metoprolol in the elderly. No significant interaction was shown except for a small increase (6%) of metoprolol AUC in the younger subjects. Mean plasma S-/R-enantiomer ratios were almost identical for the different treatments. Blood pressure and heart rate was significantly reduced for the fixed combination compared with felodipine ER in the younger and the elderly subjects. No significant difference regarding pharmacodynamics was detected between the fixed combination and the corresponding free combination. Conclusion: The fixed combination consistently provides fairly constant and effective felodipine and metoprolol concentrations after once-daily administration of one tablet. It is clinically interchangeable with the free combination of metoprolol CR/ZOK tablets and felodipine ER tablets. Finally, felodipine and metoprolol do not interact on a pharmacokinetic level when administered as the fixed combination. Received: 29 October 1996 / Accepted in revised form: 21 March 1997     

Minilaparotomy for type II and III radical hysterectomy: technique, feasibility, and complications

The objective was to assess the feasibility, the operative and postoperative outcome, and complications in the use of minilaparotomy for type II and III radical hysterectomy (RH) and pelvic lymphadenectomy (PLN) in early-stage cervical/endometrial cancer. A pilot study on 91 consecutive patients submitted to type II and III RH and PLN for early-stage cervical/endometrial cancer was performed between March 2002 and May 2003 in the Division of Gynecologic Oncology (UCSC, Rome). Thirty-two of 91 cases (35.2%) were eligible for minilaparotomy. The mean operative time was 156.7 min, whereas the mean intraoperative estimate of blood loss was 303.7 ml. A mean number of 32.7 pelvic lymph nodes and 6.2 common iliac nodes were removed. Ileus and removal of bladder catheter were on mean postoperative day 2.4 and 3.4, respectively. The mean number of postoperative days spent in the hospital was 3.7. Intra- and postoperative parameters were compared to laparotomy controls and literature data on laparoscopy and Pfannenstiel incision, showing substantially comparable results. Minilaparotomy is acceptable for selected patients undergoing radical abdominal hysterectomy (RAH) and PLN and does not compromise the adequacy of the procedure. It can be considered as an alternative to the classic midline vertical incision or even to the Pfannenstiel incisions and laparoscopy.     

A Novel Extravascular Input Function for the Assessment of Drug Absorption in Bioavailability Studies

Purpose. Flexible parametric models describing the input process after extravascular drug administration are needed for the assessment of absorption rate and the use of population methods in bioavailability and bioequivalence studies. Methods. The oral concentration-time curve modeled as the product of the input and disposition function in the Laplace domain was obtained by numerical inversion methods for parameter estimation. The utility of the inverse Gaussian input density was examined using bioavailability data of an extended-release dosage form. Measures of rate of absorption and the cumulative absorbed amount profile were defined in terms of the estimated model parameters. Results. Accurate estimation of absorption parameters was achieved by simultaneous fitting of the extravascular and intravascular data (describing the latter by a triexponential function). The new input function allowed a direct estimation of both extent of absorption and mean absorption time. Conclusions. The findings suggest that the inverse Gaussian density is a useful input function. Its flexibility may reduce the effect of model misspecification in parameter estimation. All parameters can be readily interpreted in terms of the absorption process.     

Surgical results of performing R4 gastrectomy for gastric cancer located in the upper third of the stomach

Because gastric cancers located in the upper third of the stomach are difficult to detect at an early stage, the surgical results remain poor. We performed R4 gastrectomy as a radical procedure for 25 patients, involving complete resection of the latero-aortic and interaorticovenous lymph modes above and below the left renal vein, in combination with the ordinary R2 or R3 gastrectomy (the R4 group). These patients were compared with 156 others who underwent R2 gastrectomy alone (the R2 group). There were no significant differences in operation time, blood loss, or the incidence of complications between the two groups; however, when the survival rates of the patients with tumors invading beyond the subserosa were compared, the 5-year survival rate was found to be significantly higher in the R4 group than in the R2 group. Furthermore, in patients with para-aortic nodal involvement, a significant survival advantage was observed in the R4 group, as compared with the R2 group. These results suggest that the R4 gastrectomy is a rational approach for patients with advanced gastric cancer located in the upper third of the stomach.     

Systematic pelvic and para-aortic lymphadenectomy in advanced ovarian cancer patients with no residual intraperitoneal disease

A comparative non-randomized study was carried out to evaluate the role of systematic pelvic and para-aortic lymphadenectomy (SL) on patients with no residual intraperitoneal disease (NRID) of advanced ovarian cancer (stage IIIC–IV). A total of 142 optimally cytoreduced patients (macroscopic disease absent on peritoneal surface) were divided into two groups: Group A, consisting of 98 patients (53 previously untreated and 45 pretreated at other Institutions), who underwent SL; Group B, consisting of 44 patients (21 previously untreated and 23 pretreated at other Institutions), who did not undergo SL. Each group had statistically equivalent histology, grading, performance status and variety of cytoreductive operations performed. Group A pretreated patients had a greater number of stage III than Group B ( P  = 0.03). Systematic pelvic and para-aortic lymphadenectomy could be carried out with an acceptable morbidity and no mortality. All 142 patients received post-operative chemotherapy including carboplatin. The number of chemotherapy sessions did not differ between the two groups. Comparison of survival revealed that SL significantly improved the survival of previously untreated patients ( P  = 0.02). The survival was significantly different with nodal status ( P  = 0.006). Cox's proportional hazard analysis showed that only systematic lymphadenectomy was a significant covariate. The survival was not significantly different in Group A vs Group B pretreated patients; however, it was significantly different with respect to nodal status ( P <0.001). Cox's proportional hazard analysis showed that only the initial stage of disease was a significant covariate. The results of the present study shows that aggressive surgical cytoreduction with SL could be therapeutic in previously untreated patients with NRID. Currently, an international prospective randomized study is ongoing to clarify definitively the clinical role of SL.